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Review Article | DOI: https://doi.org/10.31579/2690-1919/250
* İzmir Faculty of Medicine, Department of Pediatric Surgery, İzmir Tepecik Health and Research Center, Sağlık Bilimleri University, İzmir, Turkey.
*Corresponding Author: Volkan Sarper Erikci, Kazım Dirik Mah. Mustafa Kemal Cad. Hakkıbey apt. No: 45 D.10 35100 Bornova-İzmir, Turkey.
Citation: Volkan S. Erikci. (2022). Airway Foreign Bodies in Children: A Review Article. J Clinical Research and Reports, 11(3); DOI:10.31579/2690-1919/250
Copyright: © 2022, Volkan Sarper Erikci. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
Received: 18 April 2022 | Accepted: 30 April 2022 | Published: 11 May 2022
Keywords: foreign body aspiration; children; treatment; FBA; epidemiology
Foreign body aspiration (FBA) in children represents a significant morbidity and even mortality producing sudden deaths. Regarded as a major public health issue, FBA may be the end result of aspiration of various organic and inorganic materials. Parental and public awareness including preventive measures is important in avoiding these injuries. The consequences of FBA may pose great challenge for both the children, their families together with clinicians dealing with these children. In this review article it is aimed to discuss the epidemiology, clinical presentations, diagnosis and treatment modalities of FBA in children under the light of relevant literature.
As a medical emergency foreign body aspiration (FBA) continues to result in high morbidity and mortality ranging from 10-20% worldwide [1]. Successful management of patients with FBA dates back to Gustav Killian in 1897 using bronchoscopic extraction and series of deaths in restaurants was first reported by Haugen in 1963 named as “café coronary” described as fatal upper airway obstruction that occurs in adults while swallowing large pieces of meat during laugh or chat [2, 3].
Children are prone to FBA because of absence of molar teeth, swallowing discoordination and their tendency to talk and play while eating [4, 5]. Bronchoscopy via rigid or flexible instruments is the gold standard of management in these cases. The aim of this study is to review FBA in children with regard to symptoms, history of presentation, physical and radiological findings, and methods of foreign body removal and outcome of these children with short and long-term sequale together with treatment modalities under the light of relevant literature.
Epidemiology
It has been reported that FBA is a primary cause of accidental death in children under 12 months to 3 years of age [6, 7]. Despite increasing awareness of this problem, there is a rise in incidence of FBA in children. It has also been reported that in United States alone, FBA resulted in thousands of emergency room visits each year, producing 5% of all accidental deaths in children under the age of 4 [8]. In another report, the incidence of FBA was calculated to be 0.66 per 100.000 and during 2000 among emergency visits in USA, 17.000 were children with FBA under 14 years of age [9, 10].
FBA in children has a unique demography and most of the cases are below 3 years of age with a peek frequency in 1-2 years of age [6, 11]. Unlike adults, children do not have recall of FBA and the diagnosis usually depends on the history obtained from mother or care-giver. There is a male gender propendarence in most studies with large number of cases [12, 13]. It has been suggested that this finding may be due to their adventurous and impulsive behavior [14, 15]. Although there is no racial difference in children with FBA, a recent study questiones this and the incidence of FBA in Arab children was found to be higher than in their Jewish peers in Israel revealing a racial difference [16].
Type of inhaled foreign objects has wide variety with global variation. In general organic materials are more common than inorganic materials and peanuts are the most commonly aspirated organic materials [17-19]. In western countries, children usually aspirate organic materials while bones are common in Asia and China and seeds of watermelons, sunflowers, and pumpkins are more prevalent in Mediterranean countries like Egypt, Greece and Turkey [17, 20, 21]. Nature of inhaled foreign bodies has an impact in pathophysiology and on the degree of inflammation they produce. Organic materials may expand due to water absorption changing the airway obstruction from partial to total occlusion. On the other hand inorganic materials may occlude the airways causing upper airway obstruction [22, 23]. Organic materials may break up in to pieces which can be lodged in distant airways making removal difficult. It has been suggested that metallic objects cause minimal reaction while lipophilic materials stimulate intense chemo-inflammation in a response to fatty acid content [24].
The most common site of FBA is right bronchus as it is anatomically shorter and wider. The most common location of affected lung lobe is the right lower lobe because it is larger and more vertical. Bilateral lower lung lobes are usually affected by aspiration during standing while alcoholics who aspirate in a prone position may have right upper lobe infiltrated commonly [25].
There is no standard classification system for FBA in children. According to degree of airway obstruction, there are two types; partial and complete obstruction. Logically complete obstruction has severe consequences compared to partial obstruction. With regard to origin of aspirated foreign body, these children may inhale internal or external materials. Endogenous sources include mucocoele and bronchial casts of plastic bronchitis while exogenous materials are numerous organic and inorganic items [26, 27].
Clinical features
There is a wide range of symptoms and to reach a definitive diagnosis a high index of suspicion is required. Choking has the highest predictive factor of FBA and is commonly present in 75-90% of cases [28-30]. Persistent cough and difficulty in breathing are usually observed. Tracheal foreign bodies have usually a clinical triad including asthmatoid wheezing, audible slap from the obstructed trachea and palpable thud [31]. In another report, one third of all cases with FBA had classical triad of wheeze, cough, and unilateral decreased breath sounds [28, 32]. It has been suggested that in patients with persistent coughing and unresolved pneumonia, FBA must be ruled out. Careful history taking is also important for a definitive diagnosis of FBA. Delays in diagnosis of FBA may be up to 54% of presenting cases [33]. The reasons for this include unintentional aspiration by child unnoticed by parents, vague clinical history, lack of symptoms, hesitancy of clinician for getting a chest X-ray and late referral [33]. Differential diagnosis include a long list of diseases and depends on foreign body location and is depicted in table 1 [34].
| Laryngeal foreign bodies | Subglottic stenosis Epiglottitis |
| Tracheal foreign bodies | Croup Mass lesions of trachea and paratrachea Tracheomalacia Tracheal stenosis |
| Bronchial foreign bodies | Congenital cystic adenomatoid malformation (CCAM) Bronchial compression Plastic bronchitis |
| Bronchiole foreign bodies | Bronchiolitis Bronchiectasis Bronchiolitis obliterans Bronchiolitis obliterans with organizing pneumonia (BOOP) |
| Lobar obstructio | Asthma Atelectasis |
Table 1: Differential diagnoses of foreign body aspiration.
Diagnosis
Diagnosis of FBA is a real dilemma and a high index of suspicion is important in diagnosing these patients. In a recent study, two out of the three was considered diagnostic and bronchoscopy was recommended: foal hyperinflation, witnessed choking crisis and leukocytosis [35]. In a scoring system created by Kadmon et al, parameters of FBA in children include age (10-24 months), history of presence of an object in a child’s mouth followed by respiratory symptoms, signs of stridor, dyspnea or hyponia, unilateral abnormal breath sounds on auscultation, and abnormal tracheal radiogram and positive chest x-ray [36].
Chest radiograph is the first-line investigation in the diagnosis of FBA. Because most of inhaled foreign objects are radiolucent they can’t be observed directly in x-rays and indirect findings of FBA should be searched for. These are unilateral lung hyperinflation, consolidation, collapse, atelectasis, tracheal or mediastinal shift [37]. Normal chest radiograph does not exclude FBA and it has been reported in previous studies that up to 50% of cases with FBA have normal chest radiographic findings [38, 39]. In unclear cases, computed tomography (CT) can be performed for diagnosis. Compared to bronchoscopy, CT is 100% sensitive, 66.7%specific, and has a positive predictive value of 93.3% and negative predictive value of 100% for detecting foreign body in the airway (40). Handicaps of CT include false positive results and radiation hazards associated with it [41-43].
Rigid bronchoscopic inspection is the gold standard in diagnosing these cases and has dual property including both defitive diagnosis and retrieval of lodged foreign object from the tracheobronchial tree. Flexible bronchoscopy is another option which is beneficial to assess distal airways for residual foreign body and for bronchial lavage in patients with negative bronchoscopy to obtain culture. Whether flexible or rigid, if there is high index of suspicion of FBA, bronchoscopy must be performed as fast as possible. It has been suggested that a negative bronchoscopy rate of 10-15% is acceptable [38]. Other treatment modalities if bronchoscopy is not helpful include invasive operations like tracheostomy, throracotomy, and bronchostomy [44, 45].
Inflammatory responses, localized edema and bronchospasm are the most common consequences of FBA [34]. Minor complications are arterial oxygen desaturation, bradycardia, and bronchospasm. Major complications include laryngeal edema, pneumothorax, and cardiac arrest. Other complications of FBA in children with long standing history include abscess formation, recurrent pneumonia, bronchiectasis and bronchial strictures.
In conclusion, FBA is a medical emergency that should be suspected in children with a history of choking. Prevention of FBA in children by parental and public education has paramount importance. First liners of medical providers should have a high index of suspicion of this clinical entity and early diagnosis and referral of these children to medical centers with a capability of performing urgent management reduces morbidity and mortality.
The author certifies that he has no affiliations with or involvement in any organization or entity with any financial interest, or non-financial interest in the subject matter or materials discussed in this manuscript.
During this study, no financial or spiritual support was received neither from any pharmaceutical company that has a direct connection with the research subject, nor from a company that provides or produces medical instruments and materials which may negatively affect the evaluation process of this study.
Idea/concept, design, control and processing, analysis and/or interpretation, literature review, writing the article, critical review, references and materials by Volkan Sarper Erikci.
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