A Study of Foreign Body Aspiration in Children

The characteristics of foreign bodies aspirated by children across different continents: A comparative review

BACKGROUND

Foreign body aspiration (FBA) is a common issue in pediatric emergencies, with regional variations. Various cultures and foods, parents' and physicians' inadequate experience, and lack of bronchoscopy equipment are some attributable factors in the regional variation of FBA.

AIM

To more accurately represent the demographic characteristics of aspirated foreign bodies (FBs) across various continents, this review attempted to provide organized information based on the reviewed articles.

METHODOLOGY

A search was conducted in PubMed/PubMed Central, EMBASE, and google scholar. From the 36 included articles, information on age, gender, bronchoscopy type, type of FB, location, history of choking, and time elapsed between aspiration and admission were extracted.

RESULTS

A total of 14,469 cases were evaluated. According to the findings, children under two accounted for more than 75% of FBAs. Nuts and seeds were the most common FBs in most countries, whereas plastic and metal objects had higher rates in Brazil, and calcified objects were more prevalent in Thailand. The right bronchus was the most frequent location, and rigid bronchoscopy was the most often utilized type of bronchoscope. In addition, a significant percentage of patients were referred to the emergency rooms in the first 12-24 h following the aspiration incident. Moreover, Asian patients reported more choking history, and Europeans had fewer witnesses of FBA.

CONCLUSIONS

There is a lack of standardized reporting systems and organized guidelines in pediatric FBA. To select the ideal time for endoscopies and create educational programs, a collaboration between experienced researchers, pediatric pulmonologists, radiologists, and otolaryngologists is required.

Utility of Optical Forceps and Tracheotomy for Tracheobronchal Foreign Body

Tracheobronchial foreign body is a life-threatening situation where quick decisions need to be taken. The preparedness for the same can never be over emphasized. This study was undertaken to understand the preference and utility of various types of foreign body forceps. This is a retrospective study in a tertiary care center. Data over 5 years (2016-2021) was analyzed to understand the utility of the optical forceps and the conventional (standard) forceps in the current scenario. The difficult cases where tracheotomy was done were also studied. Observations: 109 bronchoscopies were done during this period. In 90 patients optical forceps was used, flexible fiberoptic bronchoscope was used in 10 situations to locate and confirm the foreign body (FB) before extraction with standard or optical forceps. In 2 adult patients flexible fiber optic bronchoscope with forceps was used to extract, peripheral lying FB (pin). Standard (conventional) forceps with size 3 bronchoscope was used in 13 patients who were below 1 year. There were 2 postoperative mortalities. Tracheotomy was done in 6 patients, 4 were repaired primarily and in 2 tracheostomy tube was inserted. Conclusion: Optical forceps took care of 86% of foreign body. The Standard forceps have stood the test of time and are still useful. Having flexible fiberoptic in the armamentarium is a necessity now with newer challenges. Large swollen FB which cannot be extracted through glottis should be removed with tracheotomy rather than struggling at the glottis-sub glottis and have a complete obstruction. The optical forceps, standard forceps, ventilating rigid bronchoscope, flexible fiberoptic bronchoscope, Dormia basket, Fogarty's catheter are necessary in the armamentarium of an otolaryngologist and are not replaceable for one another.

Tracheobronchial Foreign Bodies in Children: Experience From 1,328 Patients in China

OBJECTIVE

To analyze the clinical characteristics of tracheobronchial foreign body (FB) cases in a pediatric Chinese population.

METHODS

The clinical data of pediatric patients aged 0-18 years old diagnosed with a tracheobronchial FB in the Children's Hospital of Chongqing Medical University between September 2018 and August 2021 were analyzed retrospectively.

RESULTS

Among 1,328 included cases, 92.09% of patients were <3 years old, the male to female ratio was 1.86:1. The prevalence of tracheobronchial FB was similar between patients living in rural and urban areas and tracheobronchial FBs were more common in winter. The most common presenting symptoms were cough and wheezing. The most common CT findings was local obstruction or tracheobronchial narrowing, followed by obstructive emphysema of lung and pneumonia. The 11.3% of cases that did not report FB aspiration on admission had a longer time to hospital admission and longer hospitalization time than cases reporting FB aspiration (P < 0.05). The most common FB type was nuts (81.17%). FBs were more frequently located in the right bronchus, and 64 (4.82%) cases involved multiple FBs. FBs were expelled by coughing in only 4.07% of cases. For the other cases, FB removal by first bronchoscopy in our hospital was successful and complete in 96.86% of cases. 1.51% of patients had hypoxic ischemic encephalopathy (HIE) and the location of FBs was a possible risk factor for HIE (P < 0.05).

CONCLUSIONS

Tracheobronchial FBs occurred most commonly in children <3 years old. If asphyxia occurs in children which FBs aspirated, emergency treatment is needed to reduce the occurrence of HIE. Rigid bronchoscopy remains the first-line method for FB removal in children.

May the first-line treatment for foreign body aspiration in childhood be flexible bronchoscopy?

INTRODUCTION:

Rigid bronchoscopy (RB) is the traditional treatment in foreign body (FB) aspiration in childhood but is a traumatic and invasive procedure. However, flexible optic bronchoscopy (FoB) is a noninvasive and nontraumatic respiratory intervention. The aim of this study was to evaluate FoB as a first-line treatment modality in pediatric cases presenting with a preliminary diagnosis of FB aspiration.

METHODS:

Subjects who underwent FoB under general anesthesia with the preliminary diagnosis of FB aspiration were enrolled in this cross-sectional study. Two cases were inherited from pediatric surgery because they were not removed with FoB. The demographic, clinical, and radiological findings at the presentation were recorded. Results of success rate and complications were recorded.

RESULTS:

Among the FB aspiration cases age range of 7 months to 16 years. FoB demonstrated a FB in the airways of 31 (62.2%) subjects. The duration of the symptoms in the subjects was 9.1 ± 8.8 days. Three of the cases were taken over from pediatric surgery because they were not removed with RB. Most commonly encountered FB's were organic materials (n = 20, 64%). FoB was successful in removing the FB from the proximal and also distal airways in 93% of the subjects. No significant complications and side effects were observed except post-FoB cough.

CONCLUSION:

This result has shown that FoB for the treatment of FB aspiration is successful in removing FB aspiration from both the proximal and distal airway that the RB cannot remove. Furthermore, FoB did not have any significant airway complication. FoB may be used as the first-line treatment modality for FB aspiration instead of RB in childhood the fact that noninvasive and nontraumatic respiratory intervention.

Foreign Body Aspiration in Egyptian Children Clinical, Radiological and Bronchoscopic Findings

Purpose

Foreign body aspiration (FBA) is a frequent cause of childhood morbidity and mortality. Diagnosis of FBA is challenging in the absence of a witnessed aspiration event. The aim of this study was to determine the accuracy of presenting symptoms as well as physical and radiologic findings as predictors of FBA in children. Thus, indications for bronchoscopy could be determined in such cases.

Methods

This retrospective cohort study was conducted in the ENT department, Kafr-elsheikh University Hospital. The medical records of patients younger than 16 years old who underwent rigid bronchoscopy for suspected FBA were included. Data including age, gender, symptoms, physical examination findings, radiological features, nature and location of foreign body, and outcome of the bronchoscopy were collected.

Results

This study included 130 patients, 105 (80.8%) patients were positive for the presence of a foreign body in their airways. Foreign bodies were most frequently (43.8%) lodged in the right main bronchus, and nuts (66.7%), were the most commonly retrieved. Multivariate regression analysis identified the presence of suggestive signs or symptoms as independent predictors of FBA on rigid bronchoscopy.

Conclusion

Objective finding of clinical signs eg unilateral wheezes on chest examination in the presence of symptoms such as a sudden cough, dyspnea, and hoarseness could predict FBA and help physicians in deciding bronchoscopy.

Age based evaluation of nut aspiration risk

OBJECTIVE

To identify an age at which initiation of whole nut into the pediatric diet could be considered safe, by evaluating the age distribution of children undergoing bronchoscopy with removal of nut or seed material from the airway.

METHOD

A retrospective chart review over a ten-year period identifying children age 0-18 that have undergone bronchoscopy with retrieval of airway foreign bodies. A statistical analysis of demographic data was carried out to identify age distribution of aspiration events.

RESULTS

Sixty-four cases of foreign body aspiration were identified, of which 43 (67%) were of organic origin, specifically nuts. A Fisher's exact test was carried out on the cumulative percentage of organic foreign body aspirations to identify the age distribution of nut aspiration events. A statistically significant decrease in organic foreign body aspirations occurred at approximately 36 months of age (p = 0.004).

CONCLUSION

Foreign body aspiration is a leading cause of accidental injury or death in children. Nut and other small organic foreign bodies account for a significant portion of accidental aspiration events, however, no guidelines exist regarding appropriate age of whole nut introduction into the diet. Our study suggests that 90% of pediatric nut aspiration events occur under the age of 36 months. We suggest supervised introduction of whole nuts between the ages of 3 and 4 years. Official guidelines regarding this should be considered by professional pediatric societies.

LEVEL OF EVIDENCE

4.

Risk factors affecting the treatment outcome of pediatric foreign body aspiration: significance of time factors

PURPOSE

The aim of this study was to identify the factors affecting the prognosis of children with foreign body aspiration (FBA) after undergoing rigid bronchoscopy.

METHODS

This was a case series with a chart review of 49 children under 3 years of age who underwent rigid bronchoscopy for suspected FBA at a single tertiary institution.

RESULTS

The time from symptom onset to hospitalization positively correlated with the total hospitalization time (p < 0.001), postoperative hospitalization time (p = 0.006), and operation time (p = 0.013). The time from symptom onset to operation positively correlated with the total hospitalization time (p < 0.001) and operation time (p = 0.046). The time from hospitalization to operation and the operation time positively correlated with the total hospitalization time (p = 0.026, 0.044) and postoperative hospitalization time (p = 0.049, 0.003). The time from symptom onset to hospitalization positively correlated with the incidence of pneumonia (p = 0.028).

CONCLUSION

Rapid hospitalization after symptom onset, rapid surgery after symptom onset, and rapid surgery after hospitalization improve the prognosis of patients with FBA. Further, a short operation time also plays a role in improving patient prognosis.

An apple a day won't keep the doctor away: presentation, treatment, and outcome in pediatric apple aspirations

INTRODUCTION

Foreign body (FB) aspiration is a frequent and preventable source of morbidity and mortality, especially in children under 4 years of age. Few comprehensive studies exist on presentation and outcome of apple aspirations in children.

METHODS

In a retrospective analysis of bronchoscopy records of a tertiary medical care center from January 2007 to August 2019, we identified pediatric cases of suspected apple aspirations.

RESULTS

A total of 11 suspected apple aspirations were identified (observation time 12.7 years, n = 5858 bronchoscopies, n = 226 interventions due to suspected FB aspirations in total). The mean age of patients was 24 months (standard error mean, 7 months; range, 8-83 months), and 6 out of 11 cases (55%) were male. Bronchoscopy confirmed apple aspiration in n = 6/11 cases (55%). In n = 2/11 cases (18%), a bite of the apple was located in the esophagus causing significant tracheal narrowing, and in n = 3/11 cases (27%), no FB was found. In all cases of airway FB identification, extraction was successful. Hypersalivation was associated with esophageal FB location, whereas persistent cough, stridor, or dyspnea were associated with airway FB location. Outcomes ranged from complete reconstitution 1 day after bronchoscopy in most cases to hypoxemia with severe brain damage in one patient.

DISCUSSION

This analysis shows that apple aspirations are not entirely uncommon in children and may lead to disastrous complications. Typical signs of airway location are persistent cough, stridor or dyspnea, whereas hypersalivation may point toward an esophageal location. In each case of suspected apple aspiration, timely bronchoscopy with possible FB extraction should be performed by an experienced team.

Influential factors for visit time for tracheobronchial foreign bodies in pediatrics

PURPOSE

This study aims to investigate the inflential factors for visit time for tracheobronchial foreign bodies in pediatrics, and to shorten the time of diagnosis and reduce complications.

METHODS

A questionnaire survey was designed and conducted among the caretakers of children with tracheobronchial foreign bodies, and the related inflential factors for visit time were analyzed.

RESULTS

The visit time for tracheobronchial foreign body was correlated with the age of the child, the type of foreign body, the educational level of the caretaker, a history of foreign body aspiration were provided, an examination was performed during the visit, the anti-inflammatory and anti-allergic treatment, and transfer to a higher level hospital. Age, history of foreign body aspiration were provided, and anti-inflammatory and anti-allergic treatment were the independent inflential factors for the time of diagnosis (P < 0.05).

CONCLUSION

The visit time for tracheobronchial foreign bodies was affected by many factors. It is necessary to strengthen the publicity scope and intensity on health education for tracheobronchial foreign bodies in community doctors and parents, to shorten the time of diagnosis and reduce complications.

Bronchoscopy for Pediatric Airway Foreign Body: Thirty-Day Adverse Outcomes in the ACS NSQIP-P

OBJECTIVES

(1) Describe outcomes of bronchoscopy with foreign body removal among children on the basis of a large standardized multi-institutional data set. (2) Identify factors associated with 30-day adverse events.

STUDY DESIGN

Cross-sectional analysis of a US national database.

SETTING

Public data set from the ACS NSQIP-P (American College of Surgeons National Surgical Quality Improvement Program-Pediatric) from 2012 to 2015.

SUBJECTS AND METHODS

Children <18 years old who underwent bronchoscopy with removal of foreign body were identified. Patient demographics, comorbidities, hospitalization factors, surgical characteristics, and 30-day postoperative adverse events, including complication and readmission, were analyzed. Multivariate logistic regression identified predictive factors for postoperative complications and prolonged length of stay.

RESULTS

A total of 275 children underwent bronchoscopic foreign body removal (n = 165 male, 60%; n = 75 nonwhite and/or Hispanic, 27%; mean age, 3.5 years [range, 0.63-17.9; median, 2.0]). Adverse events occurred among 10 children (4%). Seven had pulmonary-related complications, and 1 patient died. Three patients were readmitted; there were no reoperations. On multivariate analysis, preoperative pulmonary disease or need for pulmonary support (odds ratio [OR], 6.42; P = .04) predicted postoperative complications. Preoperative pulmonary compromise (OR, 8.10; P < .01), American Society of Anesthesiologists class 3 or 4 (OR, 4.13; P < .01), and prolonged operative time (OR, 3.05; P = .01) were associated with prolonged hospital stay.

CONCLUSION

Bronchoscopy for retrieval of foreign body among children has an overall low incidence of 30-day adverse events. Children with preoperative pulmonary compromise have a significantly higher risk of postoperative complications. These findings may be applied to optimize perioperative care and counsel parents and families.

Geographic health disparities in the Los Angeles pediatric esophageal foreign body population

OBJECTIVE

To assess geographical sociodemographic differences in the pediatric esophageal foreign body population of Los Angeles.

METHODS

We retrospectively reviewed the medical records of 128 consecutive pediatric patients at Children's Hospital Los Angeles (CHLA) from 2014 to 2017 with a diagnosis of a retained foreign body in the esophagus removed by rigid or flexible esophagoscopy. Sociodemographic information including zip code of residence was extracted and analyzed with Chi-square, Fisher's exact test, and multivariable logistic regression.

RESULTS

The average age of patients with a retained esophageal foreign body in this study was 2.5 years old, 52.3% were male, 91.4% had no past medical history, 53.1% were Hispanic, 82.0% had public health insurance, and 63.3% were transfers from an outside hospital. The most common foreign body removed was a coin. There were no significant differences in gender, race, type of health insurance, or income between patients that lived within 10 miles of CHLA versus farther than 10 miles. On multivariable analysis, zip codes with a high volume of esophageal foreign bodies were more likely to be lower income neighborhoods. Gender, race, type of health insurance, and distance from CHLA were not risk factors for zip codes with a high volume of esophageal foreign bodies.

CONCLUSION

Geographic areas in the greater Los Angeles community with a high volume of retained esophageal foreign bodies requiring endoscopic removal at our institution are associated with lower income neighborhoods. Further studies should be performed to better understand health disparities within the U.S. pediatric esophageal foreign body population.

The multivariate analysis of indications of rigid bronchoscopy in suspected foreign body aspiration

OBJECTIVE

Foreign body aspiration (FBA) could be a serious life-threatening condition in children. Patients usually underwent bronchoscopy with suspicious of FBA alone. In this study, we aimed to determine which patients need to go to bronchoscopy based on pre-operative findings.

METHODS

Retrospective analysis of patients underwent bronchoscopy between 1999 and 2015 was performed. Clinical symptoms, witnessed aspiration event (WAE), physical examination findings (PEFs) and radiological findings (RFs) were analyzed by multivariate analysis to evaluate the indications of bronchoscopy.

RESULTS

431 patients (266M, 165F) underwent bronchoscopy with a median age of 2 years (7 months-16 years). A foreign body was detected in 68% of the patients. Univariate analysis demonstrated that wheeze was the sole distinctive clinical symptom for detection of FBA (p<0.001). The rates of positive WAE, PEFs and RFs were 83%, 71.7% and 36.9%, respectively. All of them were identified as independent predictive parameters in the detection of FBA by univariate analysis (p = 0.003&p<0.001&p = 0.015). Multivariate analysis was performed with considering the association between them. The rate of positive bronchoscopy was 91.3% in patients with positive WAE, PEFs and RFs together(84/92). In patients with a positive WAE alone who had not got PEFs and RFs, the rate of positive bronchoscopy was 34.2% (25/73). A foreign body was detected in 84% of the patients who had not got a WAE but positive PEFs and RFs together(21/25). Bronchial laceration was occurred in one patient during bronchoscopy. Pneumothorax was not seen in any of the other patients. The rate of mortality was 0.4% in the overall group (2 patients).

CONCLUSION

The indications of bronchoscopy in suspected FBA are usually based on clinical suspicious. The definition of " suspicous" could be a WAE or positive PEFs and RFs. The association of these factors increase the rate of positive bronchoscopies. In the light of our study, the classical indication for suspected FBA is still valid as "suspicious requires bronchoscopy".

Foreign body aspiration in children: A study of children who lived or died following aspiration

Foreign body aspiration (FBA) is a preventable cause of mortality and morbidity in children. We conducted a chart review of children who presented to a university hospital due to FBA in the period 1999-2014. Children were either managed with bronchoscopy for removal of the foreign body or died due to FBA. A total of 103 children were seen due to FBA including 27 deaths. The majority of children were boys and were less than 3 years old. Most aspirated foreign bodies were food-related, mainly peanuts. The majority of children presented with acute choking incidents, a smaller number presented with recurrent chest infections, and few children's choking incidents were unwitnessed. X-ray had a high rate of false negatives and bronchoscopy was the gold standard technique for assessment and management. Aspiration of foreign bodies is a preventable, life-threatening condition that calls for increased parent education and awareness.