Foreign body aspiration into the lower airway in Chinese adults

Saviour tool now a foreign body

ABSTRACT

Foreign bodies are commonly seen in children, here presenting a case of a male adult with an impacted thumb pin in the left lower lobe bronchus. Extraction required fiber-optic bronchoscopy, failure of which led to thoracotomy with bronchotomy.

Obstructive pneumonia with bronchial foreign body: A case report

The age of predilection for foreign body aspiration into the lower airway shows a bimodal distribution, with the majority of cases occurring in children or infants and in the elderly. Although several pediatric airway foreign bodies have been summarized, in adults, bronchial foreign bodies are relatively uncommon. There are a variety of symptoms induced by airway foreign bodies, although the typical symptoms of some bronchial foreign bodies are cough. Bronchial foreign bodies, especially in the elderly, may have few symptoms and it is necessary for careful identification. Therefore, it is very important to carefully perform medical consultations about current and past medical history. Herein, we report a case of an elderly Japanese with obstructive pneumonia with a bronchial foreign body of fish bone with a long history of cough. It is known that people in some countries such as Japan have a habit of eating fish. Therefore, it is necessary to more carefully explore the possibility of some bronchial foreign body such as a fish bone, when we observe symptoms of persistent cough in such countries.

Ex-aspirated: A Case of Dental Product Aspiration With Retrieval Methodology and Current Review

Foreign body aspiration is of significant prevalence in the pediatric and young adult populations. After dental work, patients are more likely to develop pulmonary symptoms secondary to aspiration events within the tracheobronchial tree. Herein, we describe the clinical case of a 22-year-old man with a past medical history of epilepsy and tuberous sclerosis who presented to his primary care provider for chronic coughing and wheezing. With symptoms refractory to albuterol and control of allergies, radiography was obtained, revealing a 4.1 cm dental product in the right bronchus. We provide an overview of our retrieval method as well as a comparison of flexible and rigid bronchoscopies and the bronchoscopic tools available.

Surgical Emergencies in the ICU

Surgical emergencies are common in the critical care setting and require prompt diagnosis and management. Here, we discuss some of the surgical emergencies involving the gastrointestinal, hepatobiliary, and genitourinary sites. In addition, foreign body aspiration and necrotizing soft-tissue infections have been elaborated. Clinicians should be aware of the risk factors, keys examination findings, diagnostic modalities, and medical as well as surgical treatment options for these potentially fatal illnesses.

Risk factors associated with radiolucent foreign body inhalation in adults: a 10-year retrospective cohort study

BACKGROUND

Foreign body aspiration (FBA) is a serious condition with high morbidity and mortality rates. Although chest radiography is generally the first radiologic modality used in diagnosis, a substantial percentage of foreign bodies are radiolucent in adults with diagnosis challenging.

METHODS

Retrospective review of adult patients with FBA diagnosed by flexible electronic bronchoscopy from 2012 to 2022 collecting demographics, history, hospital presentation, radiographic, and operative details. Risk factors associated with radiolucent foreign body inhalation in adults were explored using appropriate statistical methods.

RESULTS

Between 1 January 2012 and 1 January 2022, 114 adult patients diagnosed with FBA were enrolled. The median age of participants was 65 years (IQR 52-74). Multidetector computed tomography (MDCT) examinations identified 28 cases (25%) showing direct visualization of the foreign body (defined as the radiopaque group) and 86 cases (75%) in the radiolucent group. Multivariable stepwise linear regression analysis showed increased odds of radiolucent foreign body inhalation in adults associated with pneumonic patches in MDCT (OR 6.99; 95% CI 1.80-27.22; P = 0.005) and plants/meat foreign bodies (OR 6.17; 95% CI 1.12-33.96; P = 0.04). A witnessed choking history (OR 0.02; 95% CI 0-0.14; P < 0.001) was a protective factor of radiolucent foreign body inhalation in adults.

CONCLUSIONS

Unlike radiopaque FBA, in those presenting with a suspected radiolucent foreign body aspiration, the diagnosis is far more challenging. Risk factors such as lacking a choking history, non-resolving pneumonia (pneumonic patches) in MDCT findings, and plants/meat foreign bodies may help in the early diagnosis of radiolucent foreign body inhalation in adults. Further prospective multicenter studies should be conducted to validate the findings.

Foreign-body aspiration into the lower airways in adults; multicenter study

Background

Foreign-body aspiration is common in children aged 6 months to 3 years. However, with the aging population and increasing prevalence of disabilities such as hemiparesis and neuromuscular diseases in adults, an increased incidence of aspiration is expected.

Methods

This was a multicenter retrospective, observational study in four major referral hospitals in Daegu, South Korea, between 2000 and 2019. We included patients aged over 18 years who were evaluated for tracheobronchial foreign-body aspiration by flexible bronchoscopy. Comorbidities, type and location of foreign body, and radiologic findings were recorded.

Results

Of 138 patients who underwent flexible bronchoscopy for tracheobronchial foreign body aspiration, 91 (65.9%) were men; the mean age was 66.3 (range: 29–87) years. A history of definite choking was present in 60 (43.5%) patients. The most common site of the foreign body was the right bronchus intermedius (27.5%). The most common type of aspirated foreign body was teeth (37.7%), followed by chicken bone (15.2%), nuts (14.5%) and fish bone (9.4%). Iatrogenic events accounted for 37.0% of the cases of aspiration, and the foreign body was successfully removed by flexible bronchoscopy in 91.3% of cases.

Conclusion

Foreign-body aspiration is not rare, even in adults who do not have predisposing factors. Iatrogenic events accounted for about 40% of all cases of foreign body aspiration. In adults, flexible bronchoscopy is relatively safe and has a high success rate for foreign-body removal.

Acute-onset Breathlessness: An Unexpected Etiology?

Acute-onset breathlessness has multifactorial causes where early spotting of etiology assists in prompt treatment of these cases. Other than usual causes, an often-neglected cause, especially in adults, is non-asphyxiating foreign body aspiration. Here, we describe a case of a 40-year-old male who had aspirated an organic foreign body under alcohol intoxication and presented with symptoms of acute-onset breathlessness and severe hypoxia. Prompt diagnosis and bronchoscopy-guided removal result in a quick recovery of symptoms in the index patient.

Single-Use and Reusable Flexible Bronchoscopes in Pulmonary and Critical Care Medicine

Flexible bronchoscopy plays a critical role in both diagnostic and therapeutic management of a variety of pulmonary disorders in the bronchoscopy suite and the intensive care unit. In the set-ting of the ongoing viral pandemic, single-use flexible bronchoscopes (SUFB) have garnered attention as various professional pulmonary societies have released guidelines regarding uses for SUFB given the concern for risk of viral transmission when using reusable flexible bronchoscopes (RFB). In addition to offering sterility, SUFBs are portable, easily accessible, and may be more cost-effective than RFB when considering the potential costs of treating bronchoscopy-related infections. Furthermore, since SUFBs are one time use, they do not require reprocessing after use, and therefore may translate to reduced cleaning and storage costs. Despite these advantages, RFBs are still routinely used to perform advanced diagnostic and therapeutic bronchoscopic procedures given the need for optimal maneuverability, handling, angle of deflection, image quality, and larger channel size for passing of ancillary instruments. Here, we review the published evidence on the applications of single-use and reusable bronchoscopes in bronchoscopy suites and intensive care units. Specifically, we will discuss the advantages and disadvantages of these devices as pertinent to fundamental, advanced, and therapeutic bronchoscopic interventions.

Clinical Value of Bronchoscopy in Acute Respiratory Failure

Bronchoscopy may be considered the “added value” in the diagnostic and therapeutic pathway of different clinical scenarios occurring in acute respiratory critically ill patients. Rigid bronchoscopy is mainly employed in emergent clinical situations due to central airways obstruction, haemoptysis, and inhaled foreign body. Flexible bronchoscopy (FBO) has larger fields of acute applications. In intensive care settings, FBO is useful to facilitate intubation in difficult airways, guide percutaneous dilatational tracheostomy, and mucous plugs causing lobar/lung atelectasis. FBO plays a central diagnostic role in acute respiratory failure caused by intra-thoracic tumors, interstitial lung diseases, and suspected severe pneumonia. “Bronchoscopic” sampling has to be considered when “non-invasive” techniques are not diagnostic in suspected ventilator-associated pneumonia and in non-ventilated immunosuppressed patients. The combined use of either noninvasive ventilation (NIV) or High-flow nasal cannula (HFNC) with bronchoscopy is useful in different scenarios; the largest body of proven successful evidence has been found for NIV-supported diagnostic FBO in non-ventilated high risk patients to prevent and avoid intubation. The expected diagnostic/therapeutic goals of acute bronchoscopy should be balanced against the potential severe risks (i.e., cardio-pulmonary complications, bleeding, and pneumothorax). Expertise of the team is fundamental to achieve the best rate of success with the lowest rate of complications of diagnostic and therapeutic bronchoscopic procedures in acute clinical circumstances.

Foreign body aspiration

The clinical manifestations of foreign body (FB) aspiration can range from an asymptomatic presentation to a life-threatening emergency. Patients may present with acute onset cough, chest pain, breathlessness or sub-acutely with unexplained hemoptysis, non-resolving pneumonia and at times, as an incidental finding on imaging. Patients with iatrogenic FB such as an aspirated broken tooth during difficult intubation or a broken instrument are more common scenarios in the intensive care unit (ICU). Patients with post-obstructive pneumonia with or without sepsis, or variable degree of hemoptysis often require ICU level of care and bronchoscopic interventions. Rigid bronchoscopy has traditionally been the modality of choice; however, with the innovation in instrumentation and wider availability of flexible bronchoscopes, most of the FB removal is now successfully performed using flexible bronchoscopy. Proceduralists choose instruments in accordance with their training and expertise. We describe the use of most common instruments including forceps, balloon catheters, and baskets. Role of cryoprobe and LASER in FB removal is reviewed as well. In general, larger working channel bronchoscopes are preferred; however, smaller working channel bronchoscopes may be used in situations when the patients are intubated with a smaller diameter endotracheal or tracheostomy tubes. Large size FB are removed en bloc with the grasping tool, bronchoscope, and endotracheal or tracheostomy tube, requiring preparation to safely re-establish the airway. After FB removal, bronchoscopy is re-performed to identify any residual FB, assess any injury to the airway, suction post-obstructive secretions or pus, control any active bleeding and remove granulation tissue that may be obstructing the airway. Additional interventions like balloon dilatation may be required to dislodge an impacted FB or to maintain patency of bronchial lumen. If bronchoscopic methods fail, surgery may be required for retrieval of FB in symptomatic patients or to resect suppurative or necrotizing lung process. Multidisciplinary approach involving intensivists, surgeons, and anesthesiologists is the key to optimal patient outcomes.

Unusual longstanding intrabronchial foreign body masquerading as intractable bronchial asthma in an adult: Case report and literature review

Introduction and importance

Tracheo-bronchial foreign body inhalation is a very common encounter in clinical practice among pediatric patients and rarely seen among adults. When inhalation of foreign bodies occurs in adults then it tends to lodge within the right bronchial tree but in children it lodges in the central airways.

Case presentation

We present a 58 year old woman, known asthmatic for 20 years and non-smoker who presented to our clinic which history of chronic cough, wheezing and pulmonary infections that did not respond to regular antibiotics and the usual antiasthmatic medications. She reported to have inhaled a foreign body about 18 years earlier. Extraction of the foreign body was performed without complications.

Clinical discussion

A chest x-ray done was found to be normal and computerized tomography scan (CT scan) of the chest was ordered and revealed bronchial wall thickening with a calcified foreign body seen in the right intermediate bronchus.

A combined rigid and flexible endoscopic bronchoscopy was performed and a chicken bone (measuring 2 cm × 1.5 cm) was extracted from the right intermediate bronchus with very minimal bleeding being encountered during and post bronchoscopy. Extraction of the foreign body was performed without complications. Post endoscopic intrabronchial foreign body removal, the patient recovered completely.

Conclusion

An intrabronchial foreign body being masked for more than a decade by co-existent bronchial asthma is a rare encounter. Moreover, adult patients with chronic cough should be handled with caution to rule out the possibility of FB aspiration.

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FB inhalation is a very common encounter in clinical practice among pediatric patients and rarely seen among adults.

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Inhaled FBs in adults tends to lodge within the right bronchial tree and in the central airways in children.

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Adult patients with chronic cough should be handled with caution to rule out inhaled FBs.

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Co-existing bronchial asthma may mask the diagnosis of FB inhalation in unclear history of its inhalation.

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Bronchoscopy remains to be the main stay in management of inhaled FBs.

A Trip Down the Bronchus- A Tracheostomy Complication in COVID Pandemic

Foreign body of the trachea and the bronchus are critical emergencies which can lead to life threatening complications. But the advent of the 2019 novel corona virus disease, pandemic has dramatically changed the comfort of these procedures since aerosol generating medical procedures pose a risk and spread of infection to the health care workers. Even the patients are uncomfortable visiting the hospital due to the fear of acquiring the COVID infection.A 41-year-old obese female with grade 4 subglottic stenosis status post tracheostomy presented with foreign body Fuller’s tracheostomy tube flange in the right bronchus during the COVID 19 pandemic. The patient had delayed presentation to the hospital due to fear of getting exposed to COVID and poor access to health care facilities due to lockdown imposed in various places in the nation. The patient was tested for COVID and taken up for surgery where rigid bronchoscopy and foreign body removal was done via the tracheostoma. The details of the procedure, challenges faced during the procedure, the effect of the COVID pandemic on the patients and hospital staffs are discussed. The complications of the broken tracheostomy tube can be most efficiently dispelled by proper tube care by the attenders and frequent tube change.

Asymptomatic fixed partial denture aspiration: A case report

Introduction and importance

Foreign body aspiration (FBA) is more frequently presented in children and considered a rare presentation in adults. One of the most common causes of FBA in adults are orthodontic appliances.

Case presentation

We present a case of a 70-year-old male with an accidently discovered fixed partial denture (bridge) in the right mainstem bronchus. The partial denture was removed successfully by flexible bronchoscopy.

Clinical discussion

FBA is an event that most frequently occurs with children, and rarely with adults having various risk factors and complications on patients.

Conclusion

This study aims to spotlight the danger of asymptomatic FBA and how retrieving sharp objects can be managed by flexible bronchoscopy thus leading to better management and increased awareness of such cases.

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Foreign Body Aspiration (FBA) is very uncommon in adults.

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Dental procedures and appliances are considered the second most common leading cause of FBA.

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High level of physicians' susception is needed to identify FBA cases in adults is needed.

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Flexible bronchoscopy has an important role in retrieving aspirated foreign bodies.

Neglected Foreign Body Aspiration Mimicking Lung Cancer: A Case Report

Tracheobronchial aspiration is relatively rare in adults as compared to children although incidence rates tend to increase with advancing age. The diagnosis of tracheobronchial foreign body aspiration can be challenging and warrants a high index of suspicion as the symptoms are often vague and patients may fail to recall the history of choking. The failure to diagnose the condition promptly may result in serious complications such as recurrent pneumonia, hemoptysis, or atelectasis. We present the case of a 72-year-old female with multiple comorbidities who presented with acute respiratory failure, which required urgent intubation and mechanical ventilation. Eventually, she was found to have aspirated green peas and pomegranate seeds, which were successfully removed by flexible bronchoscopy, leading to a dramatic improvement in both clinical condition and radiological imaging findings.

Recurrent Respiratory Tract Infection in a 24-Year-Old Female Secondary to a Foreign Body Aspiration

Foreign body aspiration (FBA) is a common problem necessitating prompt recognition and early treatment to minimize the potentially severe and sometimes fatal consequences. We presented a 24-year-old girl who was admitted for chronic cough and recurrent pneumonia associated with constitutional symptoms. She was feverish with a temperature of 39°C and had tachycardia and tachypnoea with an oxygen saturation of 98%. Investigations revealed leukocytosis. CXR showed right lower lobe consolidation, and CT thorax demonstrated collapse consolidation of the right middle and lower lobe, along with associated dilated segmental bronchioles and diffuse patch ground-glass opacity in both lung fields. Bronchoscopy revealed a pen cap at the entrance of the right lower lobe. Patient symptoms improved after removal of the foreign body. In patients with recurrent chest infection, the physician should check for the possibility of FBA and prompt for a referral to a tertiary center for further evaluation.

Airway Foreign Body Mimicking an Endobronchial Tumor Presenting with Pneumothorax in an Adult: A Case Report

Foreign body (FB) aspiration occurs less frequently in adults than in children. Among the complications related to FB aspiration, pneumothorax is rarely reported in adults. Although the majority of FB aspiration cases can be diagnosed easily and accurately by using radiographs and bronchoscopy, some patients are misdiagnosed with endobronchial tumors. We describe a case of airway FB that mimicked an endobronchial tumor presenting with pneumothorax in an adult. A 77-year-old man was referred to our hospital due to pneumothorax and atelectasis of the right upper lobe caused by an endobronchial nodule. A chest tube was immediately inserted to decompress the pneumothorax. Chest computed tomography with contrast revealed an endobronchial nodule that was seen as contrast-enhanced. Flexible bronchoscopy was performed to biopsy the nodule. The bronchoscopy showed a yellow spherical nodule in the right upper lobar bronchus. Rat tooth forceps were used, because the lesion was too slippery to grasp with ellipsoid cup biopsy forceps. The whole nodule was extracted and was confirmed to be a FB, which was determined to be a green pea vegetable. After the procedure, the chest tube was removed, and the patient was discharged without any complications. This case highlights the importance of suspecting a FB as a cause of pneumothorax and presents the possibility of misdiagnosing an aspirated FB as an endobronchial tumor and selecting the appropriate instrument for removing an endobronchial FB.

Role of bronchoscopy and imaging in long-standing foreign body bronchus presenting as recurrent or non-resolving lower respiratory tract infection

INTRODUCTION

A long-standing retained foreign body in the bronchus is unusual. In majority of cases, an adequate history is not obtained, the clinical picture is usually clouded by superadded pathological changes.

CASE SERIES

We report three cases of long-standing foreign body in the airway who presented with recurrent lower respiratory tract infection. Examination of respiratory system revealed no significant abnormality. Chest radiograph was normal. CT scan of the chest was useful to indicate endobronchial opacity in the airway suggestive of a foreign body. The patients underwent rigid bronchoscopy under general anesthesia for successful removal of the foreign body.

CONCLUSION

So the patients with non-resolving or recurrent lower respiratory symptoms in spite of medical treatment and without any obstructive findings must undergo diagnostic bronchoscopy evaluation and imaging.

Longitudinal changes of laboratory measurements after discharged from hospital in 268 COVID-19 pneumonia patients

BACKGROUND AND OBJECTIVE

Monitoring recovery process of coronavirus disease 2019 (COVID-19) patients released from hospital is crucial for exploring residual effects of COVID-19 and beneficial for clinical care. In this study, a comprehensive analysis was carried out to clarify residual effects of COVID-19 on hospital discharged patients.

METHODS

Two hundred sixty-eight cases with laboratory measured data at hospital discharge record and five follow-up visits were retrospectively collected to carry out statistical data analysis comprehensively, which includes multiple statistical methods (e.g., chi-square, T-test and regression) used in this study.

RESULTS

Study found that 13 of 21 hematologic parameters in laboratory measured dataset and volume ratio of right lung lesions on CT images highly associated with COVID-19. Moderate patients had statistically significant lower neutrophils than mild and severe patients after hospital discharge, which is probably caused by more efforts on severe patients and slightly neglection of moderate patients. COVID-19 has residual effects on neutrophil-to-lymphocyte ratio (NLR) of patients who have hypertension or chronic obstructive pulmonary disease (COPD). After released from hospital, female showed better performance in T lymphocytes subset cells, especially T helper lymphocyte% (16% higher than male). According to this sex-based differentiation of COVID-19, male should be recommended to take clinical test more frequently to monitor recovery of immune system. Patients over 60 years old showed unstable recovery process of immune cells (e.g., CD45 + lymphocyte) within 75 days after discharge requiring longer clinical care. Additionally, right lung was vulnerable to COVID-19 and required more time to recover than left lung.

CONCLUSIONS

Criterion of hospital discharge and strategy of clinical care should be flexible in different cases due to residual effects of COVID-19, which depend on several impact factors. Revealing remaining effects of COVID-19 is an effective way to eliminate disorder of mental health caused by COVID-19 infection.

A Rare Case of a Massive Food Bolus Mimicking Lung Cancer

Tracheobronchial aspiration is a very common and serious medical condition. It can present acutely with an aspiration pneumonia, or it can be chronic and occur over a long period of time. In some instances, the diagnosis can be missed, and patients may be treated for years for other medical conditions such as asthma, with no significant improvement. We present here a very interesting case of a 69-year-old gentleman with multiple comorbidities who presented with a fever and shortness of breath. He was initially diagnosed with aspiration pneumonia, but when he did not improve, a bronchoscopy was performed, which showed a mass in the right bronchus suspicious for a carcinoid tumor. However, a biopsy was taken and sent to pathology for analysis, which showed food material. He underwent a rigid bronchoscopy for mass removal, which indeed confirmed that the whole mass was composed of food material as a result of tracheobronchial aspiration.

Extraction of airway foreign bodies with bronchoscopy under general anesthesia in adults: an analysis of 38 cases

Background

To explore the efficacy and safety of extracting airway foreign bodies with bronchoscopy under general anesthesia in adults.

Methods

Altogether, 38 adult patients who underwent airway foreign body extraction with bronchoscopy under general anesthesia in the Pneumology Department of Beijing Tiantan Hospital, Capital Medical University, from January 2005 to December 2014 were included in the study and retrospectively analyzed concerning the extraction methods and complications. The indications and experience and lessons were summarized.

Results

In 38 patients with general anesthesia who had foreign bodies removed by bronchoscopy, 1 case failed to be removed, and 37 cases were successfully removed, with a success rate of 97.4%. One of the patients failed to remove the foreign body due to massive hemorrhage during the resection of the right middle bronchial stone, and the operation was interrupted. Blood loss was analyzed in all patients, 4 patients (10.5%) lost blood greater than 10 mL, and 1 patient (2.63%) lost blood greater than 300 mL. To analyze the status of airway injury, 3 patients (7.9%) had local airway mucosal tearing, and 1 patient had mild glottis edema. All the patients in this group had silent portal injury, severe hypoxemia or asphyxia, and no complications such as pneumothorax, mediastinal emphysema or pulmonary edema occurred.

Conclusions

Extraction of airway foreign bodies with bronchoscopy under general anesthesia in adults is safe and effective and can avoid surgical treatment in some patients.

An update on the role of bronchoscopy in the diagnosis of pulmonary disease

Bronchoscopy has evolved over the past few decades and has been used by respiratory physicians to diagnose various airway and lung diseases. With the popularization of medical check-ups and growing interest in health, early diagnosis of lung diseases is essential. With the development of endobronchial ultrasound, ultrathin bronchoscopy, and electromagnetic navigational bronchoscopy, bronchoscopy has been able to widen its scope in diagnosing pulmonary diseases. In this review, we have described the brief history, role, and complications of bronchoscopy used in diagnosing pulmonary lesions, from simple flexible bronchoscopy to bronchoscopy combined with several up-to-date technologies.

Diagnosis and management of chronic cough: similarities and differences between children and adults

Cough is a natural process that protects the airway. Cough can occur spontaneously or voluntarily. It is considered chronic when it is present for longer than 4 weeks in children or 8 weeks in adults. In both, chronic cough causes patient distress and increased healthcare utilization. Etiologies of pediatric chronic cough include asthma, protracted bacterial bronchitis, tracheomalacia, habit cough, and various systemic disorders. While some diagnoses are identifiable by careful history alone, others require testing guided by specific pointers. Flexible fiberoptic bronchoscopy has been an important tool to identify etiologies of chronic cough that were not otherwise apparent. In adults, asthma and bronchitis are well-defined etiologies of chronic cough, but much chronic cough in adults is largely a conundrum.

Reviews of adult chronic cough report that at least 40% of adults with chronic cough have no medical explanation. Gastroesophageal reflux and upper airway cough syndrome (a.k.a. post-nasal drip) have been common diagnoses of chronic cough, but those diagnoses have no support from controlled clinical trials and have been subjected to multiple published critiques. Cough hypersensitivity is considered to be an explanation for chronic cough in adults who have no other confirmed diagnosis. Gabapentin, a neuromodulator, has been associated with a modest effect in adults, as has speech pathology. While habit cough has not generally been a diagnosis in adults, there is evidence for a behavioral component in adults with chronic cough. Treatment for a specific diagnosis provides a better outcome than trials of cough suppression in the absence of a specific diagnosis. More data are needed for chronic cough in adults to examine the hypothesized cough hypersensitivity and behavioral management. This article reviews etiologies and the treatment of chronic cough in children and the conundrum of diagnosing and treating chronic cough in adults.

A melting, encapsulated, calcified pulmonary nodule in a healthy 51-year-old woman: a case report

Background

Foreign body aspiration is less common in healthy adults, which makes diagnosis difficult. Early detection of smaller/sharp foreign bodies in the distal airway is more difficult because patients might have no symptoms and imaging studies could appear normal.

Here we describe the course of a small, sharp foreign body (chicken bone) lodged in the distal airway of a healthy middle-aged woman. The chicken bone was initially thought to be an old calcified tuberculoma. However, it was encased in a dilated bronchus without obvious surrounding lymphadenitis or parenchymal infiltration, and it melted with time. Two years later, histopathological examination revealed that the calcified lesion was an aspirated chicken bone with a concomitant tuberculoma.

Case presentation

A 51-year-old woman showed an old calcified tuberculoma in the upper right lung lobe during routine examinations. It was “encased” in a dilated bronchus, although it was not raised from the surrounding lung parenchyma. The size of the calcified part decreased (“melted”) with time, and the surrounding inflammation progressed 2 years later, a phenomenon never described in association with tuberculosis. Bronchoscopy revealed a fragment of chicken bone lodged in the next two branches of the upper right posterior bronchus. Surgical segmentectomy was performed, and histopathological examination revealed that the calcified lesion was formed by a fragment of chicken bone as well as a tuberculoma. Eventually, the patient recalled an episode of choking on a chicken bone 5 years ago; she believed that she had coughed it out completely at that time.

Conclusions

The “melting” and “encased” phenomena observed in the present case could be useful imaging findings for early detection of small foreign body aspiration in the distal airway.

Ear, nose, and throat foreign bodies in adults: A population-based study in Taiwan

BACKGROUND/PURPOSE

This study performed a population-based analysis in the managements of adult ear, nose, and throat FBs in Taiwan.

METHODS

The Taiwan Longitudinal Health Insurance Database 2000 were used, which comprises 1,000,000 beneficiaries randomly sampled in 2000 with a follow-up period from 2000 to 2013. Patients aged >18 years with ear, nose, or throat FB were identified according to the International Codes of Diseases.

RESULTS

In total, 94,312 adults with ear (n = 21,786), nose (n = 1007), throat (n = 62,986), airway (n = 419), or esophageal (n = 8114) FB were identified. Emergency department visits were most common among patients with esophageal or airway FB (33.3% and 25.1%, respectively). X-rays were most commonly performed for patients with esophageal FB (44.8%), and computed tomography (CT) was most commonly used for those with airway FB (4.3%). Hospitalization rate was the highest among patients with airway FB (7.4%), followed by those with esophageal (3.0%) and nose (0.7%) FB. Patients with airway FBs corresponded with the highest rate of intensive care unit stay (58.1%), longest hospital stay (10.5 days), and highest in-hospital mortality rate (25.8%). A multiple logistic regression model indicated that old age, medical comorbidities, undergoing CT, and airway or esophageal FB were associated with hospitalization among adults with FB.

CONCLUSION

Disparities were identified in the treatment of ear, nose, and throat FB in adults. This study provides population-based data that may serve as a reference for otolaryngologists in clinical FB management.

New classifications for Life-threatening foreign body airway obstruction

INTRODUCTION

Foreign body airway obstruction (FBAO) is a common medical emergency; however, few studies of life-threatening FBAO have been reported and no standard classification system is available.

METHODS

We retrospectively evaluated patients who presented to the emergency departments of two hospitals and were diagnosed with FBAO. The primary outcome was cerebral performance category (CPC) score at discharge. To establish a new classification system for FBAO, FBAO was classified into three types based on the anatomical and physiological characteristics of the obstructed airway.

RESULTS

A total of 137 patients were enrolled. Median age was 79.0 years. The most common cause of FBAO was meat, followed by bread, rice cake, and rice. Of all patients, 65.7% suffered cardiac arrest and 51.1% died. In contrast, 28.5% had favorable neurological outcomes, defined as CPC 1 and 2. Upper airway obstruction (type 1) was the most common (type 1, 78.1%), while trachea and/or bilateral main bronchus obstruction (type 2, 12.4%) showed significantly higher mortality than type 1 obstruction (82.4% vs 47.7%, P = 0.0078). Patients with unilateral bronchus and/or distal bronchus obstruction (type 3, 9.5%) were significantly more likely to consume a dysphagia diet than type 1 patients (23.1% vs 0%, P < 0.0001).

CONCLUSION

The majority of patients with life-threatening FBAO were elderly and had poor neurological outcomes. Our new classification system divides FBAO into three types, and revealed that mortality was significantly higher with type 2 than type 1 obstruction. This classification system may improve the management of patients with FBAO and assessment of patient outcomes.

Clinical features and treatment outcomes of airway foreign body aspiration in adults

Background

There are few reports comparing flexible and rigid bronchoscopy in adult foreign body (FB) aspiration. The aim of this retrospective study was to review the clinical characteristics, outcomes and factors associated with success in adult patients who underwent flexible or rigid bronchoscopy for airway FB removal.

Methods

We retrospectively reviewed the records of 103 patients who underwent bronchoscopy to remove airway FB at Samsung Medical Center, South Korea from January 1999 to March 2017.

Results

The median patient age was 64 years, and 70% were males. Among the 54 patients who underwent flexible bronchoscopy as first-line treatment, 43 (80%) patients had their FB successfully removed. Previous attempts at other hospitals was significantly associated with failed flexible bronchoscopy [9/11 (82%) vs. 3/43 (7%), P<0.001]. Delayed diagnosis (median 29 vs. 5 days, P=0.074) and peripherally located airway FB [9/12 (75%) vs. 23/48 (48%), P=0.115] were factors that trended towards flexible bronchoscopy failure. All of the 59 patients who underwent rigid bronchoscopy had their FB successfully removed. Rigid bronchoscopy was preferred to flexible bronchoscopy in patients with no comorbidities [38/59 (64%) vs. 18/44 (41%), P=0.018], previous attempts at other hospitals [34/59 (58%) vs. 4/44 (9%), P<0.001], delayed diagnosis (median 162 vs. 5 days, P<0.001), and hard FBs [48/62 (77%) vs. 21/49 (43%), P<0.001].

Conclusions

Our data suggest that previous failed attempts and delayed diagnosis are associated with flexible bronchoscopy failure. However, rigid bronchoscopy could be effective in removing an airway FB even in these cases. Further studies to identify factors to facilitate optimal patient selection will minimize failure rates and optimize resource utilization.

Repeated Synchronous Aspiration and Ingestion of a Sharp Metallic Foreign Body in a Mentally Disabled Adolescent

In a mentally disabled adolescent, bronchoscopic extraction failure of a metallic foreign body from the left main bronchus was followed by mediastinal emphysema. At thoracotomy, a part of the metallic hook was found to protrude through the main bronchus, just by the descending aorta. The foreign body was removed and the bronchus sutured. After the thoracotomy closure, laparotomy was performed with removal of metallic pieces from the stomach. After three years, a repeated metallic foreign body aspiration as confirmed by the chest radiography ensued, with metallic pieces in the bowels as well. With the surgical team on site, rigid bronchoscopy was done and the foreign body extracted from the intermediate bronchus. Metallic pieces left the digestive tract spontaneously after a few days. In conclusion, the appropriate preoperative workup and timing for surgery are essential for the treatment outcome of this life-threatening condition; because of the high likelihood of the major airway injury, such procedures should be done with a surgical team available whenever possible.

Airway obstruction due to sticky rice cake (mochi): a case series and review of the literature

BACKGROUND

Foreign body airway obstruction is a significant public health issue around the world. Mochi, a traditional sticky rice cake in Japan, has gained popularity in many countries including the USA. However, the associated aspiration danger has not yet been well recognized.

CASE PRESENTATION

We describe three cases of foreign body airway obstruction due to mochi. Case 1 was an elderly man who was brought to the emergency department by an ambulance after he choked on mochi. Despite extensive efforts to remove pieces of mochi including use of Magill forceps, bronchoscopy, and endotracheal intubation, he suffered severe hypoxia and died. Case 2 was a middle-aged man who was found unconscious in a park. The rhythm upon arrival was pulseless electrical activity. During intubation, large pieces of mochi were found in the oropharynx and removed with Magill forceps. He developed aspiration pneumonitis and hypoxic brain injury. The patient was discharged to a skilled nursing facility with severe neurological disability. Case 3 was an elderly man who choked while eating soup with mochi at home. His initial cardiac rhythm was asystole. During intubation, obvious foreign body was found in the oropharynx. Several pieces of mochi were removed by suctioning through the endotracheal tube. He suffered severe hypoxic injury and died.

CONCLUSIONS

All of our cases resulted in death or poor neurological outcome. As the popularity of mochi continues to increase, it is likely that cases of aspiration from mochi will also increase. Emergency physician should be aware of the potential danger of mochi and be familiar with the techniques to remove mochi from the airway.

Successful Removal of a Chronic Aspirated Foreign Body after Twelve Years

Chronic retention of aspirated foreign bodies is rare but can result in indolent systemic and respiratory symptoms. Bronchoscopy may show features of tissue reaction to the foreign body, including granulation tissue, endobronchial stenosis, strictures, edema, and airway distortion. The diagnosis of foreign body aspiration is often difficult to establish since some patients may not give a clear history of aspiration or may present late. In addition, patients may be misdiagnosed with chronic pneumonia, bronchitis, asthma, or malignancy. We present the case of a 42-year-old male who had a chronically retained piece of an aluminum beverage container in the left mainstem bronchus for 12 years. Careful history, radiographic evaluation, and bronchoscopic examination revealed the foreign body, which was successfully extracted by rigid bronchoscopy.

Evaluation of pulmonary reexpansion in a porcine model of bronchial foreign body

OBJECTIVES

This study was designed to establish a porcine model of reversible obstruction of endobronchial foreign body (FB) and to assess the natural pulmonary reexpansion process using radiology and histopathology after removal of the bronchial FB.

METHODS

A metal stent was placed in the right lower lobe bronchial lumen of 15 pigs by bronchoscopy and removed after 2 weeks of stent retention. Animals were divided into two groups (group I and II), based on when they were sacrificed (week 2 or week 4) after stent removal. Pigs underwent computerized tomography scan to document pulmonary radiological changes. The lungs were harvested for electron microscopy examination, and the expression of pulmonary surfactant-associated protein A (SPA) was determined by immunohistochemistry.

RESULTS

Thirteen (86.7%) animals successfully responded to the intervention. Atelectasis was formed by stent implantation within 2 weeks. The ratio of the residual atelectasis area was smaller in group II compared to that in group I (P < 0.01). The histological manifestations of experimental lungs were significantly improved in group II. Moreover, the expression of SPA in group II was higher compared to that in group I (P < 0.01).

CONCLUSIONS

We have established a model of reversible bronchial FB obstruction in pigs that is both feasible and appropriate for evaluating the long-term process of pulmonary reexpansion after removal of FB. Bronchial metal FB retention for a period of 2 weeks could form atelectasis, and a natural pulmonary recovery process related to atelectasis takes approximately 4 weeks after removal of metal FB.

Asthma mimic: Case report and literature review of vocal cord nodule associated with wheezing

Asthma is a heterogeneous disease, usually characterized by chronic airway inflammation. Various clinical conditions can mimic asthma, such as foreign body aspiration, subglottic stenosis, congestive heart failure, diffuse panbronchiolitis, aortic arch anomalies, reactive airway dysfunction syndrome, chronic obstructive pulmonary disease, retrosternal goiter, vocal cord tumors, other airway tumors, and vocal cord dysfunction. Upper airway obstruction can be a life-threatening emergency. Here, we present the case of a 58-year-old female with recurrent hospital visits for wheezing and exacerbations of asthma, who was later found to have a vocal cord nodule confirmed to be squamous cell carcinoma, which was mimicking like asthma.

Foreign body aspiration in adult airways: therapeutic approach

Tracheobronchial foreign body (FB) aspiration is an uncommon but potentially life-threatening event in adults. Symptoms typically consist of a choking event followed by cough and dyspnea, however, these findings are inconsistent and symptoms may mimic more chronic lung diseases such as asthma or chronic obstructive pulmonary disease. Chest radiography and computed tomography can provide information regarding the location and characteristics of foreign bodies and aid in diagnosis. Bronchoscopy remains the gold standard for diagnosis and management of FB aspiration. The authors describe the typical clinical presentation, diagnostic evaluation, and bronchoscopic management of foreign bodies in adult airways with a focus on bronchoscopic techniques and potential complications of FB extraction.

Retrieval of tracheobronchial foreign bodies by short flexible endoscopy in children

OBJECTIVES

Flexible endoscopy (FE) is frequently used to diagnose tracheobronchial foreign bodies (TBFB). However, it is still controversial for retrieval of TBFB in pediatric field. This study aims at reporting and evaluating our experiences of using short-length FE with a non-invasive ventilation (NIV) technique and intensive care unit (ICU) support in retrieving pediatric TBFB.

METHODS

A retrospective review of the hospital database and FE videos of pediatric patients aged less than 18 year-old who were diagnosed of TBFB and managed in our hospital over a 17-year period (1999-2015). The demographic data were collected and analyzed. A NIV technique of providing nasopharyngeal oxygen with intermittent nose closure and abdominal compression was routinely performed in procedural sedated patients throughout the whole FE procedures.

RESULTS

Sixty-six consecutive patients with 76 TBFB were enrolled. Among them, 72 (94.7%) TBFB in 64 patients were successfully retrieved at the first attempt of FE immediately after the diagnosis was made. There were 13 iatrogenic TBFB in patients who already had coexisting airway problems. The median age was 16 months (range 1.5 months-17 years) and the median body weight was 10.5 kg (range 3.5-48.5 kg). Seventy (70/72, 97.2%) TBFB were retrieved by short-length FE and among them, 55 procedures (55/72, 76.4%) used FE with no working channel. No significant acute or late adverse effects were noted. The mean retrieval procedural time was 23.6 ± 15.1 min.

CONCLUSION

Using short-length FE with this NIV technique, appropriate sedation and ICU support is a safe, simple and effective modality for the retrieval of TBFB immediately after confirming the diagnosis in pediatric patients.

An unusual case of chronic cough: Professional liability in dentistry?

Foreign body aspiration (FBA) is a serious medical problem, also in dental practice. The case report describes the case of a patient who for 12 years has suffered from chronic cough as a result of the aspiration of a polymeric silicone resin fragment during a dental procedure. In November 2002, the patient was underwent dental care, and she points out that, when performing dental imprint, she had sensed that something “went down in the throat” but she was immediately reassured by the dentist. After lung CT was performed, the foreign body was identified and removed with benefit to the patient. The knowledge of this case report could be useful for dentists who perform dental impressions, to be aware of the fact that the material used is radiolucent e.g. cannot be seen on plan radiographs and it can be accidentally inhaled by the patient. The knowledge of the case is also important for doctors who come in contact with patients who previously underwent dental treatment, suffering from persistent cough, in the absence of positive radiological signs.

The anesthesia of trachea and bronchus surgery

The trachea and bronchus surgery is generally performed due to stenosis, traumatic injury, foreign body and tumors. Preoperative evaluation and anesthesia management are very important issues because of higher mortality and morbidity rates. Patients may be asymptomatic, but airway difficulties, hypoxia, stridor, cough, hemoptysis are common conditions in these patient population. The collaboration between the surgeon and the anesthesiologist is very substantial and necessary. Anesthetic techniques include various applications such as one lung ventilation, fiberoptic intubation, jet ventilation, and apneic oxygenation, general anesthesia with or without neuromuscular blockade. In this review, anesthesia management of the trachea and bronchus surgery is evaluated in the light of new knowledge.

Update in the extraction of airway foreign bodies in adults

Foreign body (FB) aspiration into the airway is lees common in adults than children. Nevertheless its incidence does not decrease through time. We present clinical relevant aspects of airway FBs on the basis of a selective review of pertinent literature retrieved by a search in the PubMed database. The most common aspirated FBs by adults are organics, especially fragments of bones and seeds. Symptoms usually are cough, chocking and dyspnea. Right localization, especially bronchus intermedius and right lower lobe, is more frequent. Chest radiography can be normal in up to 20% of the cases and FBs can be detected in 26% of the patients. FBs can safely remove in the majority of patients under flexible bronchoscopy. Surgical treatment must be reserved for cases in which bronchoscope fails or there are irreversible bronchial or lung complications.

Use of cryoprobe for removal of a large tracheobronchial foreign body during flexible bronchoscopy

Foreign body (FB) inhalation in the tracheobronchial tree is an infrequently encountered event in adults. The diagnosis is suspected in the presence of a clinical history of aspiration and the presence of respiratory symptoms. Management involves confirmation by flexible bronchoscopy, which may be both diagnostic as well as therapeutic. However, in certain situations including those with large FB, FB embedded in granulation tissue or FB with very smooth margins, rigid bronchoscopy may be superior to flexible bronchoscopy in the retrieval of the FB. An alternative to rigid bronchoscopy in such situations may be the use of a cryoprobe. Herein, we describe a patient with a large tracheobronchial FB causing a complete collapse of the left lung and hypoxemia. The FB was successfully extracted using a cryoprobe during flexible bronchoscopy, obviating the need for rigid bronchoscopy.

Foreign Bodies in Trachea: A 25-years of Experience

OBJECTIVE

Tracheobronchial foreign body aspirations may cause cardiopulmonary arrest and sudden death. The incidence in children is higher than in adults. Rapid diagnosis and treatment is live saving. In this paper, we aimed to present our experience in tracheal foreign body aspirations and rigid bronchoscopy for 25-years.

MATERIALS AND METHODS

From January 1990 to January 2015, 805 patients with suspected tracheobronchial foreign body aspiration were admitted to our department. Hundred and twelve patients with tracheal foreign body were included in this study. We evaluated patients' records, retrospectively. Age, gender, clinical symptoms, physical examination findings, radiological evidences, type of foreign body and intervention types were noted.

RESULTS

Sixty-five of the patients were female (58%) and 47 patients were male (42%), and mean age was 8.1 years (8 month-58 years). Coughing was the main symptom (n=112, 100%). Other symptoms and findings included dyspnoea and bilateral decreased lung sounds (n=73, 65.1%), bilateral rhonchi (n=68, 60.7%) and cyanosis (n=41, 36.6%). Rigid bronchoscopy was performed in all patients. The most common foreign body was nuts (n=75, 67%). The main radiologic finding was radiopaque image of the related foreign body in 27 patients (n=27, 24.1%). Cardio-pulmonary arrest occurred in 11 patients and two of them died.

CONCLUSION

Tracheobronchial aspirations of foreign bodies are life-threatening events. If not diagnosed and treated rapidly, distressful results can be seen. Warning people by skilled persons on this topic will reduce the incidence of foreign body aspirations.

Diagnose of occult bronchial foreign body: A rare case report of undetected Chinese medicine aspiration for 10 long years

BACKGROUND

Occult bronchial foreign body can be very difficult to diagnose early in an adult patient without acute symptoms. This report describes a rare case of undetected Chinese medicine "Coptis chinensis" aspiration for 10 long years.

METHODS

A case was reported that a female patient complained of a 10-year history of productive cough. A battery of tests were given to confirm the diagnosis.

RESULTS

Chest computed tomography (CT) showed extensive bronchiectasis and multiple nodules, along with stenosis of left lower lobar bronchus. An extensive solid lesion with surrounding inflammatory granulation tissue was seen on her first bronchoscopy and biopsy revealed chronic mucosal inflammation. A neglected history of Coptis chinensis regularly kept in-mouth while sleeping for the last 10 years in this patient provided clues for a final diagnosis. Confirmatory diagnosis of bilateral tracheobronchial foreign bodies caused by recurrent inhalation of Coptis chinensis was made by a second bronchoscopy.

CONCLUSIONS

This case clearly demonstrates that a precise medical history is often overlooked. A high index of suspicion, a precise medical history, radiographic features of chronic respiratory symptoms not explained by other conditions were keys to diagnosing this case.

41 years into the bronchial tree: a very obstructive cap

Inhaled foreign body, which remains unknown from the childhood until the mid-age is extremely rare. We report the case of a 58-year-old man who was addressed to our department to remove a pen cap, inhaled forty-one years earlier. It was discovered during a routine pre-op check-up for bronchiectasis, caused by the long period of retention into the bronchial tree. The successful removal of the cap changed completely the therapeutic strategy, as there was no indication for surgical resection any more.

Endoscopic intervention of lower airway foreign matter in adults-a different perspective

BACKGROUND

Lower airway foreign matter (FM) is uncommonly encountered in adults. This study reviews FM in the lower airway that required bronchoscopic intervention.

METHODS

A retrospective review of patients with FM in the lower airway seen at a tertiary hospital between 1996 and 2014 was undertaken.

RESULTS

Lower airway FM was removed in 80 out of 18,650 bronchoscopies performed. Forty-seven were males, with mean age of 50.8 (range, 29-78) years and mean symptom duration of 10.3 months (range, 1 day -20 years). The most common symptoms were persistent cough, followed by dyspnea, hemoptysis, episodes of choking and fever. Three-quarters of the patients had risk factors of either aspiration or iatrogenic cause for FM in the airway. FM identified following bronchoscopy was classified as: organic (31.3%), inorganic (46.3%) and endogenous matter (22.4%). Iatrogenic etiology was evident in four-fifths of the patients with inorganic FM (stents being the most common). Forty-eight (60.0%) patients had FM removed via flexible bronchoscopy, and the remainder via rigid bronchoscopy. The majority (27 out of 32) of FM removed by rigid bronchoscopy could not be removed using the flexible scope. This was primarily due to retrieval of stents [24] could only be done with the rigid bronchoscope. There were four FM-related complications (three bronchostenosis, one actinomycosis).

CONCLUSIONS

There is an increasing indication for bronchoscopists to retrieve FM, particularly of iatrogenic and endogenous sources, lodging in the lower airway of adults. There may be a reversing trend in the utilization of rigid bronchoscopy, mainly due to the increasing need to remove airway stents as more are deployed.

Rare Cause of Recurrent Pneumonia in the Left Lower Lobe

A 52-year-old male patient was hospitalized in our department with the diagnosis of recurrent pneumonia in the left lower lobe. The patient reported possible aspiration of plastic material about 10 years ago, although repeated bronchoscopies in an external hospital had not revealed any foreign body. A multiply folded 8-cm filing strip for a ring folder was detected and successfully removed together with granulation tissue by means of rigid bronchoscopy.