Asian Cardiovasc Thorac Ann 1999;7:305-308
© 1999 Asia Publishing EXchange Pte Ltd
Lung Infections Due to Aspirated Foreign Bodies: Analysis of 84 Cases
Cemal Kahraman, MD,
Fahri O
uzkaya, MD,
Yiit Akçali, MD,
Atalay Sahin, MD
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Department of Thoracic & Cardiovascular Surgery Medical Faculty, Erciyes University Kayseri, Turkey
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For reprint information contact: Cemal Kahraman, MD Tel: 90 352 231 0551 Fax: 90 352 437 5288 Mustafa Kemal Pas a Bulvari, Nato Cad. No. 23 Hakan Sitesi, Kayseri 38010, Turkey.
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Abstract
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Tracheobronchial foreign body aspiration is a significant cause of morbidity and mortality in the pediatric population because of serious early and late complications. In our department, 84 patients with pneumonia (75), bronchiectasis (7), or lung abscess (2) due to aspirated foreign bodies were managed between 1978 and 1997. Neither the patients nor their parents reported aspiration of an object. Foreign bodies were verified during diagnostic bronchoscopies. One patient with an abscess and 74 of the patients with pneumonia were managed by medical therapy after removal of the foreign body. All patients with bronchiectasis underwent surgical treatment with lobectomy (6) or segmentectomy (1). The patients were discharged from hospital after a mean of 10 days. The mortality was 2.4% (2 patients). An aspirated foreign body should be suspected in cases of persistent or recurrent lung infection in the same location and bronchoscopy should be performed for diagnosis and management.
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Introduction
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Persistent pulmonary infection in the pediatric population requires further investigation and research. Foreign body aspiration has recently occurred with increasing frequency in our country and indications in the acute phase have often gone unrecognized by parents and others responsible for childcare. Since there may not always be a history of aspiration and the signs and symptoms are nonspecific, diagnosis may be delayed.1 Such patients report to hospital with late complications of foreign body aspiration including unresolved pulmonary infection, pulmonary abscess, or bronchiectasis.2 For this reason, foreign body aspiration should be primarily considered and broncho-scopic evaluation should be carried out in the differential diagnosis of persistent or recurrent pulmonary infection in the same location, particularly in the pediatric age group.
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Patients and Methods
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Bronchoscopic assessments and surgical interventions for unresolved pulmonary infection, bronchiectasis, and pulmonary abscess due to bronchial foreign bodies were studied retrospectively. There were 84 such patients treated in our department between May 1978 and May 1997, comprising 55 boys and 29 girls with ages ranging from 3 months to 16 years (mean, 3.64 years).
Plain chest radiographs were obtained after anamnesis and physical examination. Computed tomography was used to determine the presence of bronchiectasis in the late period after foreign body aspiration. Patients with persistent or recurrent pulmonary infection and bronchiectasis underwent diagnostic bronchoscopy, whereas those with pulmonary abscess underwent diagnostic and therapeutic bronchoscopy. All broncho-scopic procedures were carried out under general anesthesia with a rigid open-tube bronchoscope appro-priate for the age of the patient. Foreign bodies observed in the bronchial system were removed with the aid of appropriate forceps or a Fogarty balloon catheter. Specimens for microbiologic culture were taken during bronchoscopy in all cases. Prophylactic antibiotics were administered for 1 to 3 days in patients who had inhaled vegetable material. When a specific microorganism was identified in the bronchial lavage at the time of bronchos-copy, treatment with appropriate antibiotics was continued. Surgical resection was employed in all cases of bronchiec-tasis. Patients were discharged from the hospital after an average of 10 days.
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Results
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Coughing and dyspnea were observed in all cases, wheezing and stridor were striking in 34 patients (Table 1
). There were rhonchi and crepitations in 63 cases (75%). Infection was found to be due to tracheobronchial foreign body aspiration in 75 cases (89%); 17 of these (23%) had persistent pulmonary infection and 58 (77%) had recurrent pulmonary infection in the same location (Table 2). Total or partial atelectasis was observed in 14 (17%) patients (Figure 1).
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Figure 1. Posteroanterior chest radiograph of a patient with total atelectasia as a result of a foreign body located in the left main bronchus.
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All but one of the foreign bodies were removed bronchoscopically. In 54 cases (64%), foreign bodies were observed in the right bronchial system and in 30 cases (36%) they were on the left side. One of the foreign bodies was located in the left main bronchus and all others were in the more distal bronchial system. During endoscopy, foreign bodies in the bronchus were observed to be covered with granulation tissue.
Sunflower seeds were the most frequently aspirated foreign bodies (Table 3). Foreign bodies of organic origin (foodstuffs) had to be removed piece by piece because of expansion as a result of their long stay in the bronchial system. Pieces of plastic were extracted easily with forceps. A Fogarty balloon catheter was used in only one case where it was necessary for removal of an aspirated bead of a rosary. Repeat bronchoscopy was required in 21 cases (25%). Subglottic edema in 3 cases and temporary hoarseness in one occurred after bronchoscopy.
Surgical resection was performed in all patients with bronchiectasis (Table 4). During bronchoscopic examina-tion, bronchiectasis was observed to be due to a foreign body that was removed endoscopically in 6 cases. In 1 patient, wild barley in the main bronchus of the right lower lobe was removed surgically (Figures 2A and 2B).
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Figure 2. (A) Posteroanterior chest radiograph showing infiltrative appearance of the right lower lobe associated with aspiration of wild barley. (B) Bronchiectasic appearance of the right lower lobe in the thoracic computed tomography scan of this patient.
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Radiological examinations of the pulmonary abscesses showed that they were located in the right lower lobe in 1 patient and in the left lower lobe in the other. The abscesses were approximately 5 x 5 cm and 4 x 6 cm in diameter. Bronchoscopic studies in these patients showed that the abscesses had developed secondary to foreign body aspiration. Medical treatment was successful in one case of abscess. In the other case, a massive amount of purulent fluid filled the whole bronchial system after extraction of foreign material during bronchoscopy; despite the aspiration of purulent fluid and all resuscitative efforts, this patient died as a result of respiratory failure. One other patient with pulmonary infection died from sepsis (mortality, 2.4%).
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Discussion
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Tracheobronchial foreign body aspiration is one of the leading causes of morbidity and mortality in the pediatric population.3 Admission to hospital frequently occurs within the first 24 hours.1,4 Secondary complications such as pneumonia, bronchiectasis, pulmonary abscess, and atelectasis occur in 13% to 15% of cases.1 Severe clinical conditions such as asphyxia and respiratory insufficiency may be observed immediately after aspiration. Therefore, the majority of deaths associated with foreign body aspiration occur before the object can be removed. Most of the victims are boys who have a higher risk of foreign body aspiration.3,4 Diagnosis is difficult in those who report later than one week unless parents mention a history of foreign body aspiration. Most of such cases are treated for pathologies developing secondary to aspiration.1,5,6
It is known that children, especially those in the 0 to 3 years age group, tend to take to their mouths any object they can handle.1,4 In most of the pediatric cases, parents or baby-sitters have not observed the moment of aspiration and are unaware of the situation. Furthermore, the majority of aspirated foreign bodies cannot be seen on radiographs as they are not radiopaque.1 Therefore, bronchoscopic examination is essential when pulmonary infection is persistent or recurrent in the same location. Attempts to remove distal foreign bodies may at times result in failure of retrieval or detection.3 In such cases, fluoroscopic evaluation during bronchoscopy may be necessary to ensure that the object is removed.3
Symptoms may vary depending on the location and characteristics of the foreign body. While coughing, wheezing, stridor, asphyxia, lifethreatening dyspnea, laryngeal edema, hemoptysis, and intercostal and subxiphoid retractions are striking in the acute period, signs and symptoms of pulmonary infection are observed in the late period. The presence of such signs and symptoms together with the anamnesis is an indication for bronchoscopic intervention.1–4
Rigid or flexible bronchoscopes are used for the removal of an aspirated object.7–9 Rigid open-tube bronchoscopes are more appropriate than flexible bronchoscopes for pediatric cases and they were employed in all of the cases in this series. The open-tube bronchoscope affords a favorable passage of air during application and the only drawback is an intrinsic difficulty in removing bodies located in the distal bronchioles.2,10 Advances in bronchoscopic techniques and increased experience of the staff improved the success, safety, and ease of removal of aspirated foreign bodies during the period of this study.
Most children with persistent pulmonary infection due to aspiration of a foreign body are in the age range of 1.5 to 2 years.1,2,5 The aspirated objects most frequently reported are sunflower seeds and pumpkin seeds.1,2,7 Produced and consumed abundantly in our region, sunflower seeds were the most frequently aspirated material in our patients (49%). In bronchoscopic studies, it was observed that aspirated organic material was covered with granular tissue that might suggest other etiologic factors since the foreign material cannot be seen clearly. When the radiological picture seems normal, the foreign body may remain in the bronchus for a long time without any complications.10 On the other hand, metallic objects can be easily diagnosed radiologically.
Tracheobronchial foreign body aspiration may cause chronic pulmonary infection, atelectasia, acute respiratory failure, and death. Coughing, wheezing, and suffocation have been reported in 95% of patients.3 Development of bronchial necrosis was noted in the late period following aspiration of an iron tablet.5 Bronchial inflammation with large areas of necrosis involving the bronchial wall as well as massive hemoptysis resulting from damage to the pulmonary artery and vein have been observed in some cases wherein pulmonary resection is essential if fatal complications are to be averted.5 Aspiration of lipid has been implicated in chronic cough and late detection of bronchiectasis requiring surgical resection.6 Previously, we reported a case of lipoid pneumonia with cavity formation, which was treated surgically.11 We are not aware of any previous study on persistent or recurrent pulmonary infection secondary to foreign body aspiration.
Repeated bronchoscopic interventions may be necessary in some cases of foreign body aspiration and thoracotomy is required in approximately 1%.3,7,10 Thoracotomy was required in only 1.27% in our series of 948 cases of foreign body aspiration in the last decade.12 On the other hand, the incidence of surgical intervention for persistent pulmonary infection caused by aspirated foreign bodies was 8%.
We recommend that foreign body aspiration should be considered in the differential diagnosis of pulmonary infection in pediatric patients when the infection is persistent or recurrent in the same location. In the absence of radiological detection, bronchoscopy is indicated at an early stage to avoid unnecessary surgical intervention.
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References
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Abstract
Introduction
