Removal of aspirated tracheobronchial foreign bodies by bronchoscopy can be difficult, and the technique may differ depending on whether the patient is an adult or a child. The medical literature provides inadequate comparative data on differences in the symptoms and management of tracheobronchial foreign bodies in children and adults. Baharloo and colleagues performed a retrospective study of their institution's 20-year experience in removal of aspirated foreign bodies.
A total of 112 patients (121 endoscopic procedures) underwent removal of an aspirated foreign body at the 900-bed hospital from 1976 to 1996. The authors arbitrarily divided the patients into two groups: those eight years of age or younger (84 patients; mean age: 2.6 years) and those over eight years of age (28 patients; mean age: 48 years). The overall group ranged in age from two months to 90 years.
The peak incidence of foreign body aspiration occurred in children who were a year old. They accounted for 48 percent of all of the cases. Aspiration of a foreign body was rare after the age of three. Among the adults, the peak incidence occurred in the sixth decade of life.
The most common presentation was the “penetration syndrome,” defined as the sudden onset of choking and cough, with or without vomiting. This was the manner of presentation in 48 (49 percent) of the patients. Other symptoms included cough in 36 patients (37 percent), fever in 30 patients (31 percent), breathlessness in 25 patients (26 percent) and wheezing in 25 patients (26 percent). Eight patients presented with cyanosis. Two patients did not have symptoms. The two asymptomatic patients included a nine-year-old boy who aspirated a needle, which was seen on plain radiographs, and a 59-year-old man with persistent atelectasis who had unknowingly aspirated a peanut. There was no difference in symptoms between the two age groups.
The aspirated foreign body was an organic object, most commonly a peanut, in 72 (91 percent) of the children who were eight years of age or younger and in 16 (59 percent) of the patients over age eight.
Air trapping was the most common radiographic feature in the group eight years of age or younger, whereas atelectasis was the most common feature in the group over eight years of age. Air trapping was visualized in 49 (64 percent) of the patients in the child group. In contrast, this feature occurred in three (17 percent) of the patients in the group over eight years of age. Atelectasis was present in nine (50 percent) of the adult group but in only 11 (14 percent) of the child group. Radiographic findings were normal in 10 percent of the patients. (Chest radiographs were not available in seven patients in the child group and 10 patients in the adult group.)
In the group eight years of age or younger, 42 (52.5 percent) of the foreign bodies were located in the right bronchial tree and 38 (47.5 percent) were in the left bronchial tree. In the adult group, 20 (69 percent) of the foreign bodies were in the right bronchial tree and nine (31 percent) were in the left bronchial tree.
The overall delay in diagnosis ranged from three hours to 11 months. The mean delay in the adult group was 40.3 days, compared with a mean delay of 9.5 days in the child group.
The aspirated foreign body was removed by rigid bronchoscopy under general anesthesia in 103 (92 percent) of the 112 patients. The remaining nine patients underwent flexible bronchoscopy under local anesthesia. There were no immediate or late complications. However, nine patients required a repeat procedure because of incomplete removal of the foreign body.
Physicians who were most experienced at removal of aspirated foreign bodies were more successful in removing the objects on the first attempt. The two most experienced pulmonologists performed 85 of the 121 procedures, and repeat bronchoscopy was required in only three instances. Seven other pulmonologists performed the remaining 27 procedures; repeat bronchoscopy because of persistent symptoms and incomplete removal was required in six of the 27 procedures.
The authors conclude that symptoms of an aspirated foreign body are not different in adults and children. The most frequent symptoms are the sudden onset of choking and intractable cough, with or without vomiting (the penetration syndrome). Although conventional wisdom is that foreign bodies preferentially lodge in the right bronchus, this was true only in the older patients. Because 10 percent of the chest radiographs were normal in this series of patients, the authors believe that normal radiographic findings should not be relied on to exclude the possibility of an aspirated foreign body. The findings also indicate that foreign body removal requires a significant degree of skill, suggesting that consideration be given to referring patients to a center where physicians are experienced in the removal of aspirated foreign bodies.