Tracheo- bronchial foreign bodies presentation, diagnosis management at tertiary care center

Introduction: The aim of this work was to study the clinical presentation of tracheo-bronchial foreign body aspiration in children for early diagnosis and prompt treatment. This article attempts to address the potential hazards of foreign body aspiration in children and its subsequent management. Materials and Methods: This is a prospective study of 63 cases in age group of 1 to 8 years that underwent Rigid Bronchoscopy for suspected tracheo-bronchial FB over a period of three years in the ENT Dept. of Venkateshwara Institute of Medical sciences. Cases presented in ENT OPD or referred from emergency/department of paediatrics, with history/ suspicion of foreign body aspiration, with sudden breathlessness, sudden onset of cough with or without cyanosis/ pyrexia were included in the study. Results: In our study, mean age of patients presenting with foreign body aspiration is 2.4 years. Males (57.1%) presented with foreign body aspiration more frequently as compared to females (42.9%). In 62% cases, there was definite history of foreign body ingestion observed by parents or relatives. Maximum no. of patients presented with sudden onset of cough 38%, followed by sudden onset difficulty in (17.4%), noisy breathing (14.2%), hoarseness of voice(11.2%), vomiting and retching (11.2%), 7.9% patients presented with drooling of saliva(7.9%). In our study majority of FB in air passage were in left main bronchus 54% followed by right main bronchus 36.5% and 6.3% in carina. Conclusion: Tracheo-bronchial foreign body aspiration is common in children. Foreign body aspiration may present as unwitnessed episode and a high index of suspicion, even in absence of a positive history, it is necessary to prevent morbidity and mortality due to delayed or misdiagnosis. Foreign body aspiration is an emergency and should be removed by rigid bronchoscopy at the earliest to prevent fatal complications.


Introduction
Tracheobronchial foreign body aspiration (TFBA) is a common clinical emergency, with symptoms including hoarseness, cough and dyspnea, more likely to appear in children and possibly associated with immature teeth and uncoordinated swallowing. [1][2][3][4] The anatomical structure of the right main bronchi makes foreign bodies more likely to be incarcerated. 5,6 Right bronchus is straighter and broader than the left bronchus, facilitating the deposit of foreign body on right side. 7,8 Patients with mild symptoms may delay hospital visits for longer periods of time, leading to more severe complications.
The most commonly inhaled foreign bodies include food, coins, dentures, metallic objects, plant seed, animal bone, mineral, and chemical compounds. Generally, free fatty acids of plant seed cause substantial irritation to the airway, leading to mucosal congestion, swelling and secretion, making the surgical procedure more intricate. 9,10 The symptomatic triad of choking, coughing and unilateral wheeze is present is most cases. Acute respiratory distress is fortunately uncommon but most alarming presentation of inhaled foreign body. 11,12 Long standing airway foreign body can result in spectrum of symptoms ranging from cough and wheeze to recurrent or nonresolving respiratory sequelae. The symptoms mimic other respiratory conditions like asthma, pneumonia or tracheobronchitis. 13 The diagnosis of tracheo-broncial foreign body requires high index of suspicion. Even in absence of a positive history early therapeutic intervention is required to prevent morbidity and mortality due to delayed or missed diagnosis.
Diagnosis of such airway foreign body (FB) is facilitated by a new imaging modality -Virtual bronchoscopy. Virtual bronchoscopy (VB) is software based, three-dimensional visualization formats created from noninvasive medical imaging methods such as CT & magnetic resonance imaging, with the goal of creating views similar to minimally invasive bronchoscopy procedure. This technique offers a detailed view of the airways, with reduced risk of infection or perforation and facilitates preoperative planning for airway interventions that would otherwise not be possible. 14 In presence of a positive clinical diagnosis & inconclusive chest radiography, CT virtual bronchoscopy must be considered to avoid rigid bronchoscopy. Virtual bronchoscopy simulates an endoscopic view of the internal surface of the airway. It gives excellent results regarding location, severity and shape of airway narrowing.
So, any person with history suggestive or suspicious of foreign body aspiration or with clinical or radiographic evidence of tracheo-bronchial foreign body is considered an emergency and should be treated immediately.
Rigid bronchoscopy under general anaesthesia is gold standard treatment for tracheobronchial foreign body. Rigid bronchoscopy should be considered the definitive diagnostic and therapeutic intervention in all cases where history and clinical examination is suggestive or suspicious of airway foreign body.
This study was undertaken to determine the proportion of FBs among all paediatric cases seen in the ENT clinic at our hospital, their clinical characteristics and demographic factors associated with this condition.

Materials and Methods
The study involves 63 cases in age group of 1 to 8 years that presented with suspicion of tracheobronchial FB over a period of three years in the ENT department.

Technique Diagnosis
1. Inspiratory and expiratory decubitus films of the chest X-Ray may be helpful in establishing the diagnosis of FBA. More than 50% of patients with early diagnosis (<24 hours) had normal chest Xrays. In Post-24hr period, the common radiographic finding in lower airway aspiration is air trapping. This occurs owing to the Ball valve mechanism, wherein, negative intra-thoracic pressure on inspiration causes dilatation of lumen around foreign body while positive pressure on expiration causes obstruction of lumen and resultant air trapping 2. An early finding on radiographs is a hyper inflated lung contralateral to the obstructed airway. Obstructive emphysema (45%), a contralateral mediastinal shift (35%), atelectasis, consolidation are late findings on radiographs of the affected airway. 3. Computed tomography of the chest may have some additional benefit in acute aspirations, i.e. it can help define radiolucent foreign bodies such as plant seed. CT scan provides useful information (such as the location and size of the foreign object, parenchymal lung changes, and the degree of granulation tissue formation) before attempted extraction.

Method
1. Bronchoscopy is performed under general anesthesia in the operation theatre, with inhalational induction agent Halothane. Skilled pediatric anesthesia is vital and close cooperation between anesthetist and bronchoscopist is essential to ensure the alveolar ventilation is maintained throughout the procedure. 2. The use of ketamine, a short-acting dissociative anesthetic and analgesic, may be useful in this examination. Although the agent produces a dissociative state, the patient maintains respiratory and airway reflexes, while reducing bronchospasm. The drug is short acting, with an action duration of 15-30 minutes. The dose is 1-2 mg/kg IV. This in combination with Fentanyl (1-2 mg/kg), Glycopyrolate (0.004-0.008mg/kg) and Midazolam (0.04-0.06mg/kg) gives reliable anaesthesia.

Rigid bronchoscopy is a valuable tool in
tracheobronchial foreign body removal. The optical forceps are integrated with telescope which can be passed through the most rigid ventilating bronchoscopes. Preferred bronchoscope with a rod-lens telescope is Doesel-Huzly bronchoscope (Karl Storz). Age appropriate size of bronchoscope minimizes laryngeal edema.

Results
A total of 63 cases were reviewed within the age range from 1 to 8yr. The observations pertaining to commonest age of presentation, sexual predominance , most common symptoms and signs of presentation, frequently presenting chest radiograph findings, correlation between history, chest radiography and CT bronchogram findings with the Rigid Bronchoscopy findings, most common foreign bodies removed and their commonest location in the tracheo-bronchial tree are summarized below:- The mean age of patients presenting with foreign body aspiration at our set up is 2.4 yrs.  In 62% cases, there was definite history of foreign body ingestion observed by parents or relatives.       In 47 cases out of 63, history given by parents/guardians of patients matched with Rigid Bronchoscopy findings. This is proved by using the independent t test (for quantitative data within two groups) level of significance was set at P=0.5. On comparing the correlation between the Chest radiogram and Rigid Bronchoscopy findings, we found that out of 63 cases, total 40 cases showed relevance between the two and P value is less than 0.5 CT Bronchogram was found to be more reliable as compared to Chest Radiogram as it has 100% sensitivity.

Discussion
FB aspiration in tracheobronchial tree is one of the emergency problems met in otorhinolaryngology practice and the victims are mainly children. The common age group for tracheobronchial foreign body aspiration is between 1 and 8 years with a male predominance. Incidence of FB is less among older children & adults. Our findings are in similarity to those of François M et al who also in their studies found 71% children less than 3 years of age. 15 In study of Hollinger L.D, male to female ratio was 2:1.6. 16 In our country, a substantial number of babies must be succumbing to this problem before appropriate health care can be arranged. It is important for the treating physician to suspect FB if there is sudden onset of respiratory symptoms or there is history of choking. Ezer SS et al found a positive correlation between presence of wheezing and FB, presence of symptomatic triad of cough, wheezing & diminished breath sound aided in diagnosis of airway FB in 88%. 17 In our study, sudden onset of cough was the most common symptom (38%). Difficulty in breathing was second most common symptom followed by vomiting and retching and drooling of saliva. Hollinger LD stated that varied symptomatology of tracheobronchial FB depends on its character, size, shape, site of FB age of host & relative area of lung involvement are other factors giving rise to symptoms. 16 Our findings are consistent with those of Amir Kugelman et al who also in their study stated that choking and acute cough are the most common presenting symptoms of FBA. 18 According to Burton EM et al cough and wheezing were the most common symptoms. 19 In our study, majority of FB in air passage were in left main bronchus 54% followed by right main bronchus 36.5% & 6.3% in carina. Our findings are in accordance with Cataneo AJ, who in their studies of 74 patients suffering FBA, reported that the foreign body was lodged in the left bronchus in 50% of the patients, in the right bronchus in 35% and in the trachea in 15%. 20 Chest radiography is the preferred initial investigation in cases of tracheobronchial FB aspiration. So, a negative chest radiograph does not rule out FB in airway. Wolach B et al observed that clinical signs and radiological studies, in most children, were pathognomonic, but sometimes not conclusive. 21 In our study Chest X-ray finding shows that 52.3% cases of Ipsilateral emphysema were most common pathological finding in patients with FB aspiration. However, because diagnosis was not confirmatory by radiograph further evaluation was done by CT bronchogram. In our study, all the tracheobronchial FBs were successfully removed by bronchoscopy under general anaesthesia.

Conclusion
FB aspiration is an emergency and team help should be sought early. Techniques should be tailored to the clinical context but spontaneous respiration should be maintained wherever possible. Understand the limitations of imaging techniques such as chest radiographs: plastic is radiolucent. Diagnosis depends on high level of suspicion in a child with sudden onset respiratory distress. Children witnessed to choke while having small objects in their mouth and subsequently develope raspy respiration, wheezing, or coughing should undergo prompt bronchoscopy under general anaesthesia, regardless of radiographic findings. In conclusion, the results of bronchoscopy are very satisfying when the child recovers from airway obstruction. This can be achieved by early diagnosis, supervised transportation to a good centre and rigid bronchoscopy by an expert team with back up ICU facility.

Source of Funding
None.