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Home , Foreign body aspiration, Respiratory sounds

Turkish Journal of Medical Sciences Turk J Med Sci (2016) 46: 795-800 http://journals.tubitak.gov.tr/medical/ © TÜBİTAK Research Article doi:10.3906/sag-1504-86

Complications of tracheobronchial foreign bodies

Bayram ALTUNTAŞ*, Yener AYDIN, Atila EROĞLU Department of Thoracic Surgery, Faculty of Medicine, Atatürk University, Erzurum, Turkey

Received: 18.04.2015 Accepted/Published Online: 16.08.2015 Final Version: 19.04.2016

Background/aim: Tracheobronchial foreign bodies may cause several complications in the . We aimed to present the complications of tracheobronchial foreign bodies. Materials and methods: Between January 1990 and March 2015, 813 patients with suspected tracheobronchial foreign body aspiration were hospitalized in our department. Patients with complications related to foreign bodies in airways were included in this study. We retrospectively evaluated the records of patients according to symptoms, foreign body type, localizations, and complications. Results: A foreign body was found in 701 of 813 patients (86.2%). Complications related to foreign bodies settled in airways were seen in 96 patients (13.7%). The most common complications were and in 36 (5.1%) and 26 (3.7%) patients, respectively. Other complications were (n = 12, 1.7%), cardiopulmonary arrest (n = 11, 1.6%), bronchostenosis (n = 3, 0.4%), death (n = 2, 0.3%), migration of foreign body (n = 2, 0.3%), (n = 2, 0.3%), tracheal perforation (n = 1, 0.15%), (n = 1, 0.15%), and (n = 1, 0.15%). Coughing (n = 74, 77.1%) and diminished (59.3%, n = 57) were the most common findings. Conclusion: Careful evaluation and rapid intervention are life-saving methods in tracheobronchial foreign body aspirations.

Key words: Atelectasis, foreign body, pneumonia

1. Introduction Before interventions, routine radiographs were taken, all Foreign bodies in airways may be present with different patients were examined carefully, and detailed histories clinical symptoms (1). Although the majority of cases can were obtained from the patients, parents, or other close be diagnosed correctly in the early period, some patients relatives. Rigid was the principal method. are misdiagnosed in the acute period (2). The symptoms Fiberoptic bronchoscopy was used to determine the and findings at the beginning are usually related to airways location of the foreign bodies when rigid bronchoscopy obstruction. However, lately, suppurative symptoms are failed. Lobectomy was performed in patients who had seen because of parenchymal damage (3). Furthermore, irreversible diseases. Recommendations of the the incidence of complications of tracheobronchial International Committee for Medical Journal Editors were foreign bodies increase when diagnosis and treatment are respected by all authors during manuscript writing. delayed (4). The most feared complication in the acute period is cardiopulmonary arrest. In this paper, we aimed 3. Results to present our experience about the complications of All patients underwent rigid bronchoscopy. A foreign tracheobronchial foreign bodies. body was found in 701 of 813 patients (86.2%). Complications related to foreign bodies settled in airways 2. Materials and methods were seen in 96 patients (13.7%). Fifty-four patients were Between January 1990 and March 2015, 813 patients with male (56.2%) and 42 patients were female (43.8%), and suspected tracheobronchial foreign body aspiration were the mean age was 5.2 years (8 month to 83 years). Peak hospitalized in our department. Patients with complications incidence of the complications occurred between 1 and related to foreign bodies in airways were included in this 3 years, accounting for 51.1% of the total number (Table study. We retrospectively evaluated the records of patients 1). The most common complications were atelectasis, according to age, sex, symptoms, findings, therapeutic pneumonia, and respiratory distress in 36 (5.1%), 26 options, foreign body type, localization, and complications. (3.7%), and 24 (3.4%) patients, respectively (Table 2). * Correspondence: [email protected] 795 ALTUNTAŞ et al. / Turk J Med Sci

Table 1. Age distribution of patients. Table 3. Symptoms and physical findings.

Age range N % Symptoms and findings N % 0–1 15 15.6 Coughing 74 77.1 1–3 49 51.1 Diminished respiratory sounds 57 59.3 3–10 23 24 38 39.6 10–20 4 4.2 Dyspnea 24 25 20–30 1 1 14 14.6 30–40 0 0 Rhonchi 11 11.5 40–50 1 1 50–60 1 1 with a mean of 34.1 days. Twenty-one patients did not >60 2 2.1 have an aspiration history (21.9%). Total 96 100 The chest plain showed atelectasis, pneumonia, radiopaque images of metallic objects, bronchiectasis changes, pneumomediastinum, and pneumothorax in 36 Table 2. Complications of foreign bodies. (37.5%), 29 (30.2%), 12 (12.5%), 2 (2.1%), and 2 (2.1%) patients and 1 (1%) patient, respectively. The chest plain was normal in 1 (1%) patient. Before bronchoscopy, the Complications N % chest plain was not taken in 13 patients because of severe Atelectasis 36 5.1 respiratory distress. Pneumonia 26 3.7 The locations of the foreign bodies were the , right bronchial tree, left bronchial tree, and both bronchial Respiratory distress 24 3.4 systems in 23 (24%), 45 (46.9%), 26 (27%), and 2 (2.1%) Bronchiectasis 12 1.7 patients, respectively (Table 4). Nuts were responsible for majority of the complications (n = 76, 79.2%) (Table 5). Cardiopulmonary arrest 11 1.6 Rigid bronchoscopy indications were positive Bronchostenosis 2 0.4 , symptoms and findings supporting Death 2 0.3 Migration 2 0.3 Table 4. Localizations of foreign bodies.

Pneumomediastinum 1 0.3 Localization N % Pneumothorax 1 1.5 Trachea 23 24 Tracheal perforation 1 1.5 Right bronchial system 45 46.9 Hemoptysis 1 1.5 Main 21 21.9 Intermediary bronchus 7 7.3

Other complications were bronchiectasis (n = 12, 1.7%), Middle lobe bronchus 1 1 cardiopulmonary arrest (n = 11, 1.6%), bronchostenosis (n Lower lobe bronchus 16 1 16.7 = 3, 0.4%), death (n = 2, 0.3%), migration of foreign body Left bronchial system 26 27 (n = 2, 0.3%), pneumomediastinum (n = 2, 0.3%), tracheal perforation (n = 1, 0.15%), pneumothorax (n = 1, 0.15%), Main bronchus 11 11.4 and hemoptysis (n = 1, 0.15%). Coughing was the main Upper lobe bronchus 2 2.1 symptom (n = 74, 77.1%). Diminished respiratory sounds (59.3%, n = 57), fever (39.6%, n = 38), dyspnea (25%, n Lower lobe bronchus 13 13.5 = 24), cyanosis (14.6%, n = 14), and rhonchi (11.5%, n = Both bronchial systems 2 2.1 11) were the most common findings (Table 3). The time Total 96 100 interval of the symptoms ranged from 30 min to 4 years,

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Table 5. Types of foreign bodies. patients were intubated outside the hospital. All foreign bodies in arrested patients had settled in trachea. Extracted Types N % bodies were peanuts, kidney beans, and a roasted chickpea in 7 patients, 3 patients, and 1 patient, respectively. Nuts 76 79.2 Peanut 49 51 4. Discussion Complication severity of tracheobronchial foreign body Sunflower seed 14 14.6 aspiration is usually related to age, type and localization of Hazelnut 9 9.4 the foreign body, and the time passed after the aspiration. Roasted chickpea 4 4.2 While mortal complications are seen in the acute period, suppurative complications occur in later years. Life- Plastic object 11 11.5 threatening results after aspirations are usually seen in Kidney bean 5 5.2 children because their airway size is smaller than that of adults (5). The most dangerous period is between 1 and Headscarf pin 2 2.1 3 years (4). Organic materials are the most common Voice prosthesis 1 1 aspirated foreign bodies (6–8). The causes of the high Fragment of glass 1 1 incidence of foreign body aspiration in children are high interest in the environment, immature swallowing reflex, Total 96 100 inadequate chewing of foods, and their desire to take objects into the mouth (9). The worst complications after aspiration are the tracheobronchial foreign body aspiration, positive cardiopulmonary arrest and sudden death, and they radiologic evidence, and recurrent and/or antibiotic- are seen when big and solid objects settle in the trachea. resistant pulmonary infections. Foreign bodies were Nevertheless, swellable organic bodies settled in the right extracted by rigid bronchoscopy in all patients. Fiberoptic or left bronchial system can leave their location in time and bronchoscopy was used to determine the location of objects move to the sites that are more proximal (10). As a result, in two patients who had aspirated headscarf pins, because the trachea may be completely obstructed by the foreign these objects migrated to the distal airways while patients body. Furthermore, asphyxial and sudden were waiting for the rigid bronchoscopy. In one patient death may occur when both main bronchial systems are who had referred from another city, pneumothorax was blocked by smaller foreign bodies. The causes of asphyxial seen on the chest plain before bronchoscopy. After tube cardiac arrest are alveolar hypoxia and hypercarbia (11). thoracostomy, a rigid bronchoscopy was performed under Respiratory and metabolic acidosis occur as a result of sedoanalgesia because of the presence of laryngectomy, hypoxia and hypercarbia and cardiac arrest is seen quickly and the foreign body was removed. The tracheobronchial (11). When cardiopulmonary arrest occurs in patients in system was then examined and membranous rupture the emergency department or clinics, the intubation tube of the trachea was seen. Primary repair was performed should be pushed to the right or left bronchial system after under sedoanalgesia. In 2 patients with bronchiectasis, patients are intubated, and then it must be pulled back up right lower lobectomy was performed. Before lobectomy, to the top of the carina. This is a life-saving maneuver for patients underwent rigid bronchoscopy and pen caps were foreign bodies settled in the trachea. After resuscitation, extracted. rigid bronchoscopy must be performed rapidly. During Hospitalization durations were 1 day, 2 days, and bronchoscopy, if the foreign body settled in the trachea longer than 2 days in 33 (34.4%), 21 (21.9%), and 42 is organic, it should be pushed to the sites that are more (43.7%) patients, respectively. The longest hospital stay distal and then should be crumbled by forceps. After was 22 days and the mean hospital stay was 4.9 days. these maneuvers, fragments of the foreign body must be Twenty five pediatric patients with pneumonia were extracted by suitable forceps and irrigation of the bronchial transferred to the department of pediatrics 1 day after the tree with physiological serum must be performed, and bronchoscopy procedure. Cardiopulmonary arrest related then secretions and small fragments must be suctioned to and occurred in 11 patients in the (10). In our series, cardiopulmonary arrest occurred in 11 preoperative period. Nine of them were intubated and patients. Two of them were intubated outside the hospital resuscitated in the emergency services; the other 2 patients and the others were intubated in the hospital because of the were intubated and resuscitated by paramedics outside the fact that the cardiopulmonary arrest occurred shortly after hospital. Although foreign bodies were extracted from their arrival at the emergency room. After the intubation, these patients, two patients could not be saved. Dying patients were transferred to the operating room rapidly.

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We performed the maneuvers mentioned above during bronchi are occluded by foreign bodies. This condition may bronchoscopy. Despite the fact that all foreign bodies were be the indicator of cardiopulmonary arrest that will appear extracted, patients intubated outside the hospital could not soon after. Often, the clear medical history of aspiration be saved. is a sufficient reason for urgent bronchoscopy in patients Recurrent and/or persistent pneumonia may occur as with respiratory distress. Nevertheless, a detailed history a result of gastroesophageal reflux disease, tuberculosis, must be obtained and a careful pulmonary hypoplasia, cystic adenomatoid malformation, must be done in the absence of a clear aspiration history. scimitar syndrome, immunodeficiency, and foreign body Because some bacterial and viral diseases such as in the airway (12). The incidence of recurrent pneumonia may mimic foreign body aspirations, unnecessarily related to foreign body aspiration in all recurrent performed may provoke symptoms. pneumonia cases has been reported as 2.4% in the literature Therefore, is very important in (12). Recurrent or resistant pneumonia related to foreign cases of respiratory distress. We found 24 patients with bodies settled in the airway are usually seen in young age respiratory distress among our patients and, as mentioned groups. In patients in this group, aspiration history is above, 11 of them were intubated due to cardiopulmonary usually absent because of parents’ poor attention to the arrest that followed the respiratory distress. A clear children. The incidence of pneumonia in foreign body foreign body aspiration was present in all patients. Rigid aspiration is between 2.9% and 19% in children and 11.8% bronchoscopy was performed as soon as possible and in the general population in the literature (1,4,5,10,14,15). the objects were extracted in all patients. Localizations of Nevertheless, pneumonia incidence in foreign body foreign bodies were the trachea, right main bronchus, and aspirations was reported as 42.9% in patients younger both main bronchi in 13 (18.7%), 7 (4.2%), and 4 (2.1%) than 3 years (2). Pneumonia is the most important cause patients, respectively. of increased cost in management of tracheobronchial Bronchiectasis is the most frequent complication in foreign body aspirations. Usually patients with recurrent tracheobronchial foreign body aspirations in the late pneumonia receive extensive medical treatment before period (3). The incidence of bronchiectasis due to foreign bronchoscopy. If these patients continue to receive medical bodies settled in airways was reported in a range between treatment after the procedure, the length of hospitalization 1% and 5.6% in the literature (19,20). Bronchiectasis may is prolonged. In our series, there were 26 patients with be a reversible form the so-called pseudo-bronchiectasis recurrent/persistent pneumonia and 25 of them were or an irreversible form. Pseudo-bronchiectasis occurs as a children. After bronchoscopy, these pediatric patients were result of acute infection or inflammation, and it can regress transferred to the pediatric department since our hospital after the foreign body is removed. Nevertheless, irreversible is a multidisciplinary center. Pulmonary infections in bronchiectasis can be cured by resection. However, there transferred patients were cured successfully in pediatric are studies reporting that severe bronchiectasis may clinics and repeated bronchoscopy was not required. improve after the removal of the longstanding foreign body Atelectasis may occur as a result of pulmonary in airways (21–24). Usually, neglected inorganic foreign parenchymal compression or (16). bodies cause permanent bronchiectasis in later years This abnormal condition may be seen in several situations (3). In our series, 12 patients had bronchiectasis changes such as bronchopulmonary dysplasia, , on the chest plain and 10 of them had aspirated organic , tuberculosis, and foreign body aspirations (17). foreign bodies. In the remaining two patients, lobectomy Foreign body aspirations are the foremost of preventable was performed because of irreversible bronchiectasis. The causes of atelectasis. The clinical symptoms of atelectasis first of the last two patients was an 18-year-old male and depend on the underlying disease, the amount of affected he had a medical history of foreign body aspiration 3 years lung, and the time passed after the atelectasis (16). Though ago. The second patient was a 22-year-old female with a asymptomatic, coughing, fever, wheezing, respiratory history of aspiration 4 years ago. Before lobectomy, rigid distress, and hyperpnoea may be seen. The incidence of bronchoscopy was performed and plastic objects were atelectasis in tracheobronchial foreign body aspirations is extracted from both patients. between 4.4% and 41.6% in the literature (1–5,10,13,14,18). Surgical procedures, thoracic trauma, congenital In our series, the incidence of atelectasis was 5.1%, and lesion, , and tuberculosis may cause bronchial after bronchoscopy, atelectatic reexpanded in all stenosis (25). Although bronchostenosis due to foreign patients. There were no asymptomatic patients. Coughing, bodies settled in the bronchus is reported as a complication diminished respiratory sounds, fever, dyspnea, rhonchi, of the foreign body, its true incidence is unknown (26). and cyanosis were the most common findings. The principal mechanism in bronchostenosis related to Respiratory distress in tracheobronchial foreign body foreign bodies is mucosal inflammation and this situation aspiration is usually seen when the trachea or both main results in bronchial narrowing. Eventually atelectasis,

798 ALTUNTAŞ et al. / Turk J Med Sci pneumonia, and parenchymal occur as results of pneumomediastinum usually occurs as a complication the retention of bronchial secretions (26). In our series, of asthma in children (30). If asthma is misdiagnosed as we found bronchostenosis in 3 patients who aspirated foreign body aspiration and bronchoscopy is performed, nuts (0.4%). Symptoms of these patients were fever and bronchospasms may be exacerbated. The incidence of coughing. Localizations of stenosis were at the right pneumothorax related to foreign body aspiration is lower lobe and intermediary bronchus in 2 patients and 1 between 0.48% and 1.9% in reports (32,33). The foreign patient, respectively. After bronchoscopy, bronchial lavage body blocks the trachea or bronchia and pressure in the was taken and bacteriological examination and PPD tests lungs rises suddenly because of obstructive emphysema, were done for tuberculosis. Fortunately, all of them were and, finally, pneumothorax occurs as a result of aspiration negative. (33). Additionally, pneumothorax may occur due to the Foreign body migrations are usually seen with thin penetrating effect of the foreign body in the airway. Pointed objects such as pins. However, as mentioned above, some foreign bodies may cause superficial or deeper in unfragmented swellable organic bodies such as kidney the airway mucosa and hemoptysis or perforation may beans and roasted chickpeas settled in the bronchial tree occur as a result of these damages. However, airway injuries may leave their sites in time and may move to the trachea, are usually seen related to bronchoscopy procedures (34). and fatal events may occur (10). Furthermore, some large In our series, pneumomediastinum was seen in 2 patients inorganic bodies can be displaced between the right and (0.3%). The first patient was an 8-year-old male and the left main bronchus and can move from the trachea to the second patient was an 83-year-old male. A peanut had bronchial tree (27,28). In our series, migration was seen occluded the right main bronchus in the pediatric patient in two patients who aspirated headscarf pins. Foreign and a pointed plastic object had settled in the trachea in the bodies moved forward while the patients were waiting adult. At the same time, pneumothorax was also present for bronchoscopy and fiberoptic bronchoscopy was used in the adult patient. Before bronchoscopy, a right tube to determine the localization of the objects. Objects were thoracostomy was performed, and then the foreign body successfully extracted by these methods in these two was extracted under sedoanalgesia since the patient had patients. laryngectomy. Tracheal perforation was repaired primarily The incidence of pneumomediastinum in foreign body under sedoanalgesia. Hemoptysis was seen in a patient aspirations is between 0.8% and 5.8% in the literature who had aspirated a fragment of glass and conservative (29,30). General etiological factors in pneumomediastinum treatment was sufficient after the object was removed. are mucosal of the tracheobronchial system or Foreign bodies in airways may cause different the esophagus, mediastinitis, and damage of alveolar complications in the acute and chronic periods. The basics structures (31). Sometimes pneumomediastinum of the management of tracheobronchial foreign body may be associated with pneumothorax. Before aspirations are careful evaluation and rapid intervention. bronchoscopy, a detailed medical history and a careful Early diagnosis and treatment reduce the incidence of physical examination are sine qua non conditions in the complications and they may be life-saving in the acute presence of pneumomediastinum, because spontaneous period.

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