CHAPTER 10

Airway foreign bodies: clinical presentation, diagnosis and treatment

A. Delage, C-H. Marquette Service de Pneumologie, Centre Hospitalier Universitaire de Nice, Hopital Pasteur, Nice, France. Correspondence: C-H. Marquette, Service de Pneumologie, Centre Hospitalier Universitaire de Nice, Hopital Pasteur, 30 de la Voie Romaine, Nice 06000, France. E-mail: marquette.ch@chu-nice.fr

G. Killian opened the era of bronchoscopy in 1897 when he extracted a pork bone from the trachea of a German farmer using an oesophagoscope [1]. Since that time, fibreoptic bronchoscopy has become the cornerstone of the diagnostic evaluation in adults and older children with suspected foreign body aspiration (FBA). Rigid bronchoscopy remains the standard of care for removal of foreign bodies (FBs), except in selected situations. The evolution of ultrathin bronchoscopes has expanded the role of pulmonary physicians, especially paediatric pulmonologists, in the diagnosis and management patients who present with suspected FBA. In children, tracheobronchial FBA is a potentially life-threatening accident that may be suspected on the basis of a choking episode, if such an episode is witnessed by an adult or remembered by the child. In contrast, the clinical presentation of FBA in adults is often more subtle, and diagnosis requires careful clinical assessment and judicious use of bronchoscopy.

Epidemiology
FBA is more common in children than in adults: y80% of recognised cases occur in patients aged ,15 yrs [2]. Overall, death caused by suffocation following FBA is the fifth most common cause of unintentional injury mortality in the USA and the leading cause in children aged ,1 yr. About 4,100 fatal episodes of FBA were reported in the USA during 2001 [3]. Children aged ,1 yr and adults aged .75 yrs have an increased risk of dying following FBA [2]. Most cases of tracheobronchial FBs are seen in children, with 80% of cases occurring in children aged ,3 yrs [411]. Retrospective series suggest a peak age incidence of 12 yrs, an age at which most children are able to stand and explore their world via the oral route, using their improving motor skills to put small objects in their mouth. In contrast with children, tracheobronchial FBA is uncommon in adults [12]. Five large series have been reported [1317]. The largest of these, based on the clinical experience at the Mayo Clinics, identified 60 adults over a 33-yr period [15]. Two studies from Taiwan reported 47 and 43 cases over a 13- and a 15-yr period, respectively [16, 17]. In children, peanuts (3655% of all FBA), other nuts and seeds, food particles and pieces of hardware and toys account for the large majority of FBs [4, 5, 79]. Overall, food items are more commonly seen in infants and toddlers whereas older children more commonly aspirate nonorganic material (coins, pins, pieces of toys) [18, 19]. In adults, the nature of the FB is highly variable. Nail or pin aspiration occurs primarily in young
Eur Respir Mon, 2010, 48, 135148. Printed in UK - all rights reserved. Copyright ERS 2010; European Respiratory Monograph. Print ISSN: 1025-448x; online ISSN: 2075-6674. DOI: 10.1183/1025448x.00991009

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or middle-aged adults during do-it-yourself activities. Aspiration of dental debris, appliances, or prostheses can complicate facial trauma or dental procedures [20]. Neurological disorders, loss of consciousness, and alcohol or sedative abuse predispose to FBA in adults as well as older children and adolescents [15, 21]. The type of food aspirated depends on local customs. In Western, Chinese and Middle Eastern populations, vegetable matter, bones and watermelon seeds are the most frequently aspirated food particles, respectively [1517, 22]. One syndrome, referred to as the cafe coronary, consists of fatal or near fatal food asphyxiation caused by incompletely chewed meat [23, 24]. This generally occurs in older patients with dentition problems, swallowing disorders, or Parkinsonism, with an estimated annual incidence of 0.66 per 100,000 population [2529]. For practical management of acute food asphyxiation, it is crucial to remember that the FB is in a supraglottic position in about one-third of cases.

Presentation and diagnosis

Presentation in children
Clinical presentation of tracheobronchial FBA differs in children and adults. As a general rule, FBA tends to present with a more acute picture in children since the FB will often obstruct the trachea or larynx and cause respiratory distress, whereas adults generally tend to present with a more subtle clinical picture due to distal impaction of the FB. In children, presentation depends on a number of factors, which include the age of the child, the type and location of the object aspirated, the time elapsed since aspiration and whether the event was witnessed. .50% of the time, children with FBA will present within the first 24 h after aspiration [6, 9]. During a choking episode, the child will usually violently cough to expel the FB, which will move up and down the trachea and proximal bronchial tree, sometimes causing respiratory distress when it obstructs the central airway. At the end of the episode, the FB will either be expelled from the airway and the child will swallow it or spit it out. Conversely, the FB may also wedge in a main stem bronchus (fig. 1). In this case, coughing stops and symptoms and signs will become more subtle. Children with laryngeal or tracheal FBs usually have a more acute presentation, often with respiratory distress, stridor and cyanosis. This represents a medical emergency that demands prompt recognition and treatment. The majority of FBs in children are, however, located in the bronchi and cause less severe symptoms [6, 9]. In a review of 1,160 cases of suspected FBA, the right main bronchus was the most common site of impaction (52% of cases), followed by the left main bronchus (23%) and the trachea (13%) [6]. In less life-threatening cases, presentation of FBA can be more subtle and nonspecific findings will be present. A history of choking is present in 8090% of confirmed cases, but often has to be specifically sought [6, 9, 10, 30]. The classical triad of wheezing, cough and unilateral diminished breath sounds is found in only 57% of cases but has a specificity of .96% when present [9, 11]. Chest radiograph may reveal the FB if it is a radiopaque object (figs 2 and 3), but the most common FBs, nuts and organic materials, are usually radiolucent. The most common radiological findings in lower airway FBA are unilateral hyperinflation, atelectasis, mediastinal shift and pneumonia (figs 4 and 5) [30, 31]. The chest radiograph is, however, normal in most cases of FBA and does not rule out the diagnosis [31]. As a whole, in children with suspected FBA, the combination of unilateral decrease of breast sounds and ipsilateral hyperinflation on chest radiograph has a positive predictive value .95% for the presence of an FB in the lower respiratory tract [32].
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a)

b)

Fig. 1. a) During a choking episode the foreign body is moved up and down the tracheobronchial tree by coughing efforts. When it lodges in the subglottic area or trachea, it may cause respiratory distress. At the end of the episode, it will either be expelled from the airway or b) become encased in a more distal airway, in which case symptoms and signs will become more subtle.

Presentation in adults
No prospective study has evaluated the diagnostic utility of clinical and radiographic abnormalities in adults with suspected FBA. Thus, the best available evidence is drawn from retrospective case series of confirmed FBA. Acute presentation in adults is rare, since the FB usually is wedged distally in lower lobe bronchi or the bronchus intermedius. Dyspnoea is uncommon in adults with confirmed FBA, reported by only 25% of patients in one series [16]. Coughing is seen in up to 80% of all cases; other associated symptoms include fever, haemoptysis, chest pain or wheeze [2]. The diagnosis of FBA in adults is complicated by the fact that patients do not always volunteer or recall a history of choking [14, 16, 24, 28, 33, 34]. The diagnosis is frequently overlooked, except when patients (or witnesses) report a typical choking episode, or in the presence of a radiopaque FB. Unilateral hyperinflation may be noted but is more commonly seen in paediatric FBA. An FB may be noted unexpectedly during fibreoptic bronchoscopy performed for symptoms of endobronchial disease, such as chronic cough, haemoptysis, asthma not responding to therapy, and recurrent or nonresolving pneumonia.

Diagnostic bronchoscopy
The tracheobronchial tree should be examined in all cases of suspected FBA as the morbidity and mortality may be increased if diagnosis and treatment are
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Fig. 2. Accidental inhalation of a key in a patient with psychiatric illness.

delayed [9, 10, 1517, 33, 35]. Fibreoptic bronchoscopy has become the diagnostic procedure of choice for FBA in adults and children aged .12 yrs. In younger children, it is used when suspicion for FBA is either weak or absent.

Fig. 3. Aspiration of a small electrical diode in a 9-month-old child who was with her father while he was doing doit-yourself activities.

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a)

b)

Fig. 4. Foreign body impacted in the right main bronchus of a child. a) Chest radiograph shows normal lung fields during inspiration since the foreign body is radiolucent. b) When an expiratory film is done, right lung hyperinflation is seen.

Most authorities recommend the use of rigid bronchoscopy in children aged ,12 yrs with strongly suspected FBA. Rigid bronchoscopy permits control of the airway, good visualisation, manipulation of the FB with various forceps and prompter management of mucosal haemorrhage. However, this is the topic of an ongoing debate [32, 3640]. The bronchoscopist performing flexible bronchoscopy as a diagnostic procedure must be able to convert immediately to the extraction procedure using a rigid bronchoscope, especially in the setting of complete central airway obstruction. In addition, FB removal should not be attempted during a diagnostic bronchoscopy, unless the operator is skilled

Fig. 5. Foreign body impacted in left main bronchus. Anteroposterior radiograph shows left lung hyperinflation.

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in the extraction technique, and the appropriate equipment and personnel are available. The bronchoscopist who comes across an FB during diagnostic bronchoscopy should also be very careful not to push the FB more distally in attempting to extract it, since it may ultimately become impossible to remove via endoscopy, making a thoracotomy necessary. In our experience, soft beans and bronchial soot plugs are the only FBs that can be removed easily using simple suction. Diagnostic fibreoptic bronchoscopy in the setting of a suspected FBA is not technically different from diagnostic bronchoscopy performed for other indications. Fibreoptic bronchoscopy allows precise identification and localisation of FBs, facilitates the choice of rigid bronchoscope and type of forceps, and may shorten the duration of the rigid bronchoscopy procedure. The 4.9-mm outer diameter bronchoscopes with a 2.2-mm diameter working channel are used in patients aged .12 yrs. The 3.5-mm or even the 2.7-mm outer diameter bronchoscopes with 1.2-mm diameter working channels are available for younger patients. The operator must be aware that, even in patients with stable respiratory status, clinical decompensation may occur during the diagnostic procedure due to accidental dislodgement of the FB. Thus, every time FBA is suspected, fibreoptic bronchoscopy should be performed in a room equipped for resuscitation, definitive airway management, mechanical ventilation and rigid bronchoscopy. Fibreoptic bronchoscopy can be performed under local anaesthesia in most patients. In children, we also use intravenous sedation (e.g. midazolam 0.10.3 mg?kg-1). In general, patients with suspected FBA, including children, can be managed diagnostically on an outpatient basis.

FB removal
Once the diagnosis of FBA has been established, a number of factors influence the timing and choice of procedure used to remove the FB. Except in the case of a severe life-threatening emergency, FB removal should be attempted by a skilled operator. Displacement of the FB or a fragment of it into the contralateral lung or trachea with subsequent complete airway obstruction is a potentially lethal complication. Also, foreign body extraction (FBE) may be complicated by mucosal haemorrhage and distal displacement of the FB into the airway. Thoracotomy is rarely required in the case where an FB is visualised but cannot be removed using a bronchoscopic technique.

Timing of the procedure

Bronchial obstruction by an FB can result in potentially serious complications, including asphyxia, haemoptysis, post-obstructive infection and bronchiectasis, all of which can lead to increased morbidity and mortality [9, 10, 1517, 33, 35]. Organic FBs, particularly those with a high oil content (such as nuts), cause severe mucosal inflammation and accumulation of bulky granulation tissue within a few hours (fig. 6). When long-standing, these bulky tissue masses can cover the entire FB, cause bronchial obstruction and be confused with bronchial tumours. This also can be seen with chronically impacted sharp or rusty FBs, and following iron or nortriptyline pill aspiration [4143]. Once the diagnosis is established, extraction should be performed without delay. Although anaesthetists usually do not like to perform general anaesthesia in subjects with uncontrolled sepsis, we do not postpone FBE in patients with an acute postobstructive pneumonia, since the most effective therapy in this situation is to relieve the underlying obstruction.
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Fig. 6. Peanut impacted in the right mainstem bronchus. Within a few hours such an oily foreign body may cause severe mucosal inflammation and granulation tissue.

Role of corticosteroids
When an FB is completely encased in bulky and bleeding granulation tissue, extraction can be very difficult or impossible. In these cases, it may be useful to postpone extraction and initiate a short course (1224 h) of intravenous corticosteroids (12 mg?kg-1 prednisolone or equivalent), provided the patient is clinically stable. A retrospective case series of children with FBA suggested better outcome with pretreatment using antibiotics and corticosteroids [44]. In our experience, this practice usually results in dramatic resolution of the inflammatory reaction and facilitates subsequently attempted FBE. Corticosteroid therapy may, however, result in dislodgement of the FB followed by unwitnessed expectoration and swallowing, and these patients should remain under observation until the extraction procedure. In adults with a significant delay between diagnosis and attempted removal, it is reasonable to perform a repeat fibreoptic bronchoscopy under local anaesthesia in order to verify that the FB is still present.

Technique
In general, bronchoscopy, either flexible or rigid, is required for FB removal in patients who present with FBA. However, in young and healthy adults with a small, movable FB (fruit pit or bead), positional manoeuvres (lateral decubitus and Trendelenburg) are worth trying prior to bronchoscopy. This may result in spontaneous expectoration of the FB, or bring it into a more proximal position prior to definitive management.
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Rigid bronchoscopy
The rigid bronchoscope provides excellent access to the subglottic airways, allowing gas exchange and coaxial passage of multiple instruments, including grasping forceps and a suction catheter. General anaesthesia with short-acting agents, including propofol, is safe in this setting as procedure time rarely exceeds 10 min. Optical forceps allow direct visualisation of the FB and optically guided grasping (fig. 7). Alternatively, a rigid telescope and a forceps can be used coaxially through the bronchoscope. During the extraction procedure, it is crucial not to push the FB distally with the bronchoscope, the forceps, or the suction catheter. If blood and secretions are present proximal to the FB, these should be cleared by careful suctioning. In adults with profuse bleeding, epinephrine (0.25 mg) may be instilled for haemostasis and in order to shrink the swollen mucosa encasing the FB. The optical forceps are then advanced in the bronchial axis, a few millimetres proximal to the FB. For smooth and rounded FBs, the key is to grip the largest volume of the FB. In this setting, the smooth forceps (foreign body forceps) are preferred to the sharp alligator forceps. The forceps cups are opened maximally and the forceps is advanced under visual control using great care not to push the FB downwards. The FB is then gently but securely gripped. Both forceps and FB are pulled up, a few millimetres distal to the tip of the bronchoscope, and then the instruments and FB are withdrawn en bloc from the trachea (fig. 7). Alligator forceps are used for grasping sharp or irregular FBs. In case of large, hard FBs, such as pistachio shells, breaking the FB into two or three fragments may help extraction. In contrast, vigorous grasping of friable FBs, such as peanuts, should be avoided, since it may result in maceration and distal wedging of small fragments. Heavy FBs, such as metallic FBs, tend to move distally due to gravity; in this setting, it may be helpful to place the patient in the Trendelenburg position. Bronchoscopic cryotherapy probes can be used in conjunction with either flexible or rigid bronchoscopes, and may also be considered in patients with organic FBA, which contain water. The probe is placed against the FB, activated in order to freeze it, and subsequently withdrawn with the FB stuck to the probe. During the last step of extraction, the FB can be lost accidentally, either because it is blocked in the narrow glottic area, or because there was some inappropriate coaxial movement between the bronchoscope and the forceps, causing the tip of the bronchoscope to push the FB out of the forceps cups or jaws. If this occurs, the operator should first
a)

b)

Fig. 7. An optical forceps (a) is passed through the rigid bronchoscope to grab a peanut firmly (b). The foreign body is then brought to the tip of the bronchoscope before both the rigid bronchoscope and the forceps with the foreign body are removed simultaneously from the respiratory tract.

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carefully inspect the oral cavity and the larynx with the laryngoscope and grasp the FB with a Magill forceps, if possible, prior to reintubating the trachea with the bronchoscope. Once the FB is removed, the trachea is reintubated with the rigid bronchoscope and the airways are carefully re-examined, ideally with a fibreoptic bronchoscope passed through the rigid tube, to rule out another FB or residual fragments [45]. When managing food asphyxiation, which is generally caused by meat, one should always be aware that in about one-third of the cases the FB is impacted at the glottic or subglottic level [29]. Proximally encased meat pieces can be removed with a Magill forceps or manually by sticking the middle and index fingers down the throat [24].

Flexible bronchoscopy
Many types of ancillary equipment (including forceps, grasping claws, snares, balloontipped catheters and magnets) have been developed to allow FBE using fibreoptic bronchoscopes (fig. 8) [2, 46, 47]. Previously, most of the available baskets were developed for the gastrointestinal or the urinary tract. New zero tip baskets developed for endobronchial use are now available and greatly facilitate extraction of FBs with the flexible bronchoscope. In selected cases, fibreoptic bronchoscopy may be used as an alternative to rigid bronchoscopy for extraction. Several authors have demonstrated that FBs, even large ones, can be effectively removed with paediatric fibreoptic bronchoscopes [32, 3638, 40, 4851]. The success rates of fibreoptic bronchoscopic extraction in adults range from 6090% [1517]. Thus, in adults and most children aged .12 yrs, FBE can be performed under local anaesthesia using a i4.9-mm outer diameter fibreoptic bronchoscope and appropriately designed forceps or snares. However, fibreoptic extraction with specialised instruments can be cumbersome, and ultimately rigid bronchoscopy may still be required for FB removal [1517]. One key aspect to remember when attempting an FBE with a flexible bronchoscope is to use the oral route, since the FB may not pass through the nasal cavity when retrieved from the tracheobronchial tree. In addition, fibreoptic bronchoscopy extraction entails some risks. For example, when an impacted FB obstructs a mainstem bronchus, accidental migration of the FB into the contralateral lung, due to insufficient grasping with the fibreoptic forceps, is potentially lethal. This is less likely to occur with rigid forceps used for rigid bronchoscopy than with the forceps, grasping claws, and baskets used in conjunction with fibreoptic bronchoscopy [48]. Also, inflammatory lesions encasing FB are friable and may bleed when touched. Since the grasping instrument is passed through the suction port of the fibreoptic bronchoscope, simultaneous FB manipulation and suctioning are impossible when a flexible bronchoscope is used. Finally, unsuccessful attempts may also push the FB distally into a wedged position (fig. 9). Once the FB is removed, the entire tracheobronchial tree should be checked for another FB or residual fragments. If doubt persists, a repeat fibreoptic bronchoscopic examination a few days later should be considered. We agree with other experts that fibreoptic is superior to rigid bronchoscopy in the setting of a distally wedged FB, in mechanically ventilated patients, or in the presence of spine, craniofacial, or skull fractures that prevent the manipulation required for rigid bronchoscopy [15].

Peri-operative management
Controversy regarding the need for corticosteroids or antibiotics in the peri-operative management of FB aspiration results from the absence of comparative controlled
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a)

b)

Fig. 8. a) Different types of instrument that can be used to extract a foreign body using a flexible bronchoscope. b) Even large foreign bodies can be extracted using these instruments. In these cases, it may however be preferable to pass the flexible bronchoscope through a rigid bronchoscope in order to be prepared for a rigid forceps extraction of the foreign body.

studies on these issues. We recommend the use of a short course of corticosteroids before FB removal when a well-tolerated FB is encased in bulky and bleeding granulation tissue [37]. Prophylactic use of corticosteroids to decrease the incidence of post-operative subglottic oedema should be avoided. When post-operative subglottic oedema occurs, parenteral corticosteroids, aerosolised epinephrine, or heliumoxygen therapy should be considered. Antibiotics are indicated only in cases of clinically, radiologically, or bronchoscopically documented respiratory tract infection.

Conclusions
Tracheobronchial FB aspiration is most commonly seen in younger children and can be a life-threatening emergency. Peanuts and food particles account for most cases of FBA. In children with FBA, clinical and radiographic signs can be subtle, but most have a history of choking when sought more specifically. In adults, the clinical presentation of
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a)

b)

Fig. 9. a) Gravel impacted in the bronchi of a patient with geophagia. b) Rigid forceps were used to securely grasp the small stones, preventing them from impacting more distally in the bronchial tree.

FBA is often subtle or silent, and many do not report a history of choking. Hence, one should have a high index of clinical suspicion and the tracheobronchial tree should be examined when FBA is suspected. In children, controversy still exists regarding the initial procedure of choice, but most experts recommend the use of rigid bronchoscopy in children with suspected FBA. Fibreoptic bronchoscopy generally can be used both for diagnosis and treatment of FBA in adults and older children, with a success rate of 6090%. In all cases, diagnostic and therapeutic procedures should be performed by an operator skilled in both flexible
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and rigid bronchoscopy, in conjunction with trained assistants, in a room equipped with full resuscitation equipment.

Summary
Tracheobronchial foreign body aspiration (FBA) is more commonly seen in children than adults. 80% of cases of FBA are seen in children aged ,3 yrs and it is the most common cause of death due to unintentional injury in children aged ,1 yr. Peanuts and food particles account for most cases of FBA. Clinical presentation varies from life-threatening respiratory distress to, more commonly, subtle signs and symptoms, especially in adults and older children. A high degree of clinical suspicion is needed in the diagnosis. The tracheobronchial tree should be examined in all cases of suspected FBA since a delay in the diagnosis can lead to complications. Fibreoptic bronchoscopy is the initial diagnostic and therapeutic procedure of choice in adults and children aged .12 yrs. Forceps, specially designed snares or a cryotherapy probe can be used to extract the foreign body (FB). Rigid bronchoscopy is preferred in children aged ,12 yrs and in cases where the FB cannot be removed via flexible bronchoscopy. Rigid bronchoscopy allows better control and visualisation of the airway and easier manipulation of the FB with different types of forceps. Haemorrhage and FB displacement may complicate foreign body extraction. In most circumstances, FB extraction should be attempted by a trained physician in a setting where rigid bronchoscopy is readily feasible in case of failure or complications. Keywords: Bronchoscopy, extraction, foreign body, tracheobronchial.

Statement of interest None declared.

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