Foreign Body Aspirations

Introduction
Foreign body aspiration may be fatal or went symptomless depending on the type of foreign bodies. Solid or semi solid object may dislodged in respiratory airway and lead to asphyxia or dyspnea varies according to exact site they are dislodged. As children grow and explore the new world, they tend to put small objects they found into their mouth and swallow it. They complained of some signs and symptoms or perhaps detected by their parents.

Site of foreign body aspirations

The foreign body is either obstructing the respiratory airway or the gastrointestinal tract. But most commonly is the respiratory airway. Depending on size of the foreign body, it may be obstructing the laryngeal inlet or beyond the trachea. Small objects blocking the laryngeal inlet may be dangerous as it completely obstruct the airway while obstruction beyond level of trachea or in the bronchus has better prognosis. But this may subjected to type of foreign body trapped and distance of it from the main bronchi. The right bronchus is commonly affected as it is more into line with the trachea and more widely than left bronchus (Figure 1).

Figure 1 show the percentage of foreign body location affecting the airway.

Foreign bodies
Foreign bodies that get swallowed or inhaled are usually radiopaque objects which are visible in X ray examination such as buttons, pins, screw, button batteries and toy parts (Figure 3). Foods

can also be trapped such as peanuts, beans, seed and others. These objects may irritate the lining mucosa of the trachea and bronchus as these food objects can initiate an inflammatory action which may lead to congestion and edema. The edematous swelling can cause airway obstruction either complete or partial and suppuration in lungs. Percentage of foreign body types

Figure 2 show percentage of foreign body types commonly affect children.

Figure 3 above show some foreign bodies retrieved by endoscopy

Person at high risk of foreign body aspirations

Children aged 1-3 years are at risk of foreign body aspiration as they tend to put objects into their mouth and the way they chew the food. At this age, the molar tooth is not developed yet. So they usually chew with incisor teeth and the chewing may not become complete. Adults are also suspected at risk of foreign body aspiration if they had undergone oropharyngeal procedures,

intoxicated, have several oral appliances, receive sedatives, or having neurologic or pscyhologic disorder which increased probability of foreign body ingestion.

Sign and symptoms

Signs and symptoms present might be early and chronic. Some of the early signs and symptoms are choking, coughing, fever, dyspnea, haemoptysis and chest pain. Foreign body such as inorganic material and inert bone may go symptomless or has delayed diagnosis which takes few months and years. Choking may not go frequently or being misdiagnosed. In some chronic symptoms, patient may misdiagnosed as having asthma attack or chronic bronchitis. In patients suspected with foreign body aspirations, signs shown maybe cough, wheezing, stridor and reduced breath sounds. Cyanosis happens if the obstruction is severe (Figure 4).

Figure 4 show infant cyanosis that could be happen if obstruction is severe.

Complications
Complications resulting from foreign body aspirations are atelectasis which is due to prolonged airway obstruction. The complete obstruction of airway cause the alveoli of lung to collapse. The other complications are bronchiectasis. Pathogenesis of this disease is due to destruction of muscle and elastic tissue of respiratory muscle. This is caused by chronic infections which can be initiated by foreign body obstruction. Complication risk is increased if the extraction of foreign body is delayed.

Diagnosis
There are few tests can be take to identify these foreign body as well as diagnosing foreign body aspirations. Firstly, the chest radiograph which can show the exact locations of the foreign body in respiratory airway (Figure 5). If the obstruction is complete, no residual air present as it was

absorbed and no air entry. This condition leads to opacification of distal lung which can be seen in chest radiograph (Figure 6). However, in partial obstruction, an area of overinflation will be seen in the lung distal to the affected bronchi (Figure 6).

Figure 5 show chest radiograph that reveal foreign body objects dislodged in trachea of patient.

Figure 6 show chest radiograph reveals hyperinflation of right lung and opacity of lower lobe left lung Second test that can diagnose foreign body aspirations is CT scanning (Figure 7). It can reveal the material and site of object dislodged. Moreover, it can also detect the focal airway edema.

Figure 7 show suspected foreign body in CT scan (arrow). Then, other test that can be undergone is fluoroscopy test. It will scan the chest and reveal diaphragmatic and mediastinal shifting or the location of air trapping. Bronchoscopy procedures may also undergo which will be explained later. However beside these scientific test, action showed by patients may indicate that they are having foreign body aspirations. If the patients are holding their neck, coughing and could not talk, they maybe suspected of it. In case of children, they may admitted by themselves to the parents or they witness by themselves the children swallowed the foreign body.

Treatment and management

Procedures that can be performed is bronchoscopy test. Bronchoscophy is a test used to view the airway, diagnose lung disease and for treatment purpose. It has a light and small camera which allows the doctor to view the airway. There are three types of bronchoscopes that are rigid, flexible and CT (computed tomography) virtual. Rigid bronchoscope advantages are it has a wider diameter tube which can facilitate passage of grasping device which functions to grasp the foreign body and lead it out (Figure 8). Also, the air ventilation of the patient can be maintained throughout the procedures. Rigid bronchoscope is a treatment of choice in most patients as it is easy and does not have many complications.

Figure 8 show rigid bronchoscope being inserted into patient.

But in patients with maxillofacial or cervical trauma, flexible bronchoscope is highly recommended to avoid any serious injury (Figure 9). It also has more advantage as it can pass as far to the subsegmental bronchi due to its smaller diameter. CT virtual bronchoscopy is newly developed technique (Figure 10). It is a non invasive technique. Bronchoscopy test will be accompanied with anesthesia either local or general.

Figure 9 show close up of flexible bronchoscope

Figure 10 show CT virtual bronchoscopy that reveal foreign body.

Hiemlich maneuver or abdominal thrust is performed if the children cannot speak or cry or having respiratory distress (Figure 11). These conditions may refer to complete obstruction of airway. However, Hiemlich maneuver is contraindicated if the patients are able to speak. The object may shift its position to where it can cause complete obstruction. Back blows can also be performed to force foreign body out.

Figure 11 show how to do Hiemlich maneuver and back blows in kids and baby.

References
http://www.nlm.nih.gov/medlineplus/ency/article/003857.htm http://emedicine.medscape.com/article/298940-overview http://www.nhlbi.nih.gov/health/health-topics/topics/bron/ http://emedicine.medscape.com/article/1001253-workup#showall http://earnosethroatclinic.blogspot.com/2010/12/management-of-foreign-body-in.html http://www.nejm.org/doi/full/10.1056/NEJM194611142352002 http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1406903/?page=13