Foreign Body Airway Obstructions in Children Lessons Learnt from a Prospective Audit

Transcription

1 Foreign Body Airway Obstructions in Children Lessons Learnt from a Prospective Audit KL NARASIMHAN, SK CHOWDHARY, S SURI, JK MAHAJAN, R SAMUJH, KLN RAO Aim : To prospectively audit 75 consecutive children referred for foreign body airway obstructions in a 2 year period and to highlight the rarer forms of presentations and morbidity of this procedure. Observations : Of the 75 patients, 63 were boys. Thirty eight (50%) of the patients were 1 to 3 years of age. There was a seasonal increase in vegetable foreign bodies during Lohri (winter). Chest X-rays of these patients showed obstructive features in 52 patients. Three patients with foreign bodies in the airway presented with unusual radiological features like pneumothorax, subcutaneous and mediastinal emphysema, and pneumoperitoneum. Five patients presented with refractory bronchial asthma and 2 of them had vegetable foreign bodies in the airway. Two patients with foreign bodies in the airway presented with acute aphonia. One needed a tracheostomy to remove a very large foreign body. Five of the older children had chosked with a whistle dislodged from toys. In 3 patients the bronchoscopy was complicated by attacks of temporary intraoperative hypoxia without sequela due to foreign body in both the bronchi. Two patients needed postoperative ventilatory therapy due to multiple foreign bodies in the respiratory tree and needed more than one attempt at bronchoscopy. Majority of the foreign bodies were vegetable in nature though some toy parts, stones, bones, screws and nails were also found. There were 2 mortalities, m 1 due to a missed postoperative pneumothorax resulting in refractory cardiac arrest and the other due to an impacted foreign body at the carina. Conclusions : Children between the age groups 1-3 years are more susceptible to foreign body bronchus though no age group is exempt. The usual presentation is an acute onset of respiratory distress with or without history of choking. One must suspect foreign bodies in the respiratory tract in situations like refractory asthma, bronchiectasis, or hemoptysis without any underlying Depts of Pediatric Surgery and Anesthesia PGIMER, Chandigarh PGIMER, Chandigarh Fax : , Dr KL Narasimhan ushal21@mantraonline.com Department of Pediatric Surgery

2 FOREIGN BODY AIRWAY OBST IN CHILDREN 185 cause. Uncommon X-ray findings like pneumothorax, pneumomediastinum, and presentations like massive subcutaneous emphysema of sudden onset must make one suspect an underlying foreign body bronchus. The patients must be managed at selected centers with a backup Intensive Care facility. The existing mechanisms of referral must be strengthened with supervised ambulance transportation, preventive education and effective legislation regarding toys. Key words : Bronchoscopy, airway obstruction, mediastinal emphysema. Inhalation of foreign body into the respiratory tract in children is an emergency. 1 Though recent improvements in instrumentation and anesthetic techniques have made, it safer to remove foreign bodies it is still associated with occasional fatalities. 1 ' 9 The real challenges are in preventive advice, effective legislation, early recognition, resuscitation and transportation so that mortalities are totally avoided. We audited our data on foreign body aspirations prospectively on consecutive patients which forms the basis of this report. Patients and Methods Seventy five patients who underwent bronchoscopy for foreign bodies in the period Fig 1 Chest X-ray of a child with massive subcutaneous emphysema and foreign body in the bronchus. Fig 2 X-ray of a child with (R) pneumothorax who had a right bronchial foreign body.

3 186 J INDIAN ASSOC PEDIATR SURG VOL 7 (OCT-DEC 2002) Fig 3 X-ray of a child with severe respiratory distress showing pneumoperitoneum. There was a foreign body in the right main bronchus. between June 1998 to June 2000 are included in the study. All children who had history of choking, respiratory distress of sudden onset and clinical or radiological features of decreased air entry into one or both lung fields were subjected to diagnostic rigid bronchoscopy by one of the consultants. Storz ventilating bronchoscope was used along with optical telescope and optical forceps. The anesthetic technique varied with the condition of the baby. The technique of bronchoscopy was in 3 phases viz localisation of the foreign body with good suction and optical telescope, removal of the foreign body using optical forceps and checking the airway for patency. Postoperatively all patients received monitoring, oxygen therapy and appropriate antibiotics. Results All the patients were transported by the relatives without any medical supervision. There was a seasonal variation with a very high incidence during the winter months prior to the Lohri season. There were 63 males and 12 females. Thirty eight patients were between 1-3 years and 15 were under 1 year of life. The oldest patient referred was a 12 year old female child (Table I); 2 patients presented with acute aphonia, 3 patients with massive subcutaneous emphysema (Figs 1, 2 & 3), with associated pneumothorax and pneumoperitoneum. Five patients were referred for chronic symptoms viz bronchiectasis, hemoptysis (Table II). Ten patients were referred late and had a delay upto 2 years. X-ray chest was ordered when the clinical condition of the child was stable (Table III). Six patients with a normal chest X-ray had a foreign body bronchus. Only 64 of the 75 patients actually had a foreign body in the bronchus (Table IV). Problems were encountered during bronchoscopy when the foreign body was subglottic, carinal, or located on both sides of the bronchial tree (eg. peanut and its shell, or bits of peanut). The mortality and morbidity are shown in Table V. The mainstay of treatment was a bronchoscopy. Patients who were very sick, tachypneic and unable to maintain oxygenation and asphyxiated, were intubated and shifted to the operating room. Patients who were stable were taken up in the next operating list. The children who had acute onset of aphonia with respiratory distress were anesthetised with halothane without a muscle relaxant and the foreign body was

4 FOREIGN BODY AIRWAY OBST IN CHILDREN 187 Table I : Vulnerability to foreign body inhalation Age groups Male Females Table III : Radiological signs of patients with foreign bodies Table II : Presenting features of laryngo-tracheal foreign bodies Table IV : Types of Foreign body Table V : Mortality and Morbidity removed after indirect laryngoscopy. Acute aphonia was due to foreign body lodged between the vocal cords. One patient had a very large foreign body (tamarind seed) and this required a tracheostomy for removal as the seed had swollen up and could not be removed through the glottic chink. Five patients who were being treated for bronchial asthma and had differential air entry between the two sides of the chest were referred for bronchoscopy. Two of these patients had vegetable foreign bodies. Two of the patients who underwent bronchoscopy

5 188 J INDIAN ASSOC PEDIATR SURG VOL 7 (OCX-DEC 2002) required postoperative ventilation. The postoperative problems encountered after bronchoscopy were slight bleeding from the bronchial tree in 4 patients which subsided spontaneously and transient cough which settled down. There was one death in a child who had a missed tension pneumothorax. The other death was due to an impacted FB in the carina. Discussion Foreign body aspirations cause death in over 300 children per year in the U.S.A. 3 In our country a substantial number of babies must be succumbing to this problem before appropriate health care can be arranged. Our audit highlights the extent of the problem in a hospital set up and focuses on the rarer forms of presentation. Children between 1-3 years are most susceptible. It is important for the first treating physician to suspect foreign body if there is sudden onset of respiratory symptoms or there is history of choking. 1-6,9 It is necessary to remember that presentations like aphonia, massive subcutaneous emphysema, bronchial asthma, hemoptysis and bronchiectasis can be due to an underlying foreign body in the bronchus. It is also important to note the rarer radiological features like presence of mediastinal emphysema and pneumothorax as presenting features of foreign body in the bronchus. In a review of the radiological features of 343 patients of foreign body bronchus not single patient with mediastinal or subcutaneous emphysema was reported. 4 However this form of presentation is not unknown and has been reported and its pathogenesis well explained. 7,8,9 Obstruction to the airway results in high pressure in the alveolus with alveolar rupture. The air dissects along the pulmonary vascular sheath producing interstitial emphysema and then medastinal emphysema. Because of the anatomy of the investing layer of the cervical fascia the emphysema spreads into the neck. Once the diagnosis is made the urgency of the procedure depends on the clinical condition of the child. Bronchoscopy must be done with a backup of Intensive Care facility as some children need postoperative ventilation. This may be because of the underlying chemical pneumonia due to fat in the vegetable foreign bodies. Morbidity and mortality of bronchoscopy varies with the kind of foreign body aspirated and the clinical condition of the child. Postoperative pneumothorax is an important treatable condition. Bronchial trauma, hypoxia, airway edema, bleeding and death have been reported. 8 With increasing experience these can be eliminated. Rarely a thoracotomy is necessary to remove foreign bodies from the bronchus. In conclusion the results of bronchoscopy are very satisfying when the child recovers from the airway obstruction. This can be achieved by early diagnosis, supervised transportation to a good center, and rigid bronchoscopy by an expert team with back up ICU facility. Legislation regarding toy parts and preventive education prior to Lohri can reduce the incidence of this problem. Unusual forms of presentation must be remembered.

6 FOREIGN BODY AIRWAY OBST IN CHILDREN Banerjee A, Subba Rao KSVK, Khanna SK. et al. Laryogo-tracheo bronchial foreign bodies in children. J Laryngol Otol 1988; 102: Zerella JT, Dimler M, Mcgill LC. Foreign body aspiration in children : Value of Radiography and Complications of Bronchoscopy. J Pediatr Surg 1998; 33: Black RE, Johnson G, Matlak ME. Bronchoscopic removal of aspirated foreign bodies in children. J Pediatr Surg 1994; 29: Mu L, Sun D, Pe H. Radiological diagnosis of aspirated foreign bodies in children. A review of 343 cases. J Laryngol Otol 1990; References 104: Vane DEW, Pritchard J, Coville CW, et al. Bronchoscopy for aspirated foreign bodies in children. Arch Surg 1988; 123: Lakhkar BB, Kini P, Shenoy V, et al. Foreign body aspiration : Manipal experience. Indian Pediatr 2000; 37 : Soaji R, Ramachandra CD, Cruz A. Subcutaneous Emphysema : an unusual presentation of foreign body in the airway. J Pediatr Surg 1995; 30: Johnson DG, Condon VR. Foreign bodies in the paeditric patient. Current problems in Surgery. 1998; 35: