Children with an Airway Foreign Body


Fig. 27.1

Bronchial sequelae of a foreign body. Anteroposterior chest x-ray of a 5-year-old child presenting with chronic atelectasis in the left inferior lobe (a). Axial CT scan of the chest, showing bronchiectasis in the left lung (b)



Radiological Study


In the case of a radiolucent foreign body, which is the most common type, localized hyperinflation is the most evocative radiological sign (occurring in 30–60% of cases). This results from air trapping secondary to partial obstruction of the airway, where the foreign body represents a valve that allows greater air passage on inspiration than on expiration (Fig. 27.2). This sign is more evident on forced expiratory or lateral decubitus radiography, which should be done systematically when there is suspicion of a foreign body. Atelectasis is a product of complete bronchial obstruction, particularly in the case of infants, in whom reabsorption of distal air causes alveolar collapse because of the absence of well-developed collateral ventilation. Other suggestive radiological findings are mediastinal deviation, interruption of an air bronchogram, and radiopaque foreign bodies, such as metal, bone, a tooth, or a stone (Figs. 27.3 and 27.4). A normal chest x-ray (which is present in up to 30% of cases) does not rule out the presence of a foreign body, which is why the clinical picture is the most important factor in deciding whether or not to perform bronchoscopy.

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Fig. 27.2

Lung hyperinflation. Anteroposterior chest x-rays of a 4-year-old child during inhalation (a) and during exhalation, showing hyperinflation of the left hemithorax (b)


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Fig. 27.3

Radiotranslucent foreign body in the left source bronchi, with secondary left lung hyperinflation


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Fig. 27.4

Radiopaque foreign body (a screw) in the right posterior basal bronchi


If the foreign body remains in the bronchi for an extended period, radiography may show atelectasis or bronchiectasis, the extent of which depends on the level of interlocking.


The usefulness of computerized tomography (CT) and virtual endoscopy is debatable. It has been suggested that these are indicated in cases of penetration syndrome with normal radiography, to avoid the anesthesia required for rigid bronchoscopy. However, in these cases, fiber bronchoscopy evaluation under sedation is more advantageous than CT, which, in addition to involving a radiation dose and being less readily available, also does not show the nature of the foreign body or the presence of granulation tissue, and thus has no therapeutic value.


Treatment


Immediate action in response to penetration syndrome can result in dislodgement of the foreign body. In an infant, this involves slapping the child’s back while he or she is being held with his or her head downward, with or without chest compression. In an older child, the classic Heimlich maneuver can be performed.


Treatment in response to inhalation of a foreign body is based on endoscopic extraction. There is no consensus as to the best anesthetic protocol, but there is more support for having the patient pharmacologically paralyzed than for maintaining spontaneous ventilation.


The most universal therapeutic approach is based on the degree of certainty about the presence of the foreign body.


Absolute certainty: There is absolute certainty in the case of dyspnea or persistent coughing after penetration syndrome, with asymmetry on pulmonary auscultation, localized hyperinsufflation, or a radiopaque foreign body. In these cases, the use of therapeutic bronchoscopy is indicated. Most often, the clinical situation is stable because the foreign body is located in the bronchi; thus, removal can wait for the recommended fasting time and to ensure the availability of the ideal equipment for extraction. On the other hand, extraction is urgently required if there is severe respiratory distress, mediastinal diversion, massive atelectasis, a pneumothorax, or, in the case of a particularly harmful foreign body such as a battery, because it can cause tissue necrosis, or spikes, that rapidly migrate distally.


Suspicion of a foreign body: In cases where there are few specific symptoms following penetration syndrome (especially if the child was symptomatic before the syndrome), or when the chest x-ray is normal or there are chronic or recurring radiological abnormalities, diagnostic exploration by flexible bronchoscopy is performed, which requires simple sedation (Fig. 27.5).

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Nov 7, 2020 | Posted by in Uncategorized | Comments Off on Children with an Airway Foreign Body
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