Thorax (1976), 31, 635.

Aspirated foreign bodies in thetracheobronchial tree: report of 250 cases

OSAMA A. ABDULMAJID, ABDELMOMEN M. EBEID,MOHAMED M. MOTAWEH, and IBRAHIM S. KLEIBO

Thoracic Surgical Unit and A naesthesia Unit, Chest Diseases Hospital, Kuwait

Abdulmajid, 0. A., Ebeid, A. M., Motaweh, M. M., and Kleibo, I. S. (1976). Thorax,31, 635-640. Aspirated foreign bodies in the tracheobronchial tree: report of 250 cases.During the last 14 years 250 patients with aspirated foreign bodies in the tracheo-bronchial tree were admitted to Kuwait Chest Diseases Hospital. Ninety-six per cent ofthe cases were under 10 years of age and 38% gave a clear history of foreign bodyinhalation. The rest were diagnosed either clinically, from the chest radiograph findingsor because of unexplained pulmonary symptoms. In 247 cases, bronchoscopy undergeneral anaesthesia was successful in removing the foreign bodies. In only three caseswas bronchotomy needed. Seventy per cent of the foreign bodies were melon seeds.Asphyxia and cardiac arrest occurred in four cases during bronchoscopy but the patientswere successfully resuscitated. In 10 cases a tracheostomy was done before bronchoscopyand the removal of the foreign body, while in five it was needed after the bronchoscopy.Fifteen patients developed late complications such as recurrent pneumonia or atelectasisof the lung. Early diagnosis and adequate treatment are essential to prevent pulmonaryand cardiac complications and to avoid radical lung surgery.

PATIENTS

Of our 250 patients, 105 were under 2 years ofage (42%), 105 were aged 2-6 years (42%), and30 were 6-10 years old (12%). Only 4% of caseswere above 10 years of age. One hundred andforty patients were female (46%) and 110 weremale (44%). Of the foreign bodies, 70% werelocated in the right bronchial tree, 17% in thetrachea, and only 13% in the left bronchial tree.

DIAGNOSIS OF FOREIGN BODY INHALATION

Early diagnosis depends on the following factors:1. History of foreign body inhalation: 96 of

the patients (38%) gave a clear history offoreign body inhalation which was in itselfdiagnostic.

2. Clinical picture: 54 of the patients (22%)presented with a history of an acute episodeof choking and cough, which was highlysuggestive of foreign body inhalation. Theremaining 100 patients (40%) presented withwheezing, cough, and dyspnoea which gaverise to a suspicion of foreign body inhalation.

3. Radiographic findings: 80% of patients

showed normal radiographic findings andonly 8% showed a definite foreign bodyshadow (Fig. 1). In eight cases the radiographshowed bilateral obstructive emphysema dueto partial obstruction of the trachea, and in12 cases it showed right or left lung em-physema due to partial obstruction of thebronchi (Fig. 2). Ten patients showed atel-ectasis of a lobe, of which seven were rightlower lobes (Fig. 3) and three left lowerlobes (Fig. 4).

NATURE OF FOREIGN BODIES

Seventy per cent of the foreign bodies were melonseeds and 15%1 were peanuts, shells of variousnuts, and almond kernels. The rest (15%) werescrews (9 cases), metal pins (6 cases), fish bones(4 cases), a rosary bead, metal clips (2 cases), anear-ring, a pebble, a nail cutter, and a metal toy(Fig. 5).

MANAGEMENT OF ASPIRATED FOREIGN BODIES

The course of the illness after inhalation of theforeign body and its management depend on the

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FIG. 2. Chest radiograph showing emphysema ofright lung due to foreign body in right main bronchus.

FIG. 1(a, b). Chest radiographs showing foreign body(whistle) just above carina.

patient's age, the position of the foreign body inthe tracheobronchial tree, the duration of stay ofthis object in the air passages, and the nature ofthe foreign body. In our experience, over the last14 years it has been possible to remove the foreignbodies in 247 cases by bronchoscopy under generalanaesthesia, using for induction either thiopentonesodium 2-5% or inhalational anaesthesia withnitrous oxide, oxygen, and halothane followed by

succinylcholine and maintenance with inhala-tional anaesthesia.Our successful results with bronchoscopy are

attributable to two factors. First, the majority offoreign bodies were melon seeds which wererelatively easy to remove at bronchoscopy.Secondly, the majority of patients were broncho-scoped soon after inhalation of the foreign bodyand before secondary inflammatory changes haddeveloped in the bronchial tree. In three casesonly did bronchoscopic removal fail. Two of thesehad screws penetrating the wall of the rightbronchus, and in the third case there was arosary bead impacted in the posterior segmentalopening of the right lower lobe bronchus. Inthese three cases thoracotomy was done and theforeign bodies were removed through broncho-tomy (Salomon, Shindel, and Levy, 1968).

COMPLICATIONS OF ASPIRATED FOREIGN BODIES

IMMEDIATE COMPLICATIONS

1. Asphyxia and cardiac arrest occurred in fourof our 250 patients. Management of such casesconsisted of external cardiac massage and endo-tracheal intubation followed by thorough oxy-genation. All four were successfully resuscitatedand the foreign bodies were removed.

2. Severe obstructive dyspnoea occurred in 10cases. Such a complication needed an urgenttracheostomy.

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FIG. 3(a, b). Chest radiographs showing nail in right bronchus with collapseof right lower lobe.

3. Complications of bronchoscopy(a) Trauma to the glottis: five patients de-

veloped severe respiratory distress shortlyafter bronchoscopy and successful re-moval of the foreign body. In spite ofcortisone therapy after bronchoscopy atracheostomy was necessary.

(b) A right tension pneumothorax occurredin one patient after removal of theforeign body. This was due to injury ofthe right main bronchus and it was sus-pected from deepening cyanosis not re-sponding to oxygenation. The diagnosiswas confirmed by a chest radiograph. A

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FIG. 4. Chest radiograph showing atelectasis of leftlower lobe with obstructive emphysema of left upper

lobe due to foreign body in left main bronchus.

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FIG. 5. Metal toy removed from trachea.

pleural drain was immediately insertedand the bronchial leak was closed byopen thoracotomy.

LATE COMPLICATIONS In 15 patients late compli-cations developed owing to retention of theforeign body in the bronchial tree for a few weeksor more. This gave rise to recurrent pneumonia in12 cases (Fig. 6), lung abscess in one case, andcystic bronchiectasis in two cases (Deney et al.,1968).

DISCUSSION

The two striking features of our series were that70% of the foreign bodies aspirated were melonseeds and 96% of our patients were under the ageof 10 years. Eighty-four per cent of the patientswere under 6 years of age, while among Johanssonand William-Olsson's (1961) patients only 44%were less than 6 years old. In the majority of Arabcountries melon seeds are saved from watermelons, dried, salted, and roasted, and then thekernel is eaten after removal of the shell. As theseeds are mixed with saliva they become slipperyand may be inhaled by children while crying ortalking. A salted melon seed, if retained for morethan two to three weeks, irritates the bronchialmucosa, absorbs fluid, and becomes swollen. Itmay thus completely obstruct the bronchiallumen, pedisposing to infection, granulation tissueformation, and irreversible pulmonary change,which may necessitate resection of one or morelobes. Only 38% of the patients gave a clearhistory of foreign body inhalation. However, aforeign body may be retained for a long time inthe tracheobronchial tree, the patient remainingasymptomatic after an acute episode of chokingand cough. The family or the patient may not re-member the episode distinctly. It is therefore im-portant for the physician to suspect foreign bodyinhalation in patients with unexplained pulmonarysymptoms and signs such as unilateral wheeze,haemoptysis, recurrent pneumonia occurring inthe same lung, and isolated lung abscess. The re-moval of aspirated foreign bodies depends on theskill and experience of the chest surgeon and theanaesthetist.A common cause of death after foreign body

inhalation is hypoxia, so preoxygenation, quickand smooth induction of anaesthesia, and laryngo-scopy may save the life of the patient as a foreignbody may impact in the subglottic region. Of our250 cases, four patients had cardiac arrest dueto severe hypoxia during the bronchoscopy pro-cedure. They were successfully resuscitated andthe foreign body was subsequently removed. Sinceearly detection of cardiac arrest is essential, theuse of a cardioscope before induction of anaes-

thesia is helpful. Bronchoscopy, when performedby a competent specialist, is usually a safe pro-cedure, especially if the proper instruments are

available and checked carefully before use. Toavoid subglottic oedema cortisone was given im-mediately after bronchoscopy and for the follow-ing two days to all the patients under 2 years ofage. Bronchoscopy may fail to remove some

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FIG. 6(a, b, c) Chest radiographs showing (a) pneu-monia of right middle lobe due to undiagnosedforeign body in right main bronchus, (b) clearance,and (c) recurrence.

foreign bodies, such as a screw or nail penetratingthe wall of the bronchus, thus necessitatingthoracotomy and bronchotomy. If bronchoscopyfails, it should be repeated after short intervals ofphysiotherapy and antibiotic treatment, and re-

moval of the foreign body is usually possible.Cotton et al. (1973) suggested removal of foreignbodies by inhalational therapy and posturaldrainage, which may need up to 70 treatments.This may take up to seven days. We are more in

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favour of the use of bronchoscopy for the removalof foreign bodies. It is safer, much more rapid,and gives the opportunity to visualize the bron-chial tree.

REFERENCES

Cotton. E. K., Abrams, G., Vanhoutte, J., and Bur-rington, J. (1973). Removal of aspirated foreignbodies by inhalation and postural drainage:survey of 24 cases. Journal of Clinical Paediatrics,12, 270.

Deney, M. K., Berkas, E. M., Snider, T. H., andNedwicki, E. G. (1968). Foreign body bronchiec-tasis. Diseases of the Chest, 53, 613.

Johansson. L. and William-Olsson, G. (1961). Foreignbodies in the bronchi. A cta Chirurgica Scan-dinavica, Supplement, 283, 153.

Salomon, J. S., Shindel, J., and Levy, M. J. (1968).Bronchotomy for removal of aspirated foreignbodies. Diseases of the Chest, 54, 39.

Requests for reprints to: Osama A. Abdulmajid,FRCS, Head of Thoracic Surgical Unit, ChestDiseases Hospital, Post Box No. 4082, Kuwait.

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