Delayed Diagnosis of Aspirated Foreign Body

Aspirated FB 2

We all know kids love to get objects stuck in areas where no foreign body should be. We have discussed this several times (the Nasal Foreign Body, the Ear Foreign Body, and the Ingested Foreign Body), but the Aspirated Foreign Body is the one that gets our attention the quickest. That is, unless, we missed it at first. Unfortunately, a foreign body in the bronchus may be deceptive and present in a delayed fashion… so, we must be vigilant (as always).

 

Young Kids are at Risk

  • It would seem intuitive that younger kids are at greater risk for aspiration… but why?
  • Young kids:
    1. put random things in their mouths. They like to explore their world… and don’t know what is not edible (hmmm crayons).
    2. don’t chew their food well. They do not have molar teeth and are prone to have insufficient mastication.
    3. are easily distracted.  It is not a great idea to yell at your sister while stuffing hotdogs in your mouth, but they don’t know that yet.
    4. don’t protect themselves well. They have relatively high epiglottis and immature swallowing coordination.

 

Drama is Easy to See, but Subtle can be Dangerous too.

  • The aspirated foreign body that leads to respiratory distress won’t be missed by many.
  • Unfortunately, an aspirated foreign body may go undiagnosed and this can lead to significant sequelae.
    • Persistent febrile illness
    • Chronic cough
    • Recurrent pneumonia
    • Recurrent / persistent “croup”
    • Poorly controlled “asthma”
    • Lung abscess
    • Hemoptysis
    • Progressive respiratory distress
    • Death
  • Delayed diagnosis of an aspirated foreign body is associated with increased incidence of complications.
  • This is particularly true for any vegetable matter (ex, peanuts), which cause more inflammatory response the longer it is in the body.

 

Factors Related to Delayed Diagnosis

  • Younger age

    • Kids 3 years of age and younger are more likely to be diagnosed with foreign body in a delayed fashion.
    • These kids are less able to give a reliable history and more at risk (as mentioned above) for aspiration.

 

  • Negative Chest X-rays

    • Just because the child’s CXR is negative, doesn’t mean that there is not a foreign body!
      • It just means your job is more difficult.
      • ~50% of known cases of aspiration will have normal chest x-rays.
    • Special projection films (decubitus position, exhalation films) can help, but should not be used to completely rule out the condition.
    • Normal X-rays should not preclude bronchoscopy in a patient that you have concern for an aspirated foreign body.
      • That is taken from the ENT literature — in case you need some support when dealing with consultants.

 

  • Care provider negligence

    • When no one is supervising, badness can happen (says Captain Obvious).
    • One study showed that having No history of a witnessed aspiration episode was associated with delayed diagnosis.
    • A lack of a parental report of an aspiration event should not sway you from considering retained foreign body in a child who’s clinical picture suggests it.

 

  • Lack of typical symptoms

    • With a radio-opaque foreign body, the diagnosis will depend on the history (hopefully someone saw something) and the physical exam.
    • Unfortunately, after the initial choking event, the aspirated foreign body may cause little if any symptoms, particularly if it falls to the bronchus.
    • The diagnosis is then delayed until symptoms of complications arise.
    • Location matters:
      • Larynx – typically will have symptoms of obstruction, dysphonia, or hoarseness. If blockage is complete, then can have cyanosis and severe distress / arrest.
      • Trachea – similar to larynx in presentation, but can have biphasic stridor, dry cough. Often appear uncomfortable or scared.
      • Bronchus – 80-90% of foreign bodies are found in the bronchus. Only 65% will have triad of cough, wheeze, and decreased breath sounds! Can be asymptomatic!
    • The absence of symptoms and signs does not rule out the possibility of foreign body if the child has a concerning history of aspiration.

 

  • We were not vigilant

    • Simply put, we didn’t think about the possibility.
    • The diagnosis can be rather difficult, as it may present similar to other conditions:
      • Recurrent Croup and Croup are commonly diagnosed instead of Foreign Body.
      • Asthma, bronchitis, pneumonia, laryngitis, and URI are other common mis-diagnoses.

 

Believe the Parents

  • Multiple studies have shown that, while a variety of clinical signs may be seen with an aspirated foreign body…
  • The most sensitive clinical indicator for an aspiration is there being aWitnessed Aspiration Episode.”
  • Since the physical exam and radiographs may be unenlightening, the parental report of a choking crisis needs to be taken seriously!

 

References

Huankang Z1, Kuanlin X, Xiaolin H, Witt D. Comparison between tracheal foreign body and bronchial foreign body: a review of 1,007 cases. Int J Pediatr Otorhinolaryngol. 2012 Dec;76(12):1719-25. PMID: 22944360. [PubMed] [Read by QxMD]

Oncel M1, Sunam GS, Ceran S. Tracheobronchial aspiration of foreign bodies and rigid bronchoscopy in children. Pediatr Int. 2012 Aug;54(4):532-5. PMID: 22414345. [PubMed] [Read by QxMD]

Shlizerman L1, Mazzawi S, Rakover Y, Ashkenazi D. Foreign body aspiration in children: the effects of delayed diagnosis. Am J Otolaryngol. 2010 Sep-Oct;31(5):320-4. PMID: 20015771. [PubMed] [Read by QxMD]

Rodríguez H1, Passali GC, Gregori D, Chinski A, Tiscornia C, Botto H, Nieto M, Zanetta A, Passali D, Cuestas G. Management of foreign bodies in the airway and oesophagus. Int J Pediatr Otorhinolaryngol. 2012 May 14;76 Suppl 1:S84-91. PMID: 22365376. [PubMed] [Read by QxMD]

Orji FT1, Akpeh JO. Tracheobronchial foreign body aspiration in children: how reliable are clinical and radiological signs in the diagnosis? Clin Otolaryngol. 2010 Dec;35(6):479-85. PMID: 21199409. [PubMed] [Read by QxMD]

Bloom DC1, Christenson TE, Manning SC, Eksteen EC, Perkins JA, Inglis AF, Stool SE. Plastic laryngeal foreign bodies in children: a diagnostic challenge. Int J Pediatr Otorhinolaryngol. 2005 May;69(5):657-62. PMID: 15850686. [PubMed] [Read by QxMD]

Sersar SI1, Rizk WH, Bilal M, El Diasty MM, Eltantawy TA, Abdelhakam BB, Elgamal AM, Bieh AA. Inhaled foreign bodies: presentation, management and value of history and plain chest radiography in delayed presentation. Otolaryngol Head Neck Surg. 2006 Jan;134(1):92-9. PMID: 16399187. [PubMed] [Read by QxMD]

Saquib Mallick M1, Rauf Khan A, Al-Bassam A. Late presentation of tracheobronchial foreign body aspiration in children. J Trop Pediatr. 2005 Jun;51(3):145-8. PMID: 15831667. [PubMed] [Read by QxMD]

Hilliard T1, Sim R, Saunders M, Hewer SL, Henderson J. Delayed diagnosis of foreign body aspiration in children. Emerg Med J. 2003 Jan;20(1):100-1. PMID: 12533387. [PubMed] [Read by QxMD]

Mu L1, He P, Sun D. The causes and complications of late diagnosis of foreign body aspiration in children. Report of 210 cases. Arch Otolaryngol Head Neck Surg. 1991 Aug;117(8):876-9. PMID: 1892618. [PubMed] [Read by QxMD]

Sean Fox

I enjoy taking care of patients and I finding it endlessly rewarding to help train others to do the same. I trained at the Combined Emergency Medicine and Pediatrics residency program at University of Maryland, where I had the tremendous fortune of learning from world renown educators and clinicians. Now I have the unbelievable honor of working with an unbelievably gifted group of practitioners at Carolinas Medical Center. I strive every day to inspire my residents as much as they inspire me.

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