|Year : 2017 | Volume
| Issue : 6 | Page : 172-174
Bronchial foreign body: An accidental finding
Ramatu Abdullah1, Ibrahim Aliyu2
1 Department of Paediatrics, Aminu Kano Teaching Hospital, Kano, Nigeria
2 Department of Paediatrics, Aminu Kano Teaching Hospital, Bayero University Kano, Kano, Nigeria
|Date of Web Publication||8-Nov-2017|
Department of Paediatrics, Aminu Kano Teaching Hospital, Kano
Source of Support: None, Conflict of Interest: None
Airway foreign body aspiration is more common in younger children of <3 years of age; it commonly affects the right bronchus and is often characterized by sudden onset of coughing, choking, and difficulty in breathing. We report a case of a 6-year-old girl who presented with fever, cough, and difficulty in breathing who never had any preceding episode or witnessed choking or gagging event, she was diagnosed of pneumonia, and a chest X-ray revealed a left bronchial foreign body. She had bronchoscopy and the foreign body was removed successfully.
Keywords: Bronchoscopy, children, foreign body aspiration
|How to cite this article:|
Abdullah R, Aliyu I. Bronchial foreign body: An accidental finding. Ibnosina J Med Biomed Sci 2017;9:172-4
| Introduction|| |
Foreign body aspiration occurs mostly in children, especially when they start exploring their environment through mouthing of objects. This is most common among older infants and toddlers, with children younger than 3 years accounting for 73% of cases  and incidence reducing with increasing age. There is variability in its clinical presentation; therefore, a high index of suspicion should be entertained in making the diagnosis especially in younger children. Common objects often aspirated are pins, nails, pen caps and butts, beads, food particles, and seeds. The clinical presentation is dependent on the nature, size, and location of the aspirated material. They could present as pediatric emergency due to airway obstruction and asphyxia or may be asymptomatic, but a child who initially was well and suddenly develops cough, choking and difficulty with breathing with a localized wheeze should arouse the suspicion of foreign body aspiration. We present a 6 year-old-girl who was seen in the pediatric emergency unit of our health facility with a complaint of fever and cough who on chest radiograph was discovered to have aspirated a foreign body.
| Case Report|| |
A 6-year-old girl presented to the pediatric emergency unit of our health facility, with a complaint of cough, fever, and difficulty in breathing of 4 days before presentation. She had been well before onset of illness. The fever was of high grade associated with chills and rigor, no history of neck pain, headache, or loss of consciousness. She also had cough which was nonparoxysmal, nonproductive of sputum, there was difficulty with breathing at rest with complaint of chest pain worsened with coughing and no difficulty with lying flat on the bed; no history of darkening of the lips or palms or soles of the feet and no history of wheezing, no history of difficulty with breathing. Other histories were noncontributory. At the onset of illness, she was seen at a chemist and was placed on oral drugs which the mother could not remember their names; however, there was no improvement in her illness. This prompted her presentation to our hospital.
On examination, she was acutely ill-looking, in respiratory distress, febrile with temperature of 39.6°C, not cyanosed, not pale, and had no peripheral lymphadenopathy. Her anthropometry was normal for age and sex.
She had a respiratory rate of 76 cycles/minute, chest was symmetrical, trachea was central; she had reduced chest expansion on the left anterior zone and a dull percussion note, with hash breath sound on the same area but no rhonchi. Pulse oximeter reading was 92% in room air. She had a pulse rate of 120 b/min. regular, synchronous, and full volume peripheral pulses. Her blood pressure was 90/60 mmHg supine using the right arm; she had first and second heart sounds and no murmur. Other systems were not contributory; a diagnosis of the left lobar pneumonia was made. She was commenced on amoxicillin, erythromycin, and paracetamol. The patient improved on medications. The full blood count showed increased total leukocyte count with raised neutrophil count. The chest X-ray, however, showed a radiopaque [Figure 1] somewhat nail-shaped object lodged in the region of the left main bronchus, but there was no evidence of hyperinflation or atelectasis of the left lung. The patient was reviewed by the otorhinolaryngologist and the foreign body was successfully removed using an appropriate size bronchoscope. The object was a metallic sandal tag nail which measured 0.5 cm × 0.5 cm × 1.5 cm [Figure 2]. Postoperative findings showed progressive improvement in the air entry on the left lung with an increase in the oxygen saturation to 99% in room air. The patient was discharged home and is currently doing well.
|Figure 1: Chest X-ray showing the foreign body in the left bronchial area|
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| Discussion|| |
Airway foreign body aspiration is the most common in children <3 years;, this is attributable to their activity of exploring their environment through mouthing of objects. Furthermore, they are most susceptible because they lack enough dentition and ability to grind food particles adequately, and also have immature coordination of swallowing; with increasing age, the incidence of airway foreign body aspiration becomes less common except in those children who are mentally retarded. Our patient was a 6-year-old with an appropriate neurodevelopmental milestone for age, with less risk of aspiration. It is possible that the aspiration occurred at a younger age and had been neglected for a long time or it accidentally occurred unwitnessed which has been reported in 19% of children  and the child failed to complain to her parents for fear of been scolded. However, accidental finding of airway foreign body has been reported in about 1%–9% of children.
The clinical presentation of airway foreign aspiration depends on the size, its composition, and location in the airway. There are three stages of symptoms resulting from airway foreign body aspiration; the initial event is characterized by violent coughing, choking, and gagging. History of choking and coughing has a sensitivity of 90% for foreign body aspiration with a specificity of 36%–82%. Unilateral diminished breath sounds were found to have a sensitivity of 75.1%–79.4% and a specificity of 68.1%–81.3%. The second stage is asymptomatic: At this time, the foreign body becomes lodged, the reflexes become fatigued, and the irritating symptoms subside. A child with foreign body aspiration could be missed at this stage. In the third stage, which may occur days to months later, complications such as airway obstruction, erosion, and infection may occur. Bronchial foreign body aspiration is more common on the right bronchus, but it could occur on the left side as it was the case in this patient. Airway foreign body lodges in the larynx in 3%, trachea and carina 13%, right lung in 60% (right main bronchus 52%, lower lobe bronchus 6%, and middle lobe bronchus <2%), left lung in 23% (left main bronchus 18% and lower lobe bronchus 5%), and bilaterally in 2% of cases. Large bronchial foreign body could completely occlude the airway resulting in asphyxiation, while a smaller size particle could be asymptomatic. The airway size increases progressively with increasing age of children and correlate with anthropometric factors like body weight and length; there is no significant gender difference in airway size. The left main bronchus is usually smaller than the right main bronchus; the estimated left main bronchial area for this patient was 23.737 mm 2, from the formula 20.055 + 0.263xwt (kg), while the area of the aspirated object was about 8.0 mm 2 therefore occluding about 35% of the left main bronchus, hence, clinical features of bronchial obstruction should have been detected; its absence, however, does not rule it out. The foreign body in this patient could have initially been lodged in the larger airway and subsequently descended into the left main bronchus. There is often significant delay before the diagnosis of foreign body aspiration is made. This has been attributed to the high rate of initial alternative diagnoses  and has often been misdiagnosed as asthma, viral croup, upper respiratory tract infection and pneumonia. Our patient was initially managed for pneumonia before the diagnosis of foreign body aspiration was made following a chest radiograph. Therefore, this highlights the relevance of current guideline for managing children with community-acquired pneumonia which recommends chest X-ray for all patients with moderate to severe pneumonia who require inpatient care; while those without severe disease who could be treated on ambulatory basis may not require chest X-ray. The usefulness of diagnostic imaging is variable since most foreign bodies aspirated are not radiopaque. It has been reported that imaging studies have a sensitivity of 73% and a specificity of 45%, however, up to 20% of patients will have both negative history and radiographic evaluation.
| Conclusion|| |
Bronchial foreign body can occur in older-aged children, and the diagnosis can easily be missed in children who may present with features of chest infection as was seen in our patient who was initially managed for upper respiratory tract infection. Therefore, thorough investigation should always be done especially in patients with chest infection severe enough to warrant in-patient care.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Both authors contributed equally to the preparation, revision and approval of final version the manuscript.
Financial support and sponsorship
Conflicts of interest
Compliance with ethical principles
No prior IRB approval is required for isolated cases reports. The family agreed to publication on an anonymous basis.
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[Figure 1], [Figure 2]