What is foreign body aspiration into the trachea in children?

Foreign body aspiration is the ingestion of an object through the mouth or nose into the tracheobronchial system during breathing. Tracheobronchial foreign body aspiration (FBA) is the most common cause of sudden upper respiratory tract obstruction. Let's briefly talk about the anatomy of the respiratory tract without going into the details of Foreign Body Aspiration. The respiratory tract starts from the external opening of the nose and ends in the allveoli where gas exchange takes place in the last part of the lungs.

In which age group is foreign body aspiration more common in children?

The most common age group for foreign body aspiration is children between the ages of 6 months and 3 years. This age group is responsible for 7% of deaths.

In this age range, it is the period when babies start the habit of catching and taking what they catch to their mouths, chewing and swallowing. It is also the period when children begin to chew and swallow large pieces of food. Again, the presence of objects suitable for escaping into the airways, especially toys, around children starts at this age. Therefore, it is more common in this age range.

Foreign objects entering the airways are more common in boys than in girls. This is attributed to the fact that boys are more active than girls.

Which objects most commonly get into the airways?

Aspirated objects can generally be divided into two. Radioopaque, that is, objects seen directly on the X-ray film, and nonopaque objects that are not directly visible on direct radiographs. Which of these objects are aspirated more often is also related to the social lifestyles of the societies in which they live. In Turkey, nonopaque and food items are aspirated most frequently. These include sunflower seeds and shells, hazelnuts, peanuts, small candies, walnuts, apples, carrots, sausages, grapes. Among opaque objects, safety pins, evil eyes, pins with knobs, pencil caps and small toy parts are the most common objects.

What are the Clinical Complaints in Children with Foreign Objects in the Airways?

In the older age group, these patients express themselves, for example, girls say that they aspirated a needle with a knob. In young children, mothers have typical stories; In fact, this child did not have any complaints, he was eating this with his siblings, or sleeping with these toys, or these needles or charms on his neck have disappeared and they express sudden onset of terminal complaints. These complaints include coughing, wheezing, shortness of breath, shortness of breath, bruising, etc. In patients who have been ill for a long time, they present with complaints such as coughing, wheezing, shortness of breath, bruising, etc.

Can Foreign Body Aspirations be Diagnosed Late? Why?

Unfortunately, 20-45% of children with foreign body aspiration are diagnosed after three days.

What are the reasons for late diagnosis of foreign body aspiration?

• No history of foreign body aspiration,
• No one is with the child when he/she aspirates the object and the event is not seen,
• Parents may not care about the child's complaints,
• There may be no obvious findings in the chest X-ray, even the film may be normal,
• They may get a wrong diagnosis,

What is the reason for this patient being misdiagnosed and which diseases can it be confused with?

Since the complaints of the patients are not very typical, especially children without a clear history of foreign body aspiration may be misdiagnosed.  Mainly Confused Diseases; Bronchitis, tuberculosis, whooping cough, asthma, croup are the most common misdiagnoses.

Is it dangerous for a foreign body to enter the airways (aspiration)?

Foreign Aspiration is a condition that requires emergency treatment. When such a condition is seen or suspected in the child, the nearest health institution should be consulted urgently. Otherwise, it can lead to serious complications and death.

Where does a foreign body lodge in the airway?

Foreign bodies can lodge anywhere in the airways, from the nose to the very tip of the airways. However, they are often found in the largest airways. Since the right anabronch is steeper and wider, foreign body aspiration is more common in the right anabronch.

What should we do, or not do, if we witness a foreign body aspiration?

If you suspect that a foreign body has entered your child's lungs, you should contact the nearest health institution as soon as possible. If there are signs suggesting that the airways are completely blocked, such as shortness of breath and bruising after the foreign body enters the airways, some maneuvers should be performed immediately. Heimlich maneuver should be applied. This maneuver is recommended for children older than one year. For children younger than one year, successive strokes to the chest and back should be applied. These maneuvers are best performed by trained people, but if no trained person is available, they can also be performed by adults if necessary.

The foreign body should not be tried to be removed from the mouth by hand, especially in babies with teeth. Because we may unintentionally push the objects down further or cause the baby's teeth to break and cause them to escape into the patient's trachea.

What are the Clinical Complaints and Findings in Foreign Body Aspiration in Children?

• Patients who develop Foreign Body Aspiration may present to the physician urgently with sudden onset of symptoms, or they may present to the physician quite late with mild and recurrent complaints.
• It has been found that more than half of the cases present to the physician within the first 24 hours due to sudden respiratory distress.
• In addition, there are cases that present to the physician years later with late complications or are detected incidentally.
• Symptoms related to aspiration of solids vary according to the size of the aspirated object and the bronchial level in which it is located.
• Large objects are usually lodged in the larynx and trachea and if not removed result in aphonia, agitation, cyanosis, loss of consciousness and death.
• Small solid objects obstruct the right or left main bronchus or more distal bronchi. In this case, the first symptom may be coughing and wheezing.
• Dyspnea, chest pain, fever, nausea and vomiting may follow.
• On the other hand, the presenting complaints may differ in the early and late periods.
• The most common complaints in the early period are sudden onset of paroxysmal cough, wheezing, respiratory distress, fever, and sometimes aphonia, agitation, cyanosis, loss of consciousness and death due to aspiration of a foreign body.
• Late presenting complaints may include cough, wheezing, recurrent lung infection and brochiectasis. Some cases may even be diagnosed as asthma bronchiale due to excessive bronchial irritation response and treated with this diagnosis for years.

How is Foreign Body Aspiration Diagnosed in Children?

The diagnosis is made by history and physical examination and confirmed by imaging methods.

• One of the most important diagnostic criteria is the family or pediatric history. However, in 10-20% of cases, a foreign body is detected in bronchoscopy performed on the basis of clinical findings despite the absence of a history.
• Physical examination performed after a good history may reveal cyanosis, stridor, wheezing, intercostal retraction, nosebleed breathing and fever.
• Auscultation (listening with a stethoscope) may reveal decreased and/or absent bilateral or unilateral respiratory sounds, delayed rhonchi, and coarsening of lung sounds and rales in cases presenting with recurrent lung infections.

What is Imaging in the Diagnosis of Foreign Body Aspiration?

Main imaging modalities used in the diagnosis of foreign body aspirations;

• Chest radiography, computed tomography and bronchoscopy.
• Chest X-ray is the first method to be used for visualization of the tracheobronchial tree.
• Posterior anterior direct radiography may be sufficient for the diagnosis of radiopaque bodies (Figure Ia)

• However, lateral, oblique and decubitus radiographs can be taken to better define the localization and size of the object (Figure Ib).
• Studies have shown that 90% of aspirated foreign bodies are not radioopaque. In non-radiopaque bodies, increased ventilation due to air trapping on the aspiration side and opening of intercostal distances are observed (Figure IIa, IIb).

• Air trapping is better seen on the chest radiograph taken after expiration (exhalation).
• The chest radiograph taken in the lateral decubitus position normally shows less aeration in the lower lobes and segments of the lung, but increased aeration is seen due to air trapping due to foreign body aspiration.
• Sometimes lobar or total atelectasis may be seen due to obstruction of the main airways.
• Findings on direct radiographic radiographs are not specific for foreign body aspiration and other lung pathologies may also give similar images.
• Direct chest radiography was found to be normal in 24-30% of cases with proven foreign body aspiration.
• Virtual bronchoscopy can also be performed for diagnostic purposes in selected cases. However, virtual bronchoscopy with computed tomography should be performed in selected cases because of the serious radiation exposure of the patients.
• Virtual bronchoscopy is not performed with conventional CT but with multi-detector spiral CT.
• Virtual bronchoscopy should be performed in selected patients who do not accept bronchoscopy under general anesthesia, who have an unclear history, who are delayed, and who do not have a definite indication for bronchoscopy (Figure IIIa, IIIb).

• In the differential diagnosis of early foreign body aspiration, acute laryngotracheitis, epiglottitis, retropharyngeal abscess, bronchitis and bronchial asthma should be considered.
• In the differential diagnosis of suspicious and/or delayed cases, chronic bronchitis, bronchial asthma, pneumonia, tuberculosis, and compressive causes (lymphadenopathy, tumor), cystic fibrosis should be considered.
• Since bronchoscopy is also a treatment method, it will be described in the treatment.

How to remove a foreign body from the airways in children?

Children who are thought to have a foreign body in their airways should undergo a rigid bronchoscopy procedure as soon as possible to examine the airways and remove any foreign body. Rigid bronchoscopy is simply a hollow tube. It allows the airways to be examined and if there is a foreign body, it can be passed through this tube and removed with some devices used.

Does the child recover immediately and completely when the foreign body is removed from the airways?

If the foreign body is recognized immediately and removed in a short time, all complaints disappear in many children following the removal of the foreign body. However, in delayed cases where the foreign body remains unrecognized for a long time (especially after 3 days), asthma-like complaints such as coughing and wheezing may be observed in some children even after the foreign body is removed.

Are There Risks of Rigid Bronchoscopy?

The procedure is performed under general anesthesia. Therefore, anesthesia is primarily associated with risks. There may also be complications of the procedure. Especially in delayed cases, the foreign body cannot be removed at once and the procedure needs to be repeated. Air leakage and pneumothorax due to bronchial injury, lung infection and respiratory failure may require intensive care.

What Can We Do to Prevent Foreign Body Aspiration?

The most effective treatment is prevention!

Children between the ages of six months and three years often put objects in their mouths and this increases the risk of FCA. Children younger than three years of age have incomplete teeth. Therefore, especially foods that are easy to aspirate such as grapes, sausages and carrots should not be given without proper preparation.

• In order for the child to chew and swallow properly and to concentrate, he/she should not be disturbed during meals and should not be laughed at, especially while feeding.
• Children should be observed during play and should not be allowed to run with various objects or food in their mouths.
• Other precautions that can be taken include keeping objects within the reach of children in the first 3 years of life that can get into their mouths and into their airways, and keeping toys containing small parts away from children in this age group.
• In order to prevent YCAs, programs should be organized especially for the education of parents and warning labels should be placed on toys that are likely to be aspirated.
• Foods and snacks such as seeds, nuts, peanuts, chickpeas, chickpeas, chickpeas and beans should not be given to babies and children aged 4-6 years.
• Clean the seeds of fruits with seeds such as tangerines, oranges, plums, olives, watermelon and grapes and give them to your child. Due to the slipperiness of tangerine slices, we should divide these slices and feed them to your child.
• When foreign body aspiration is detected or suspected, 112 should be called immediately.
• Avoid wearing safety pins, which is a common habit in our country, and evil eye or gold tags etc.
• Young girls should not be made to talk and laugh while fastening their headscarves, especially by their friends. Because they temporarily hold the safety pin between their lips and if they talk or laugh, the needle will escape into the windpipe.

*** The information provided here, the content of the website is intended to inform the visitor, especially families. No information should be considered as advice by visitors and should not lead to any decision or action. Families should definitely have their patient examined by a pediatric surgery specialist, consult with him/her and make a decision by consulting his/her knowledge one-on-one.