Case study: foreign body aspiration
This article describes the case of a healthy 12-month-old who presented to the emergency with a case of foreign-body aspiration. The child was brought to the emergency department with a 4-hour history of coughing and stridor. Similarly, the child choked while eating, 4 hours earlier. Examination showed a respiratory rate of 38 breaths per minute. Oxygen saturation of 98% while the patient was breathing ambient air. The patient appeared well otherwise, with no signs of cough or stridor.
Clinical findings
On auscultation, the right lung was significant for crackles and wheezing, whereas the left lung was clear. Doctors further advised a chest radiograph which showed opacification and volume loss in the right lung. The mediastinum was seen to have shifted towards the right and there were signs of hyperinflation in the left lung. The doctors were concerned about obstruction of the right airway because of the abnormal radiographic appearance of the right lung. For further evaluation, doctors referred the patient for rigid bronchoscopy. During the procedure, a foreign body was removed from the left mainstem bronchus, even though the left lung appeared to be clear.
The left mainstem bronchus was partially obstructed which resulted in hyperinflation on that side with passive atelectasis and opacification on the right side. Foreign-body aspiration is a life-threatening condition in children; thus, it is important to note that the radiograph may appear normal when radiolucent objects are aspirated. If there is a high suspicion of foreign-body aspiration, patients should be referred for a prompt bronchoscopy to avoid acute and chronic complications. Doctors further advised a repeat radiograph, findings of which were normal. However, the course of treatment was complicated with pneumonia which was treated with antimicrobial treatment.
Foreign body aspiration is a common occurrence in children under the age of 3. It is the most frequent cause of accidental deaths in children under 12 months of age. The risk of foreign body aspiration increases in children because of a different structure of the pharynx and upper airways compared to adults. Similarly, children have an immature swallowing mechanism and commonly aspirate food. A foreign body aspiration is often a sudden event when the child feels like they are suffocating and choking.
Clinical presentation
The clinical presentation of an acute event of foreign body aspiration ranges from severe respiratory distress to minimal symptoms. Prevention and a rapid diagnosis of foreign body inhalation is the best course for preventing any long-term or fatal consequences. The best diagnostic and therapeutic modality for foreign body inhalation is bronchoscopy. The American Academy of Pediatrics published a paper on the prevention of foreign body aspiration in 2010. The paper stated that more proactive prevention methods are needed to prevent mortality and morbidity. The measures include creating a safe environment for children and raising awareness for parents, as well as caregivers to supervise children. Moreover, changing the design of products, such as foods and toys will also reduce the risk of choking. Whereas promoting legislation and enforcing regulations to prevent dangerous products from being sold to children will also be helpful.
Young children are particularly at a higher risk of foreign body aspiration
98% of the cases of foreign body aspiration are reported in children under the age of 5 years and the mean age is shown to be 24 months. Another reason why foreign body aspiration is more common in children is that molars are not present before the age of 2. Thus children of this age group chew with their incisors. Moreover, are not able to grind food into smaller pieces effectively. Young children also tend to exhibit high levels of activity and distractibility while eating which puts them at a higher risk of foreign body aspiration.
Interestingly, children have a narrow tracheobronchial tree compared to adults and typically, the proximal airway is the site of obstruction. Studies have further shown that 95% of foreign bodies that are aspirated are found in this location. Whereas in children under the age of 15, the foreign bodies generally lodge within the left lung, as often as in the right lung. However, regardless of age, radiographs are consistent with a noticeable aortic indentation on the trachea and the right bronchial angle is less distinct compared to the left side. Similarly, aspiration is more common in the right lung.
In 2016, a survey conducted by the National Safety Council concluded that the rate of fatal choking in American children under the age of 5 is 0.43 per 100,000 children. However, a previous study analyzed that the rate of non-fatal choking is comparatively higher in children under the age of 14 years. Most of the non-fatal choking cases involve candy and nuts that require hospitalisation.
References
Saar, K.M. and Grindle, C.R., 2022. Foreign-Body Aspiration in a Child. New England Journal of Medicine, 386(18), pp.1741-1741.
