A harrowing swallow

Aspirated foreign bodies should be considered as a differential in any young child with unexplained cough

A harrowing swallow

Small children, especially those younger than 3 years, are prone to putting small objects in the mouth. With their limited chewing capabilities and high respiratory rates, these objects are inadvertently swallowed in. Further their tendency to laugh and run around while eating also increases the chances of the object being aspirated into the trachea. Most often these are food items. However, it is not uncommon for children to explore non-food items, resulting in the aspiration of foreign bodies. Some of the most commonly found non-food items include small toys and jewelry. Aspirated objects have the propensity to get lodged in the right bronchus as it is wider and has more direct extensions from the trachea.
Clinical presentation may be extremely variable depending on the location of the aspirated object. Most often, the child experiences sudden coughing bouts or choking. In worst cases, if the object is large and causes a total or near-total occlusion of the airway, it can result in death or hypoxic brain damage. However, the more difficult and tricky cases are the ones in which the aspiration goes unnoticed and the child may present with persistent or recurrent coughing bouts, pneumonia or lung abscess.
Diagnosis can be made through one of several imaging methods. The first test is typically a chest X-ray, using anteroposterior and lateral films. Food objects are radiolucent and may, therefore, be difficult to visualize via radiography. However, in case of suspicion of foreign body aspiration, radiologists often look for an area of focal over-inflation or an area of atelectasis, depending on the extent of the airway blocking. In case of a normal chest X-ray, other imaging techniques such as computed tomography and magnetic imaging may be explored to determine the position of the foreign body. Non-invasive methods such as computed tomography with virtual bronchoscopy can be performed in cases of sharp objects that have a high risk of damaging the lung.
Once the location is identified, it is imperative to remove the foreign object to avoid further complications. Rigid bronchoscopy under general anaesthesia is the procedure of choice for removing objects. Bronchoscopic removal may fail in case of peripheral location or technical difficulties. In such cases when the foreign body cannot be grasped by endoscopic forceps, bronchoscopy should be abandoned, and an open surgical procedure or thoracotomy should be considered.
Here is a case of a 5-year-old female child who had swallowed an LED bulb with two small, sharp metal prongs. She was immediately taken to a local hospital where a chest X-ray revealed the position of the bulb in the left thoracic cavity. No foreign body was found in an upper gastrointestinal endoscopy. A bronchoscopy under general anaesthesia was attempted to remove the bulb. However, this procedure had to be abandoned due to bleeding. Post bronchoscopy, the child went into asystole and required cardiopulmonary resuscitation. She was kept on mechanical ventilation and inotropic support overnight in a cardiac intensive care unit for 12 hours until she stabilized. She was then transferred to a specialized center for further management and referred to Dr Rajeev Redkar, consulting paediatric surgeon. A chest computed tomography with virtual bronchoscopy was done to visualize the foreign body and the location was confirmed to be in the left lower bronchus. The LED bulb appeared to be embedded in the lung parenchyma with the prongs only partially in the airway and the patient was prepared for a thoracotomy. Due to its close proximity to the heart and major vessels, General Dr V Ravishankar, a cardiothoracic surgeon, was consulted. Dr Minhaj Sheikh, a consultant paediatric intensivist, was also part of the medical team. Left lower bronchus was identified and opened minimally. The foreign body was carefully removed and the incision closed with interrupted non-absorbable sutures. The procedure was completed without any bleeding and complete expansion of the left lower lobe was confirmed post foreign-body removal. An intercostal drain was kept in place for 2 days post surgery. The patient was kept on orals for 24 hours and discharged within 4 days.
It was a harrowing experience for the child and her family.
This is the primary reason for the alert on toys with small parts: “Not suitable for children under 3”. However, 3 is not a magic age and older children also put objects in the mouth with devastating consequences. Aspirated foreign bodies should be considered as a differential in any young child with an unexplained cough, and Dr Redkar cautions that the medical team should also consider the potential risks involved during and after bronchoscopy in case of tracheobronchial foreign body aspirations.

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