DOI: 10.1097/LBR.0b013e31818953eb
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Issn Print: 1070-8030
Publication Date: 2008/10/01
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Excerpt
Foreign body aspiration can be life threatening. An aspirated solid or semisolid object may lodge in the larynx or trachea. If the object is large enough to cause nearly complete obstruction of the airway, asphyxia may rapidly cause death. Lesser degrees of obstruction or passage of the obstructive object beyond the carina can result in less severe signs and symptoms.1–3
Most often, the aspirated object is food, yet a broad spectrum of aspirated items has been documented over the years. Commonly retrieved objects include seeds, nuts, bone fragments, nails, small toys, coins, pins, medical instrument fragments, and dental appliances.2,4,5
A 6-year-old boy recently visited our emergency department with a diagnosis of pebble aspiration 2 hours earlier. He had cyanosis, dyspnea, tachypnea, and wheezing on examination. Oxygen saturation on room air was 83%. He was using accessory muscles of respiration. Right hemithorax movement was limited. There was no vocal fremitus and breath sounds. Respiration rate was 30 breath/min, pulse of 98 beats/min, and blood pressure of 100/65 mm Hg. Posterior-anterior and lateral chest radiograph revealed radiopaque material at the level of the carina (Figs. 1A, B). The patient was taken to the operating room, where, under halothane anesthesia, rigid bronchoscopy was performed. The pebble was extending from the trachea into the right main bronchus and could not be grasped with different forceps (alligator, 3-4 prong snares, fishnet, and Dormia basket) because of its shape. The pebble was grasped with alligator forceps momentarily, only to dislodge into the left bronchus and lower half of the trachea. At this time, oxygen saturation dropped to 58% to 60%. Bronchoscopy was stopped and an open surgical approach was undertaken. Under unilateral lung ventilation a left lateral thoracotomy was performed. The pebble was extracted from the left main bronchus via bronchotomy (Fig. 2). It measured 27×13 mm. The patient recovered without incident, and was discharged on seventh day.
The incidence of foreign body aspiration changes with the age, sex, and geographic location. Most cases of foreign body aspiration occur in children under 3 years of age.4,6 In western society, the peanut is the most common foreign body, whereas in the Middle East countries watermelon seeds are most common. Contrary to this, sunflower seeds and watermelon seeds are most frequent in Turkey.7,8 Stone aspiration is unusual. In some series, rate of stone aspiration was reported 0.5%.2,8 Children from small villages often play with pebbles in our country and this child accidentally aspirated the pebble. The children in this age group are exploring their surroundings also by placing objects into their mouths.4 Parents, due to lack of education, are unaware of the danger of foreign body aspiration.
Chest radiographies are diagnostic for radiopaque objects. Most foreign bodies, however, are not visible in chest radiographs; thus secondary radiographic changes must be sought.2,8 These include mediastinal shift, obstructive emphysema, atelectasis, and pneumonia. The pebbles are radiopaque, but most of stones are radiolucent.9
The rigid bronchoscope has important advantages. The larger diameter of the rigid bronchoscope facilitates the passage of various grasping devices. It also greatly improves the chance for quick, successful extractions, and capabilities for removing blood clots and thick secretions. If rigid bronchoscopy is unsuccessful, surgical bronchoscopy or segmental resection may be unavoidable.
We conclude that the big pebble aspiration is a challenging problem because of difficulties during extraction and has high morbidity. In some patients, the pebble cannot be removed by bronchoscopy because of the shape, diameter, and smooth surface of the pebble. In such cases, one should be prepared to undertake thoracotomy with bronchotomy.
