Introduction
An aspirated solid or semisolid object may lodge in the trachea or larynx. Depending on the size of the object, the complications are determined. If the object is large enough to cause complete obstruction of the airway, asphyxia (unable to breathe) may immediately cause death. Fewer degrees of obstruction may result in less severe signs and symptoms.
What Are the Symptoms of Foreign Body Aspiration?
Patients may be asymptomatic or may present with symptoms like-
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Stridor (whistling sound while taking a breath).
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Wheezing.
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Diminished breath sounds.
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Localized wheeze.
What Is the Etiology of Foreign Body Aspirations?
Children are at high risk for aspiration by putting small toys, candies, or nuts into their mouths. Children aged one to three years chew incompletely with incisors before their molars erupt, and objects or fragments may be propelled posteriorly, triggering a reflex inhalation.
In adults, the following conditions, actions, and procedures facilitate foreign body aspiration:
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Mental retardation.
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Poor dentition.
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Maxillofacial trauma (refers to the injury of the face and the jaws).
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Convulsions (It is a term used alternatively with seizures and refers to the rapid, rhythmic, and uncontrollable shaking of the body).
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Loss of consciousness.
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Altered sensorium - General changes in brain functions such as loss of memory, confusion, and disorientation.
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Dental, pharyngeal, or airway procedures.
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Alcohol or sedative use.
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Impaired swallow reflex.
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Impaired cough reflex.
What Is the Pathophysiology of Foreign Body Aspiration?
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Near-total obstruction of the larynx or trachea can cause immediate asphyxia and death.
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Objects that descend beyond the trachea are more often found in the right endobronchial tree than in the left. After aspiration, objects may subsequently change position or migrate distally after unsuccessful attempts to remove the object or its fragments. The object itself might cause obstruction.
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Aspirated vegetable material may swell over hours or days, worsening the obstruction. Cough, dyspnea, stridor, cyanosis, and even asphyxia might occur.
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Organic foreign bodies, such as nuts, induce inflammation and edema.
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During a bronchoscopic evaluation, edema, local inflammation, cellular infiltration, ulceration, and granulation tissue formation can contribute to airway obstruction. Air trapping in distal to obstruction may result in local emphysema, atelectasis, post-obstructive pneumonia, hypoxic vasoconstriction, the possibility of volume loss, necrotizing pneumonia, bronchiectasis, or suppurative pneumonia.
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Under bronchoscopic evaluation, the object may appear as a tumor. Even after the removal of the objects, inflammatory changes are not completely reversible. Scar carcinoma can occur over time.
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After removing the foreign body, the complications may develop in 24 to 48 hours.
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Aspirations of live fish, leeches, and roundworms have been reported. A fish aspiration is usually obvious on examination, whereas leeches are aspirated from direct contact with leech-infested waters.
What Are the Clinical Findings of Foreign Body Aspiration?
The clinical findings of foreign body aspiration are listed below:
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Choking.
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Coughing.
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Respiratory difficulties.
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Abnormal breath sounds.
What Are the Treatment Options of Foreign Body Aspiration?
There are various treatment modalities carried out, which include-
Approach Considerations:
Acute choking with tracheal or laryngeal foreign body obstruction is successfully managed immediately on the spot with:
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Back Blows - Create a strong, forceful vibration and pressure in the airway to dislodge the blockage.
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Heimlich Maneuver or Abdominal Thrusts - A first aid procedure used to treat upper airway obstructions by foreign objects. Even in non-emergency conditions, removal of tracheobronchial foreign bodies is recommended.
In order to avoid morbidity, this method should not delay bronchoscopic extraction for more than 24 hours. If the presence of multiple objects is suspected, a bronchoscopy inspection is indicated.
Rigid Bronchoscopy:
Rigid bronchoscopy is the most commonly used procedure for removing foreign bodies in both children and in adults. It is usually carried out under intravenous sedation or general anesthesia. Rigid bronchoscopy has more advantageous features than flexible bronchoscopes. The features include-
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The larger diameter feature of rigid bronchoscopes aids in the passage of various grasping devices, including flexible bronchoscopes.
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Aids in better capabilities of suctioning clotted blood and thick secretions and chances of quick extractions.
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A pediatric flexible bronchoscope lacks a hollow working channel through which instruments may be inserted, or blood and secretions are aspirated.
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The success rates for extracting foreign bodies are reported to be more than 98%.
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The patient can be ventilated through a rigid bronchoscope; thus, the ventilation can be easily maintained.
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Large solid and semisolid objects are best managed immediately in the operating room with the help of rigid scope and other appropriate grasping equipment.
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Proper practice of grasping techniques of similar objects should be carried outside of the body to avoid the likelihood of shattering the object or of impacting the object to a less favorable position.
Flexible Bronchoscopy:
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Sedatives can be administered if necessary.
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The flexible fiberoptic bronchoscope is directly inserted into the trachea transorally or transnasally and can also be inserted through a rigid bronchoscope or large endotracheal tube.
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Fogarty balloon catheters, small forceps, and baskets can be inserted through a narrow working channel.
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This instrument has its limitations in visualizing, grasping, and removing certain bodies of appropriate size, shape, and position.
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Removal of an exposed foreign body poses the risk of trauma and impaction in the trachea, pharynx, or larynx.
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Any attempt to withdraw the bronchoscope from the nose with an exposed foreign body at its tip poses an additional risk of trauma and impaction in the nasal passage.
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Regardless of its limitations, the use of a flexible fiberoptic bronchoscope is necessary for patients with maxillofacial or cervical trauma, where rigid bronchoscopy is not feasible.
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It gives access to subsegmental bronchi beyond that provided by rigid bronchoscopes.
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If insertion of flexible bronchoscopy or in case the gas exchange is already compromised, then the use of flexible bronchoscopy is contraindicated.
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The limited ability to achieve and maintain an adequate grasp of the intact foreign body makes extraction through flexible bronchoscopy more time-consuming and less reliable than rigid bronchoscopy.
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If the foreign body is quickly and easily removed before emphysema, atelectasis, mucosal alterations, or suppurative complications set in, and if the patient is asymptomatic, no further inpatient care is necessary.
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Observation for one to two days post-extraction is necessary in case of arising complications.
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In case of pneumonia, tracheoesophageal fistula, hemoptysis, pneumothorax, airway inflammation, atelectasis, fever, or ventilatory failure may require continuous hospitalization with intensive care unit (ICU) monitoring, mechanical ventilation, intubation, repeated bronchoscopic procedures (example, obstructing granulation tissue, laser therapy of bleeding, direct suctioning of pus), corticosteroids, antibiotics, bronchodilators or chest physical therapy.
Surgical Care:
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All aspirated objects can be extracted bronchoscopically. If rigid bronchoscopy is unsuccessful, segmental resection or surgical bronchotomy may be necessary.
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Chronic bronchial obstruction with bronchiectasis and destruction of lung parenchymas may require segmental or lobar resection.
Conclusion
To prevent this, primary care starts with the dietary aspect. The diet should be appropriate for the patient's ability to chew and swallow. Speaking while eating and impaired consciousness also increases the likelihood of aspiration while eating. In children, nuts should be administered slowly after the age of three years to avoid these complications. Oral pierced jewelry should be removed priorly in case of providing general anesthesia, emergency airway management, or other such manipulation of the oral pharynx because of the risk of aspiration and dislodgement.
