Foreign Body Aspiration and Cough

Foreign Body Aspiration (FBA) is a serious and potentially life-threatening condition, especially in infancy and childhood. Advances in first aid and endoscopic technologies have reduced FBA-related deaths by 20%. The longer a foreign body stays in the tracheobronchial tree, the higher the patient’s morbidity and mortality. The first removal of a foreign body from the tracheobronchial tree was performed by the German bronchoscopist Gustaw Killian in the late 19th century.

Cough is the protective and defense mechanism of the respiratory tract. The entry of foreign bodies into the lower respiratory tract initiates the coughing process. Foreign materials are attempted to be expelled by coughing. Respiratory secretions accumulated in the bronchi are also expelled through coughing. The duration of coughing is important in patients. Coughs lasting less than 3 weeks are called acute coughs, while coughs lasting more than 8 weeks are referred to as chronic coughs (1). Cough is a troublesome symptom for patients, causing difficulties in diagnosis and treatment.

Patients who have aspirated a foreign body present early symptoms such as cough, difficulty breathing, and hoarseness. In the later stages, they may present with complications such as atelectasis, obstructive emphysema, lung abscess, empyema, and bronchiectasis.

In adult patients, cough can have multiple causes. In non-smokers, the most common causes of cough are postnasal drip, asthma, gastroesophageal reflux, and the use of ACE inhibitors. In patients with a history of smoking, chronic bronchitis and bronchogenic carcinoma should be considered. Additionally, untreated pneumonia should be kept in mind (2). Less common causes of cough in adults include upper respiratory tract infection, lymphoma, persistent pneumonia, sarcoidosis, tuberculosis, and foreign body aspiration. Foreign body aspiration poses a life-threatening situation.

In a retrospective study, the clinical presentation of FBA differs between adults and children. The majority of patients are approximately 75% below the age of 8, with a peak at the age of 2. In the adult population, the peak occurs in the 6th decade. In children, organic materials such as nuts, peanuts, seeds, beans, and small pieces of toys, pencil tips, safety pins, and straight pins are the most common objects aspirated, accounting for 97% of cases. In adults, dentures, amalgam, fish bones, and chicken bones have been reported to be aspirated (3). Cough is the most common symptom in both groups. The location of aspiration differs between adults and children. Adults tend to aspirate into the distal airways, with 67% occurring on the right side, while children tend to aspirate into the proximal airways, with 74% occurring in the proximal airways. Due to obstruction in the proximal airways, acute symptoms are more common in children. Children may experience sudden breathlessness, cyanosis, coughing, and wheezing. Diagnosis may be delayed in adults where aspiration goes to the distal, leading to atelectasis, air trapping, and pneumonia. In severe cases of foreign body aspiration in adults, the heart may shift to the left (4).

Girls and women wearing headscarves in the Middle East hold the headscarf pin between their teeth while tying the headscarf. During this process, the risk of the headscarf pin entering the tracheobronchial tree is high.

In some children, if no one sees the child during the aspiration of a foreign body or if the family does not realize the importance of the situation, and if the foreign body is small, it can descend into the lower respiratory tract and stay there for a long time. Patients may come to the doctor complaining of persistent cough, asthma, recurrent pneumonia, and subsequent bronchiectasis.

Diagnosis

Symptoms of FBA can be evaluated in three stages. The first stage is the initial stage, characterized by severe cough, a feeling of choking, and wheezing. The second stage is the asymptomatic period, where the foreign body settles in the tracheobronchial tree. The third stage is the complications stage. In this stage, complications such as obstruction, erosion, fever, cough, and hemoptysis occur due to the presence of the foreign body.

The patient’s complaints, a careful history and examination, and a chest X-ray lead to the diagnosis. Physical examination findings are not specific in patients with FBA. There are similar findings with reactive respiratory tract diseases. In about one-third of patients, a triad consisting of cough, wheezing, and decreased breath sounds is observed. On chest X-ray, air trapping during expiration, sometimes accompanied by mediastinal shift, consolidation, or atelectasis, can be observed. Radiopaque objects are easily visible in radiology and help establish the diagnosis.

Unfortunately, non-radiopaque objects cannot be seen on chest X-rays. In patients suspected of FBA, a definitive diagnosis is made by bronchoscopy. Bronchoscopy involves observing and treating the trachea and bronchi for both diagnostic and therapeutic purposes. Both fiberoptic (Figure-1) and rigid (Figure-2) bronchoscopes can be used. Rigid bronchoscopy is preferred for the removal of aspirated foreign bodies, as it allows for better visualization. Fiberoptic bronchoscopy can also be used, but it does not have the superiority of rigid bronchoscopy.

Treatment

The treatment of FBA is the removal of the foreign body. The most commonly used method is the removal of the foreign body with a bronchoscope. Bronchoscopy can be performed under local or general anesthesia. General anesthesia is preferred for endoscopic removal of foreign bodies. Bronchoscopy is a safe and effective method. In expert hands, the complication rate is very low. Rigid bronchoscopy is the most successful method for the removal of intrabronchial foreign bodies. In stable patients suspected of unilateral FBA, bronchoscopy must be performed. After bronchoscopy, the patient should be kept under observation in the hospital for one night. If there is a pneumonia or bronchitis picture before bronchoscopy, antibiotics should be given.

The Heimlich maneuver is a method used to remove a foreign body. When a patient cannot speak, cough, or breathe suddenly while eating or when there is a foreign body in the mouth, the Heimlich maneuver is life-saving. After the procedure, the patient may experience pain lasting 4 weeks in both costal arches.

Discussion

When FBA causes near-total obstruction at the level of the trachea, it leads to fatal acute respiratory failure (asphyxia). Foreign bodies that can go further distally in the tracheobronchial tree cause respiratory system problems due to impaired ventilation and the preparation of the ground for infection.

The reflex reaction of the mucosa at the level of the larynx and trachea decreases and disappears below the level of the main bronchi. Due to aspiration, the strong cough reflex, cyanosis, and respiratory distress resulting from laryngeal spasm partially reduce the symptoms clinically as the foreign body descends below the level of the main bronchi (4).

The spectrum of aspirated foreign bodies varies. In less developed countries, organic materials are aspirated more frequently, while in