Corpii străini intrabronșici la copii: dificultăți diagnostice și terapeutice

Introduction

Foreign body aspiration is one of the most common causes of upper airway obstruction in pediatric patients, and it is a respiratory emergency that usually requires prompt intervention by rigid bronchoscopy. The symptoms depend on the patient’s age, the nature of the aspirated object, the time interval between the incident and the time of presentation to the hospital, and the level at which the foreign body has impacted in the respiratory tree⁽¹⁾.

Presentation of the case

The following case illustrates the difficulty of establishing a diagnosis in the absence of a positive history of aspiration and the importance of clinical suspicion correlated with imaging explorations.

The authors present the case of a 1-year-old boy who was admitted to the “Sf. Maria” Emergency Clinical Hospital for Children, Iași, Romania, for investigation, complaining of intermittent wheezing, which had started three months prior to his admission. His personal medical history included two recent episodes of pneumonia: lobar pneumonia three months prior to the current admission and interstitial pneumonia one month prior to admission, treated at a county hospital with antibiotics and symptomatic therapy. The evolution at that time was partially favorable, with remission of the cough, but the child periodically presented wheezing, in afebrility, without alteration of the general condition, and associated with rare irritative cough, triggered especially by effort. The mother did not report any episode of foreign body aspiration. The biological investigations performed three months and, respectively, one month prior to admission revealed a moderate inflammatory syndrome. Chest X-rays performed at that time showed signs of left lower lobe pneumonia and interstitial pneumonia.

Clinically, at the current admission, the child had a good general condition, he was afebrile, and the pulmonary auscultation revealed intermittent wheezing, without rales or signs of respiratory distress. Apart from pulmonary auscultatory findings, no pathological changes were detected during clinical examination of organs and systems.

Biological explorations revealed a normal complete blood count, with no signs of biological inflammatory syndrome. Hepatic and renal samples were within normal limits, and urine analysis revealed no pathological changes.

Given that the chest X-ray performed one month prior to admission showed only changes suggestive of interstitial pneumonia, it was not repeated. In the context of persistent wheezing for over three months, a chest CT scan was performed to rule out organic foreign body aspiration, which would not have been objectified on chest X-ray.

The native chest CT scan revealed a foreign body in the left upper lobe bronchus, measuring 0.36/0.29 cm, causing “air-trapping” phenomenon throughout the entire left upper lobe.  Otherwise, the lung areas were within normal limits, with no focal lesions (Figures 1 and 2).

Under general anesthesia, rigid bronchoscopy was performed, with the extraction of a foreign vegetal body (sunflower seed) from the left main bronchus, with its tip embedded in the left upper lobar bronchus. Subsequently, antibiotic therapy and corticosteroid therapy were instituted, with favorable clinical evolution and the disappearance of wheezing.

Discussion

Foreign body aspiration constitutes a common medical emergency in pediatric practice, and it is a significant cause of mortality, particularly in young children, whose airway protection reflexes are not fully developed. Children between the ages of 1 and 3 are at greatest risk due to anatomical and physiological characteristics (incomplete dentition, poorly developed laryngeal protective reflex) and behavioral characteristics (tendency to put various objects in their mouth) that are specific to this period of development⁽²⁾.

The shape of the foreign body influences the point at which it will become lodged in the respiratory tract, as thinner objects tend to travel further down the bronchial tree⁽³⁾. The size determines the degree of obstruction, as follows: larger objects can completely block the airways and cause rapid death, while smaller objects cause less severe symptoms. There are situations in which objects reach the digestive tract and, if they are larger, can cause pyloric obstruction, but in most situations, they pass through the gastrointestinal tract, and are spontaneously eliminated in the feces⁽²⁾.

As far as the nature of the foreign bodies aspirated is concerned, organic bodies predominantly consist of seeds and nuts, while anorganic foreign bodies most commonly include coins, beads, needles, or paper clips⁽²⁾.

The diagnostic suspicion may be raised in a child presenting with a sudden onset of ineffective cough and wheezing, in the absence of any preexisting pulmonary pathology, such as bronchial asthma or chronic pulmonary infections⁽³⁾.

The classic triad (unilateral wheezing, persistent cough, dyspnea) is not constantly present, the appearance of manifestations being closely related to the shape of the object, its size, the degree of airway blockage, as well as the time elapsed since the moment of aspiration⁽²⁾. Also, nonspecific manifestations such as stridor, perioronasal cyanosis, sialorrhea or hemoptysis could appear⁽⁴⁾. The history should include questions regarding episodes of apnea, which may last from a few seconds to a few minutes, and may be followed by an asymptomatic period⁽³⁾.

The diagnosis is not always obvious, as it is one of exclusion, especially when the aspiration episode was not directly observed, and in approximately 30% of cases, the clinical manifestations are misinterpreted as symptoms of other respiratory pathologies⁽²⁾.

The first imaging investigation performed when foreign body aspiration is suspected is a chest X-ray, but this is not always conclusive, as in 30% of cases the foreign body is not radio-opaque. However, it can reveal secondary signs such as unilateral hyperinflation, lung collapse, mediastinal shift and signs of perforation (pneumothorax, pneumomediastinum)⁽³⁾. When chest X-rays do not confirm the diagnosis, CT scans and bronchoscopy become necessary, not only for diagnosis but also for therapeutic purposes, with rigid bronchoscopy being the standard method for foreign body removal⁽²⁾.

Delayed diagnosis increases the risk of complications such as atelectasis, aspiration pneumonia, bronchiectasis, abscesses, or even bronchoesophageal fistulas⁽⁴⁾.

The foreign body extraction procedure went smoothly, but both during and after the procedure, potentially life-threatening complications may arise. One of the most potentially life-threatening complications is represented by complete but temporary airway obstruction, accompanied by hypoxia and bradycardia, which can occur when the object is difficult to mobilize or cannot be adequately grasped with forceps, a common occurrence with round, smooth, or slippery foreign bodies. In situations where bronchoscopy does not allow the safe removal of the object, conversion to thoracotomy may be necessary⁽⁵⁾.

In cases of old foreign bodies, impaction may occur, in which case rigid bronchoscopy may be insufficient, requiring the use of thoracotomy. Another common complication is local infection; after the removal of the foreign body, purulent secretions accumulated at the distal end of the obstruction require drainage in order to prevent the spread of infection to the other bronchi, thus reducing the risk of septic shock⁽⁵⁾.

Both the foreign body and the rigid bronchoscopy extraction procedure can cause damage to the tracheobronchial tree, manifested as bleeding, but in most cases, this is minor and does not endanger the patient’s life. Laryngeal edema and laryngeal, tracheal or bronchial spasm are also potential complications, the severity of which may increase depending on the duration of the procedure and the aggressive technique required to remove the foreign body⁽⁵⁾.

Much less frequently, in approximately 1% of cases, tension pneumothorax may occur, due to the progressive accumulation of air in the pleural cavity, a phenomenon favored by repeated instrumentation or temporary obstruction of the airways during bronchoscopy⁽⁶⁾.

The involvement of the left bronchus in foreign body aspiration is less common, as it has a steeper angle and less favorable alignment with the trachea, explaining the predominance of foreign bodies in the right bronchus. In this case, an additional impediment was the location of the foreign body in the upper left lobar bronchus, a segment which, due to its anatomical features, limits endoscopic access and significantly reduces operative visibility, thus complicating the extraction procedure⁽¹⁾.

Conclusions

The peculiarity of this case lies in the absence of a clear history of foreign body aspiration, and even the family’s distrust that such a diagnosis could be present, as the child was being “closely monitored”. Although the patient had been wheezing for three months, the absence of a clear episode of aspiration reported by the parents made it difficult to establish the diagnosis. In this case, the lobar pneumonia diagnosed at the onset of symptoms actually represented the moment of foreign body aspiration and the complication with lobar pneumonia. The treatment with antibiotics and mucolytics resolved the infectious episode, but the child continued to mobilize the foreign body, which was located in an upper bronchus, making the extraction much more difficult.

In contrast to the standard approach, where chest X-rays initially guide diagnosis, in this case, the persistence of symptoms served as a warning sign for further investigation using advanced imaging (chest CT), allowing for diagnosis and appropriate treatment. Prompt extraction by rigid bronchoscopy led to remission of symptoms and, fortunately, there were no complications related to the extraction of a 3-month-old intrabronchial foreign body.

Autor corespondent: Bogdan-Aurelian Stana E-mail: bogdan.stana@gmail.com

CONFLICT OF INTEREST: none declared.

FINANCIAL SUPPORT: none declared.

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