Clinical Presentation

Patients that aspirate an airway FB can have a wide array of presentations, ranging from being asymptomatic to immediate death. Patients typically present with one of two presentations: acute or symptoms related to a retained FB. Acute FBs are relatively early in the sequence of events, either immediately after the aspiration event or within hours/days often associated with minimal airway in ammation. Retained FBs are those cases where

a

c

the FB has initiated a signifcant airway in ammatory cascade with subsequent complications such as mucosal in ammation, granulation tissue, stenosis, or post-obstructive pneumonia (Fig. 40.16a– c). Patients with such cases tend to have presented in a relatively delayed manner (i.e. weeks, months, or years) or aspirated a FB known to be associated with mucosal in ammatory effects. While children commonly present in the acute time period, adults more commonly seek medical attention in a delayed manner [42].

b

Fig. 40.16  Aspiration of vegetative matter leading to a retained foreign body presentation. White arrows are indicating air space consolidation in the right middle lobe. (a) Posterior–anterior chest plain flm. (b) Axial CT chest. (c)

Bronchoscopy demonstrating right middle lobe bronchus occluded by a calcifed lesion and granulation tissue. Endobronchial biopsy of this lesion revealed retained vegetative debris with surrounding mild in ammation

Acute FB

Most patients in this population will seek and require medical attention in the immediate post-­ aspiration time period, often with a relatively inert FB. Patients will usually know exactly when the aspiration event occurred and what type of FB was aspirated. When the patient is unable to provide history, witnesses may provide information regarding the event. Depending on the type of FB, the size, the location of FB impaction, and the time taken to reach medical services, presentation can range from being asymptomatic to death. The most common presentation is cough (66.1%), choking (27%), dyspnea (26.6%), and fever (22.2%) [27]. Acute asphyxiation, also referred to as a café coronary, is more commonly found in children compared to adults [43]. Usually in these cases, the laryngotracheal region is obstructed by a relatively large FB.

Correctly identifying the risk factors, potential etiologies, and comorbidities will allow the interventional pulmonologist to plan their intervention carefully and completely to ensure that the best management plan is chosen for each patient. Physical examination fndings will vary depending on the location of FB impaction. However, keep in mind, the initial symptoms are heavily reliant upon one’s airway re exes, and patients with blunted re exes, from any cause, may not demonstrate these symptoms and/or fndings.

When the laryngotracheal region is involved, choking, stridor, wheezing, dyspnea, and hoarseness of voice are commonly observed. Generally, inspiratory stridor occurs with obstruction of the larynx, while expiratory stridor occurs when the tracheobronchial tree is involved. As would be expected with an upper airway obstruction, cyanosis and/or cardiopulmonary decompensation can occur with prolonged hypoxia.Approximately one-third of patients with acute asphyxiation will have FB impaction at the level of the supraglottic region [44]. This said, the oral cavity must undergo a thorough evaluation in any presentation of aspiration to ensure that the FB or any remnants of it are not left behind.

With primary bronchial involvement, there is usually an initial choking event that is followed by dyspnea, wheezing, and usually coughing. Although less common, hemoptysis can also be a presenting symptom. More serious fndings such as severe hypoxia can occur with complete mainstem bronchial obstruction. With more distal airway involvement, patients will usually have an initial choking event that is followed by a relatively symptom-free period. For such patients, the choking event may or not be followed by respiratory symptoms such as coughing, shortness of breath, or hemoptysis.

Retained FB

A retained FB presentation is more common in the adult population. Seeking medical attention not uncommonly can be delayed by weeks or even months, and in some cases, years later. The hallmark in this population usually encompasses patients seeking medical attention for persistent respiratory symptoms due to the complications which develop because of retained foreign bodies such as chronic cough, shortness of breath, fever of unknown origin, recurrent hemoptysis, recurrent pulmonary infections, obstructive emphysema, bronchiectasis, bronchial stenosis, pleural effusion, bronchopleural fstula, pneumothorax, and pneumomediastinum [27]. The most common presenting symptom is chronic cough. A subset of patients may have a FB discovered as a consequence of clinical evaluation for suspected lung cancer because of concerning fndings during a diagnostic work-up (i.e. radiologic fndings, advanced age, constitutional symptoms, etc.).

As patients presenting with the symptoms of prolonged aspiration of a FB is not common in most practices, having a high index of suspicion is key to rapid diagnosis. The literature suggests that most adults with aspirations are unable to recall a choking episode in their history [22, 42]. This may be due to the size difference of foreign bodies in comparison to the adult airway, neurologic disease prevalence in this population, in u-

ence of medications and drugs, as well as adults in iatrogenic circumstances such as intensive care and anesthesia-related. To complicate obtaining a thorough history further, it is not uncommon to experience a transient choking event that is followed by a relatively asymptomatic period due to the distal migration of the FB. In addition to many adults’ aversion to seeing a physician, this may lead many patients to delay seeking treatment until respiratory symptoms recur or become signifcantly bothersome.

Radiologic Findings

While the sensitivity of plain flms for visualizing radiopaque foreign bodies is notoriously low and is approximately 4–21% in the pediatric and adult populations [45–50], it is reasonable to start with plain flms of the neck and chest because of their availability, ease of use, and cost. Associated radiographic changes for foreign bodies do tend to improve the sensitivity for plain flms to above 70–85% [23, 24, 42, 51]. In evaluating plain flms, it is important to evaluate two different aspects: direct visualization of FB (24.6%), and radiographic changes related to foreign body presence/impaction [19]. In acute FB aspiration event, air-trapping, atelectasis, volume loss with mediastinal shift, air-space opacities can be observed. Patients with retained FBs may have additional fndings such as persistent or recurrent air space disease, presence of a mass, and/or a pleural effusion. Visualization of foreign bodies is inherently dependent upon size and material. Most foreign bodies tend to be organic material which tends to be radiolucent (Figs. 40.2a, 40.4a, and 40.15a), while inorganic metallic materials are radio-opaque. Once again, it is important to emphasize that one must have high index of suspicion in evaluation of this population and to understand how a FB’s size and properties may have effects on plain flm appearance. Interestingly, normal chest flms may be noted in approximately 9–37% of adults and children [42, 43, 48, 52]. If foreign body aspiration is of high

concern and a normal plain flm is encountered, computed tomography (CT) imaging should be obtained.

CT imaging of the chest and neck is considered to be the most sensitive method for imaging in suspected airway FB aspiration. CT imaging has many advantages over plain flms such as the superior ability to defne location, spatial relationship to important anatomic structures (i.e. vascular structures), and better defnition of associated FB effects (Figs. 40.5a and 40.8a). Depending on the size of the FB, CT imaging also has the ability to identify radiolucent materials. Thin slice CT imaging may be preferred for identifcation of smaller foreign bodies and debris. The detection for airway foreign bodies is much greater with CT imaging than plain flms, and CT imaging has been reported to have a sensitivity of 100% in this regard [51–53]. Additionally, in situations like these, CT imaging has the beneft of providing useful information that can assist bronchoscopists in their therapeutic approach to FB retrieval. It is important to note that false positives can occur with CT imaging due to mucus impaction.

Bronchoscopy

Regardless of symptoms and radiology fndings, bronchoscopy remains the gold standard for diagnosing FB aspiration. The decision to start withexible versus rigid bronchoscopy will be discussed under the “Airway Management” section of this chapter. When performing bronchoscopy, it is of the utmost priority to perform a detailed airway exam of not only the central and segmental airways, but to also thoroughly assess the nasopharynx, oropharynx, and glottal ­structures. In examining the segmental airways, not only do the bronchopulmonary segments need to be evaluated, but complete examination of the most distal visible sub-segments needs to be performed to ensure that there is no distal impaction or residual debris. This is particularly important in the evaluation of smaller foreign bodies such as nuts, seeds,