Foreign body in bronchus is foreign objects accidentally aspirated or trapped in the airways through wound channels and fixed at the level of the bronchi. The foreign body in bronchus makes itself felt by paroxysmal whooping cough, asphyxia, cyanosis of the face, stenotic breathing, hemoptysis, vomiting, violation of phonation. A foreign body in the bronchi is recognized based on the collected anamnesis, lung radiography, tomography, bronchography, bronchoscopy. Removal of a foreign body from the bronchus is carried out endoscopically; when foreign bodies are wedged in, bronchotomy is resorted to.
T17.5 Foreign body in the bronchus
Foreign bodies of the respiratory tract are an urgent and very serious problem of otolaryngology and pulmonology. According to clinical data, among all cases of foreign bodies of the airways, foreign bodies of the larynx occur in 12%, foreign bodies of the trachea – in 18%, foreign bodies of the bronchus – in 70% of observations. Especially often foreign bodies of the airways are found in childhood. The proportion of foreign bodies of the bronchi in children accounts for 36%; at the same time, in a third of the observations, the age of children is from 2 to 4 years. In 70% of cases, foreign bodies enter the right bronchus, since it is wider and straighter.
Foreign bodies of the bronchus can pose a threat to life, so they require urgent specialized intervention. Untimely recognized and not removed foreign bodies of the bronchi in time lead to the development of secondary complications: atelectasis, aspiration pneumonia, bronchiectasis, pneumothorax, purulent pleurisy, lung abscess.
Causes of foreign body in bronchus
The ingress of a foreign body into the bronchus can occur by aspiration (when inhaled through the mouth, thrown from the esophagus and stomach with gastro-esophageal reflux or vomiting), as well as through the wound canal with chest and lung injuries. Penetration of foreign bodies is possible during surgical interventions: tracheotomy, adenotomy, removal of a foreign body from the nose, dental manipulations. Among the listed mechanisms, the aspiration pathway of foreign bodies entering the bronchi is the most common.
Aspiration of foreign bodies into the bronchi is facilitated by the habit of children and adults to hold small objects in their mouths. The ingress of objects from the oral cavity into the bronchi occurs during play, laughter, crying, talking, coughing, sudden fright, falling, etc. Often the background for aspiration of foreign bodies into the bronchi is concomitant rhinitis and adenoid growths, a state of anesthesia.
By their nature, foreign bodies of the bronchi are divided into endogenous and exogenous, organic and inorganic. Endogenous foreign bodies include untreated pieces of tissue during tonsillectomy and adenotomy, endoscopic removal of benign bronchial tumors, removed teeth, ascarids.
The most diverse group of finds are exogenous foreign bodies of the bronchi: these can be small objects made of metal, synthetic materials, objects of plant origin. Among the exogenous foreign bodies of the bronchus, there are both organic (food particles, seeds and grains of plants, nuts, etc.) and inorganic (coins, paper clips, screws, beads, buttons, toy parts, etc.) objects. The greatest aggressiveness and complexity in the diagnosis are objects of organic origin, synthetic materials and fabrics. They do not contrast with X-rays, they can stay in the bronchial lumen for a long time, where they swell, crumble, decompose; they penetrate into the distal parts of the bronchial tree, causing chronic lung suppuration.
Foreign bodies of the bronchi, having a smooth surface, are capable of movement, translational movement to the periphery. Objects of plant origin (spikelets of cereals and herbs), on the contrary, are wedged into the bronchial wall and remain fixed. There are cases of single and multiple foreign bodies of the bronchus.
Symptoms of foreign body in bronchus
There are three periods in the clinical symptoms of bronchial foreign bodies: the debut phase, the phase of relative compensation of respiratory functions and the phase of secondary complications.
In the debut phase, after aspiration of a foreign body, a sudden paroxysmal cough develops; aphonia, respiratory disturbance up to asphyxia. A similar pattern is sometimes observed with diphtheria, but in this case there is no suddenness factor, and pathological symptoms (sore throat, fever, etc.) precede the appearance of cough. With false croup, catarrhal phenomena of the upper respiratory tract also precede an attack of coughing and suffocation. With benign tumors of the larynx, aphonia increases gradually. Coughing attacks are often accompanied by vomiting and cyanosis of the face, resembling a cough with whooping cough: this can cause diagnostic errors, especially in cases when the fact of aspiration is “viewed”.
Shortly after the penetration of a foreign body into the main, lobar or segmental bronchus, a phase of relative compensation of respiratory function occurs. During this period, due to partial obturation of the bronchus and bronchospasm, wheezing is heard at a distance – inspiratory stridor. There is moderate shortness of breath, pain in the corresponding half of the chest.
The further dynamics of the pathological process with foreign bodies of the bronchus depends on the severity of inflammatory changes developing in the area of the lung that is turned off from breathing. In the phase of complications, there is a productive cough with mucopurulent sputum, an increase in body temperature, hemoptysis, dyspnea. The clinical picture is determined by the developed secondary complication. In some cases, foreign bodies of the bronchi remain unnoticed and are an accidental find during surgical interventions on the lungs.
The difficulty of recognizing foreign bodies of the bronchi is due to the fact that the fact of aspiration can not always be noticed. The nonspecific nature of symptoms often leads to the fact that persons with foreign bodies in the bronchi are treated for a long time by a pulmonologist for various bronchopulmonary diseases. The reason to suspect the presence of a foreign body in the bronchus is unsuccessful therapy for asthmatic bronchitis, chronic bronchitis and pneumonia, whooping cough, bronchial asthma, etc.
Physical data with foreign bodies of the bronchus indicate the presence of atelectasis (sharp weakening or absence of breathing, dulling of percussion sound) or emphysema (percussion tone with a boxy tinge, weakened breathing). During the examination, attention is drawn to the lag of the affected side of the chest during breathing, the participation of auxiliary muscles in the act of breathing, the sinking of the jugular pits and intercostals, etc.
In all cases, if a foreign body in bronchus is suspected, an X-ray of the lungs is shown. At the same time, bronchial constriction, local emphysema, atelectasis, focal infiltration of lung tissue, etc. may be detected. Clarification of the localization of a foreign body and the nature of local changes in the lungs is carried out using X-ray or computed tomography, NMR, bronchography.
The most reliable diagnostic method for visualizing foreign bodies of the bronchus is bronchoscopy. Often, due to the severity of local changes, a foreign body cannot be detected immediately. In such cases, the removal of granulations, thorough sanitation of the bronchial tree (bronchoalveolar lavage), a course of antibiotic therapy and then repeat the endoscopic examination of the bronchi.
Treatment for foreign body in bronchus
The presence of a foreign body in bronchus is an indication for its extraction. In most cases, it is possible to perform endoscopic removal of a foreign body in bronchus during repeated bronchoscopies. When a foreign body is detected in the bronchial lumen, the bronchoscope tube is carefully brought to it, the object is seized with forceps and removed.
Metal objects can be extracted using a magnet; small foreign bodies of the bronchi – using an electric pump. Then a bronchoscope is re-introduced to perform a bronchial revision for the abandonment of “fragments”, injury to the walls of the bronchus, etc. In some cases, the removal of foreign bodies from the bronchi is performed through a tracheostomy.
Foreign bodies tightly wedged into the bronchial wall are subject to surgical removal during thoracotomy and bronchotomy. Indications for bronchotomy are fixed or embedded foreign bodies that cannot be extracted without significant damage to the walls of the bronchi. Surgical tactics are also used in case of complications during attempts of endoscopic removal of foreign bodies (bronchial rupture, bleeding).
Prognosis and prevention
With timely extraction of a foreign body in bronchus, the prognosis is good. Complications of bronchial foreign bodies can be disabling and life–threatening diseases – pleural empyema, fistulas (thoracobronchial, esophageal-bronchial, bronchopleural), pneumothorax, pulmonary bleeding, bronchial rupture, purulent mediastinitis, etc. In some cases, the death of children from sudden asphyxia may occur.
Preventive measures should include adult control over the quality of toys and their compliance with the child’s age; weaning children from the habit of taking foreign objects in their mouths; explanatory and educational work among the population; caution when performing medical manipulations.
- Foreign body inhalation–site of impaction and efficacy of rigid bronchoscopy. Asif M, Shah SA, Khan F, Ghani R. J Ayub Med Coll Abbottabad. 2007 Apr-Jun;19(2):46-8. link
- Scar changes in the bronchus caused by a foreign body. Pogorzelski A, Zebrak J. Wiad Lek. 1995 Jan-Jun;48(1-12):140-2. link
- Endoscopic extraction of a foreign body from the distal bronchus in the middle lobe, inaccessible by usual techniques, in a 3-year old child. Rayet I, Navez M, Freycon MT, Prades JM. Pediatrie. 1992;47(7-8):589-91. link
- Three cases of bronchial foreign bodies which required thoracotomy. Tanaka F, Yoshitani M, Esaki H, Isobe J, Inoue R, Ito M, Mori A, Shiraki T, Uemura H. Kyobu Geka. 1990 Jun;43(6):471-4 link
- MSCT diagnostic value to foreign body and stenosis in trachea and bronchus of children. Yu S, Wu H, Ma C. Lin Chung Er Bi Yan Hou Tou Jing Wai Ke Za Zhi. 2007 Feb;21(3):116-8. link