Foreign-body aspiration accounts for high morbidity if the diagnosis is delayed or missed. Mortality also is reported in children, especially between ages 12 months to 3 years. (2) Most children under the age of 3 years tend to mull over most particles in their mouths, they also have flawed nibbling habits and premature swallowing coordination which makes them more prone for a FBA. Children are more susceptible for a FBA complications due to immature defense mechanisms.(6) Often the presentation and initial radiological findings are vague which impedes the early diagnosis. An alleged episode of choking and severe cough is a critical evidence in the diagnosis of FB aspiration.
In our study, choking (5.40%) and hemoptysis (2.70%) were seen in limited cases. Most common symptoms in patients who presented early (< 1 week) were Tachypnea (58.8%), Wheeze (47.05%) and wet cough (41.1%). In cases of delayed presentation (> 1 week) majority complained of fever (65%) and dry cough (45%). It was found out that delay in presentation mostly due to unintentional aspiration by child unnoticed by parents, vague clinical history, lack of respiratory symptoms, unwillingness of the treating physician for getting an chest X ray and delayed referral. It was noted that the duration of treatment at the local hospital y was directly proportional to the duration of admission later for effective management.
Unlike adults, babies do not have clear recall of FBA, thus diagnosis is most often dependent on the mothers history, clinical findings such as onset and duration of symptoms and suspicion. Chest x -ray is the most common investigation done in these cases and majority of the time chest x rays are normal. The typical findings in chest radiograph which is diagnostic is hyperinflation, collapse, consolidation of one lung and mediastinal shift. Many authors in their study have reported rates of normal chest X -ray around 20–42%( 7, 8) .In our study normal chest x-ray was found in 39% patients. Normal chest X ray are accepted in early phase as most aspirated foreign bodies are organic in nature and cannot be seen on chest x ray. Later when the organic substance swells with inflammation it occludes the bronchus completely and typical chest xray findings appear.
Recently CT has been introduced as a noninvasive procedure in diagnosis of FBA, but it is known to show false positive and has radiations hazards associated. (9, 10, 11)
Various diagnostic modalities have been reported to be effective, rigid bronchoscopic inspection being the gold standard (12). It is an invasive procedure done under general anaesthesia and has some morbidity. (7).Some authors suggested that flexible bronchoscopy is a useful procedure for foreign body retrieval from infants and children with 91.3% success rate (13) .with availability of proper bronchoscopic accessories. Rigid or flexible bronchoscopy especially in pediatric patients remains a controversy and depends on the institute protocol.. In our study all patients underwent rigid bronchoscopy initially. Only in 4 cases were incomplete retrieval was done and flexible bronchoscopy was used for inspection followed by rigid bronchoscopy for retrieval.
In our cases nature of foreign body aspirated were mostly organic 81.1% and inorganic foreign body accounted for 18.9%. Routinely found FB was peanut being present in 43.24% patients.
Many authors have reported the gap between aspiration and hospital admission was more than 24 hours and even after that there was a delay in diagnosis (14). Some of the larger reviews have documented delays ranging from 20–40% of the patients reviewed(15). In this present study 54.04% of the patients reviewed had delayed presentation. Delay in presentation were due to unintentional aspiration by child unnoticed by parents ,vague clinical history, lack of respiratory symptoms, unwillingness of the treating physician for getting an chest X ray and late referral. The severity of symptoms depends on the degree of obstruction of the tracheobronchial tree so it can be complete or incomplete and site of obstruction. If there is complete obstruction these patients are referred early. Delay usually occurs in patients with incomplete obstruction with normal chest X ray. Lack of history of inhalation most commonly led to delayed presentation and resulted in various respiratory complications like Pneumonia ,Obstructive emphysema ,Atelectasis ,Pneumothorax and Pneumomediastinum (16–118). Literature reveals there is a 7% incidence of pre hospital deaths in cases of foreign body aspiration (16).
Another factor that causes preoperative complications associated with FBA is lack of standard treatment guidelines and management procedures. (6)
Based on our study we have developed an algorithm for management on the basis of outcomes.