Pediatric TFBA refers to children who suffer from aspiration of a variety of objects by mistake while crying, smiling or yelling. It is very important to turn to specialists for professional aid immediately after aspiration occurs or to avoid it from the very beginning. In our opinion, the occurrence of TFBA was influenced by some external factors and intrinsic factors. Here, we aim to discuss these factors and search for some potentially effective measures corresponding to these factors.
Physiological elements of children were defined as intrinsic factors, including age, gender, tracheobronchial anatomy and symptoms. Accordingly, elements irrelevant to children were defined as external factors, including guardians, residence, type of FB and prehospital time.
Owing to both the laryngeal protective function and masticatory function development, TFBA usually occurs in infants, especially those less than 3 years old[3]. In our study, the age distribution of pediatric patients was mostly from 1 to 3 years, coinciding with Arias’s findings from the National Center for Health Statistics[4]. In addition, there were 72 boys and 53 girls enrolled in our study, and the male-female ratio was 1.36, similar to that in Maha’s study[5]. As is well known, infants attempt to explore the world with their tongues and mouths, and boys almost always show stronger curiosity and relative hyperactivity than girls in daily life. Therefore, we must emphasize time and again to guardians that infants are not permitted to eat nuts. It is best to put nuts and tiny objects out of children’s sight and reach.
In regard to bronchial anatomy, which would affect the movement track of FBs, the right primary bronchus is steeper and wider than the left side [6]. As a result, the occurrence rate of right bronchial foreign bodies is higher than that of other types[7]. Foreign bodies in our study were mostly located in the right bronchus, followed by the left bronchus and trachea. The tracheal foreign body was fatal despite a low incidence of morbidity. Sometimes, foreign bodies would migrate after violent coughing or patting the back. Position variance of FBs in 3 patients was observed during operation from the right bronchus to the left bronchus.
Cough, bucking and having a fever were the three symptoms of highest incidence in our patients, not only because of infection but also because of rejecting reaction. The symptoms mainly depended upon the prehospital duration and the type of FB. Tan et al summarized that nuts and seeds, with some geographic and seasonal variations, were the most common FBs[8]. In our group, most of the FBs were organic objects, such as peanuts, sunflower seeds and walnuts, which produce unsaturated fatty acid and thus promote inflammation of airway mucosa.
Most of western China is mountainous, and rural and urban districts are different in terms of infrastructure and economic conditions. We regard the regional difference as an external factor of TFBA. When the patients were divided into two groups according to their residence, we found that there was a significant difference in the guardians and medical history time but not in the gender of patients or the composition of the types of FBs.
Guardians were mostly grandparents in rural areas because some parents in rural areas migrated to urban districts to hunt for jobs, leaving children to be cared for by the parents’ parents. However, some parents also took children with them into urban districts, leading to fewer children living in villages and fewer patients with TFBA from rural areas. In our study, more pediatric patients were from urban areas, and more ill children were cared for by grandparents in rural areas. Therefore, in addition to providing information for parents, we must also pay attention to grandparents, especially in rural families.
Administering TFBA therapy as soon as possible upon arrival at the hospital is key to timely diagnosis and surgery [9]. However, Foltran et al found that approximately 40% of patients were given delayed diagnosis and treatment [10], and more than 72 hours of prehospital time was considered to potentially increase the risk of complications such as pneumonia, atelectasis, pneumorrhachis, pneumothorax, subcutaneous emphysema and pneumomediastinum[11].
When we focused on medical history time, we found that there were some significant differences between children with or without a history of FB aspiration. A total of 67.5% of pediatric patients with a history of FB aspiration were immediately dealt within 24 hours, while 58.3% of patients who had no explicit medical history were treated after 24 hours. Meanwhile, children living in different districts also showed differences in prehospital time. Although most patients in both groups were taken to the doctor within 24 hours, more children were not treated for over 72 hours in the rural group than in the urban group. Guardians in rural areas were mostly grandparents, who possibly spend inadequate time caring for children and showed a lack of understanding about . Along with distance from medical centers or competent hospitals, the type of guardian is responsible for delayed diagnosis or therapy.
As a result, it is crucial for the guardian to be aware of the danger of TFBA, which could reduce its incidence and prevent medical delay.