Complications

Complications secondary to foreign body aspiration can be identified as 1) emergent secondary to asphyxiation with airway obstruction, 2) immediate with the presence of the foreign body or secondary to surgery to treat it, and 3) delayed with secondary lung injury due to the foreign body itself or inflammatory changes in the endobronchial tree secondary to its presence.

In the operating room, the foreign body itself can be difficult to manipulate. This is particularly true with round, smooth-surfaced metallic or glass bodies. These foreign objects may fall into the normal airway, obstructing it while releasing distal secretions from the previously obstructed lung. Either of these events can lead to acute airway obstruction and death. Spherical foreign bodies need to be controlled, and

figure 36-6 Neurologically impaired child with a history of pneumonia and coughing 2 months prior to this evaluation. Calcific density in the left upper lobe is appreciated, which proved to be an aspirated tooth. It could not be extracted endo-scopically, and required thoracotomy with bronchotomy for extraction.

figure 36-6 Neurologically impaired child with a history of pneumonia and coughing 2 months prior to this evaluation. Calcific density in the left upper lobe is appreciated, which proved to be an aspirated tooth. It could not be extracted endo-scopically, and required thoracotomy with bronchotomy for extraction.

in that instance, the Fogarty catheter balloon technique is inappropriate. Control of the spherical foreign body with a Dormia stone basket during extraction is the safest course. The endoscopist should also have a well-functioning suction device immediately available to aspirate any overflow of secretions.

If there is a delay in diagnosis, when the aspiration event is not witnessed, it is not unusual for the initial evaluation to occur weeks to years after the aspiration event. Organic foreign material, in particular nuts, typically cause an intense inflammatory response in the tracheobronchial mucosa (Figure 36-7). This may lead to secondary granuloma formation and a localized tracheobronchitis, and in the most severe cases, bronchial stenosis. As the obstruction worsens, the distal lung segment will collapse. With time, lung abscess formation and bronchiectasis will occur. Rarely, erosion of the foreign body may lead to the development of a bronchopleural fistula with the appearance of pneumothorax and/or pneumomediastinum. Bronchiectasis with hemoptysis has been reported and deaths secondary to massive hemoptysis have been noted.40,41

Bronchiectasis deserves special mention as a known complication of a retained endobronchial foreign body.42 However, foreign body aspiration as the cause of bronchiectasis is only a minor subset of all patients with bronchiectasis. In the large series from Edinburgh, 8 of over 1,000 patients with known bronchiectasis were found to have an aspirated foreign body.43 Four of the 8 patients required bronchial resection because of the severity of the disease, but 4 improved without requiring additional intervention.

figure 36-7 Peanut in the left mainstem bronchus with early inflammatory changes.

If the foreign body can be extricated, then a 4 to 6 week period of observation is indicated to see if the pulmonary changes are reversible.

Timothy grass, a prevalent grass on most continents, as well as some grains, are common causes of bronchiectasis complicating aspiration. This form of aspiration often leads to a progressive, insidious, and eventually debilitating respiratory process. Unlike larger foreign materials, the flowering heads of the grasses and grains can propel the aspirated material into the more distal airway, leading to these parenchymal changes. Clinical symptoms in those instances often are mild chronic cough that may or may not be productive. Occasionally, as the disease progresses, other symptoms of infection such as fever, lethargy, and failure to thrive may occur. An alert clinician must consider this type of aspiration in a patient whose pulmonary symptoms persist or whose pneumonia recurs following adequate treatment. Endoscopic extraction of the grass or grain approaches only 30%, as opposed to the larger more proximal foreign bodies.

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