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Case Reports: Learning from unexpected outcome (positive or negative)
Child requiring tracheostomy for removal of an airway foreign body at the tracheal bifurcation
  1. Naoki Yogo1,
  2. Sachiko Mizutari2,
  3. Kei Honda3 and
  4. Hidetoshi Asai2
  1. 1Department of Pediatrics, Division of Pediatric Emergency and Critical Care, Japanese Red Cross Kumamoto Hospital, Kumamoto, Japan
  2. 2Otolaryngology, Japanese Red Cross Kumamoto Hospital, Kumamoto, Japan
  3. 3Pediatrics, Japanese Red Cross Kumamoto Hospital, Kumamoto, Japan
  1. Correspondence to Dr Naoki Yogo; naoki.y0715{at}gmail.com

Abstract

Airway foreign bodies are typically removed orally using a rigid bronchoscope. We present a rare case of a foreign body at the tracheal bifurcation that required removal via tracheostomy. A child turned pale while eating nuts and was suspected to have choked on a foreign body. CT revealed a foreign body at the tracheal bifurcation. As his respiratory condition was unstable, tracheal intubation and removal were attempted using a rigid bronchoscope. Tracheal obstruction during oral removal resulted in respiratory failure and bradycardia. Following emergency tracheostomy, the foreign body was removed via the tracheal stoma after his respiratory condition stabilised. The patient was discharged 21 days later without neurological sequelae. To avoid hypoxaemia during airway foreign body removal, as in this case, assessing the size of the upper airway and foreign body is necessary. Tracheostomy and foreign body removal through the tracheal opening should be considered proactively.

  • Ear, nose and throat/otolaryngology
  • Emergency medicine
  • Paediatric intensive care
  • Accidents, injuries
  • Otolaryngology / ENT

https://doi.org/10.1136/bcr-2022-250399

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    Background

    Airway foreign bodies (AFBs) in children are a significant public health issue, and foreign body airway obstruction is a life-threatening event. In Japan, 80 children between the ages of 0 and 14 years died from choking due to aspiration of food between 2014 and 2019. Of these, 73 were under 5 years of age, accounting for 90% of cases.1 Airway obstruction by AFBs is associated with a mortality rate of 2.8%–3.4%.2 3 AFBs are common in infants and young children, especially in those under 3 years of age.4–6 The enhanced risk of aspiration in this age group is attributable to inadequately developed posterior dentition, immature neuromuscular mechanisms of deglutition and airway protection, and the ubiquitous tendency of children in this age group to put objects into their mouths.5 The most common source of AFBs is food, especially peanuts, other nuts and seeds, but the causes differ by region due to differences in eating habits and culture.6–8 The majority of aspirated foreign bodies in children are located in the bronchi.8 9 Laryngeal and tracheal foreign bodies are less common and require urgent management. Rigid bronchoscopy is the modality of choice for extracting AFBs.10 Invasive procedures, such as tracheostomy, thoracotomy and bronchostomy, are occasionally indicated if the foreign bodies can be visualised but cannot be removed by means of rigid bronchoscopy.7 Foreign bodies at the tracheal bifurcation are uncommon. We report a case in which tracheostomy was required to remove a foreign body at the tracheal bifurcation.

    Case presentation

    A child with no notable medical history suddenly began to cry while he was eating nuts, and his face became pale. His parents suspected asphyxiation and performed back slapping and the Heimlich manoeuvre. However, the foreign body was not dislodged, and the boy was rushed to our hospital. During transport, his heart rate (HR) transiently dropped to <80 beats per minute but improved with assisted ventilation. On examination, his thorax was poorly elevated, breath sounds were diminished bilaterally and sinking breathing was evident. His peripheral capillary oxygen saturation (SpO2) was 100% on 10 L/min of oxygen. He had a respiratory rate of 30 breaths per minute, HR of 138 beats per minute, blood pressure of 120/83 mm Hg and Glasgow Coma Scale score of 13 (E3V4M6). Venous blood gas analysis revealed respiratory and metabolic acidosis and an elevated lactic acid level (pH, 7.06; PCO2, 60 mm Hg; HCO3−, 17.0 mEq/L; base excess, −13.3 mEq/L; and lactate, 7.7 mmol/L).

    Investigations

    Despite breathing being abnormal, oxygenation was maintained, which permitted rapid CT scans to be taken. CT was performed 20 min after admission to determine the location of the obstruction. It revealed a foreign body just above the tracheal bifurcation (figures 1 and 2) measuring 10.5 mm on the semimajor axis, 8.2 mm on the semiminor axis and 16.7 mm in length. His respiratory condition was unstable; therefore, he was intubated 72 min later, and a flexible bronchoscope was used to visualise the foreign body. Bronchoscopy showed the same result as the CT scan, with a foreign body lodged in the tracheal bifurcation causing almost complete blockage (figure 3). Under ventilatory control (respiratory settings: peak inspiratory pressure, 25 cm H2O; positive end-expiratory pressure, 10 cm H2O; fraction of inspired oxygen, 0.4; respiratory rate, 40 breaths per minute), his PCO2 increased to >70 mm Hg, and his SpO2 remained close to 100%.

    Figure 1
    Figure 1

    Thoracic CT on admission showing a foreign body (arrow) of approximately 16 mm in diameter at the tracheal bifurcation. The subglottis area, which is the narrowest part of the airway on CT, is then compared with the airway foreign body (arrow). (A) Coronal plane and (B) transverse plane (subglottis area and the airway foreign body).

    Figure 2
    Figure 2

    In the 3D-constructed CT image, green shows the trachea and brown shows the foreign body. The foreign body can be seen to occupy a large area of the tracheal bifurcation.

    Figure 3
    Figure 3

    Bronchoscopy showing the foreign body lodged in the tracheal bifurcation with no visible gap.

    Treatment

    We attempted to remove the foreign body by inserting a rigid bronchoscope through the patient’s mouth under general anaesthesia 4 hours later. However, the foreign body did not pass through the vocal cords. During removal, ventilation failure occurred due to tracheal obstruction. The foreign body was hard; moreover, there was not enough time for crushing it to prevent blockages. His SpO2 dropped to <70%, and HR dropped to <50 beats per minute; therefore, chest compressions were started, and a single dose of intravenous epinephrine (0.01 mg/kg) was administered. An emergency tracheostomy was performed, and ventilation through the tracheostomy increased the HR after 3 min of severe bradycardia. After the patient’s general condition stabilised, the foreign body was surgically removed through the tracheostomy. It took 48 min to remove the foreign body from the time the patient entered the operating room. The foreign body was an almond, 15 mm in diameter.

    Outcome and follow-up

    There was no postoperative hypoperfusion time. However, due to the brief period of cardiac arrest and cardiopulmonary resuscitation in the operating room, active temperature control to maintain normothermia (36°C–37.5°C) was provided. Temperature management was continued for 72 hours, thereby avoiding hyperthermia, and the patient was weaned from the respirator 5 days after the surgery. He had no neurological sequelae and was able to resume eating 10 days postoperatively. The speech cannula was replaced, and he was discharged 21 days after the surgery. The tracheostomy was closed 5 months after the incident, and the patient was healthy with no sequelae at the most recent follow-up visit 6 months later.

    Discussion

    This case is unusual in which the foreign body was located at the tracheal bifurcation. In addition, the foreign body was too large to be removed through the patient’s vocal cords; therefore, an emergency tracheostomy was required. The patient did not have any neurological sequelae after the tracheostomy.

    AFBs are most often located in the bronchi, and AFBs at the tracheal bifurcation are rare. The most common location of AFBs is the right main bronchus, accounting for 52% of cases. Trachea and carina foreign bodies account for 13% of cases.9 In a case series of AFBs, 17/196 (9.8%) cases had foreign bodies located in the carina.11 There have been a few reports of AFBs at the level of the carina. Of the three that we reviewed, the foreign bodies were partially lodged in the right main bronchus in two of the cases but at the tracheal bifurcation, as described here, in one case.12–14 The types of foreign bodies vary by country but are often of plant origin, for example, nuts or from other food categories such as candy.6 A study from North America showed that AFBs originating from hot dogs, peanuts and carrots tended to have serious consequences.4 Other reports suggest that spherical foreign bodies, such as nuts, grapes and candies, are more likely to cause asphyxia.9 AFB inhalation may result in death due to out-of-hospital cardiac arrest.5 Death may also occur as a result of hypoxaemia experienced during procedures to remove the foreign body.9 10 As was observed in the current example, foreign bodies that become lodged in the tracheal bifurcation pose a risk of choking during removal.

    In this case, the foreign body could not be removed via the mouth through the vocal cords, and a tracheostomy was required. Tracheostomy is required for the removal of AFBs in 0.3%–4% of cases.7 10 No indicators or predictors of which patients will require tracheostomy have been identified. Most tracheotomies are performed because the foreign body cannot pass through the vocal cords or because of oedema of the upper airway.9 10 In the case reports on AFBs at the carina level, two out of three cases required a tracheostomy. The two foreign bodies that required a tracheostomy were a palm kernel and a plastic whistle, and the foreign body that was removed by rigid bronchoscopy was a piece of rubber.12–14 In the present case, there was no oedema of the upper airway, but the AFB could not pass through the vocal cords. Tracheostomy is indicated if it is anticipated in advance that it will be difficult for the foreign body to pass through the subglottis or vocal cords. The same may be true in other situations, as the narrowest part of the airway in children is at the glottis or cricoid cartilage.15

    Various measurements have been reported in the size assessment of the upper airway in children, partly in relation to tracheal intubation.16 17 It is useful to refer to these measurements. In this case, the size of the foreign body on CT was 10.5 mm along the semimajor axis, 8.2 mm on the semiminor axis and 16.7 mm in length. The dimensions of the narrowest part of the upper airway as measured by CT near the subglottis were 7.8 mm in anteroposterior diameter and 9.4 mm in transverse diameter. The age-appropriate cricoid diameter sizes predicted from the literature are 6.4–7 mm for the anteroposterior diameter and 6.5–7 mm for the transverse diameter in children aged 2–4 years.16 Therefore, based on the CT measurements and values reported in the literature, it could have been predicted that the removal of the foreign body through the vocal cords would be difficult. In the case of a plastic-whistle AFB reported in the literature, the foreign body was 18 mm in length and 12 mm at the largest diameter,13 so it could be predicted in advance that its removal through the vocal cords would be difficult, given the cricoid size (7.2–7.7 mm for the anteroposterior diameter and 7.2–8.1 mm for the transverse diameter in children aged 5–7 years).13 If it is possible to perform CT, the foreign body size and upper airway diameter should be measured in advance, as these measurements can aid in planning a strategy for the removal of the foreign body.

    Extracorporeal membrane oxygenation (ECMO) should be considered in cases of hypoxia or inadequate ventilation associated with the removal of a foreign body via tracheostomy or when it is anticipated that it will be difficult to remove the foreign body safely. However, ECMO in children requires more time and preparation than in adults because of the smaller size of their vessels.18 ECMO cannulation after the onset of hypoxaemia does not prevent complications and should be followed by removal of the foreign body while in use. However, it is highly invasive, and the indications for ECMO should be carefully considered. There has been a report of a patient who underwent AFB removal using ECMO and experienced severe respiratory distress and hypoxaemia even after the ventilator settings had been adjusted.19 Therefore, as in this case, it is difficult to decide whether ECMO should be used in patients with ventilation impairment but no hypoxaemia. The use of ECMO in children with AFBs does not necessarily refer to the use of venovenous (VV) ECMO. In small children, VV ECMO may not provide adequate respiratory support.20 Since children with AFBs are generally under 3 years old and small in size, venoarterial ECMO should be considered for AFB removal, even in cases where circulatory support is not required.

    AFBs that become lodged in the tracheal bifurcation are rare. A CT scan should be performed for determining the size of the AFB and the diameter of the upper airway to make an informed decision on whether removal should be through the vocal cords or through a tracheostomy. ECMO should be performed if there is strong concern regarding possible respiratory distress following AFB removal. Whether VV ECMO is sufficient to provide respiratory support or whether venoarterial ECMO is required should also be considered.

    Learning points

    • If the general condition allows, the location and size of the foreign body should be confirmed by computed tomography and the method of removal should be considered accordingly.

    • Tracheostomy, as treatment method, should be considered after taking into account the diameter of the upper airway and the size of the foreign body per computed tomography.

    • Whether venovenous extracorporeal membrane oxygenation would provide sufficient respiratory support or whether venoarterial extracorporeal membrane oxygenation is a better option should also be assessed in children with airway foreign bodies.

    Ethics statements

    Patient consent for publication

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    Footnotes

    • Contributors NY, SM and KH conceptualised and designed the study. NY and SM collected and analysed the data. NY wrote the majority of the original draft of the paper. HA provided technical support and conceptual advice. All authors read and approved the final manuscript.

    • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

    • Case reports provide a valuable learning resource for the scientific community and can indicate areas of interest for future research. They should not be used in isolation to guide treatment choices or public health policy.

    • Competing interests None declared.

    • Provenance and peer review Not commissioned; externally peer reviewed.