European Journal of Cardiovascular Medicine

A foreign body can be defined as either an exogenous or endogenous material that appears inappropriately in an anatomical place. Foreign body aspiration is a worldwide health problem which can result in life threatening complications. Foreign body aspiration stands out as a prevalent issue encountered regularly by Otorhinolaryngologists in their daily practice. It presents a challenge each time a case is met. The condition might not always present as an emergency for the patient, but for the doctor a case of foreign body aspiration is always an emergency.

Usually the presentation of coughing, choking, cyanosis, and gagging were all indicators of foreign body aspiration, but occasionally, the patient may be stable or only provide a hazy history of minor chest pain or occasional cough. Late signs and symptoms consist of dyspnoea, fever and chest pain due to inflammatory reaction. The history of foreign body ingestion provided by the paediatric patient's parents is also a significant tool for detecting a positive finding.

Studies have reported mortality rates ranging from 1.8% to 7% in paediatric patients with foreign body aspirations [1-3]. Additionally, it is reported that the majority of patients with airway foreign bodies are between one and three years of age, with decreasing frequency in older age groups [4]. Most commonly, the foreign bodies encountered are items found in the patient's vicinity or play environment. The identification of airway foreign body lodgement heavily relies on a thorough assessment of the patient's history and clinical manifestations, complemented by radiographic examinations or CT scans when appropriate.

However, when it comes to conclusively ruling out foreign bodies within the laryngo-tracheobronchial tree, bronchoscopy stands out as the preferred procedure of choice.

The goal of this retrospective study is to evaluate the number of patients who presented to the emergency and paediatric departments during a three-year period, the kind of presentation, the nature of the foreign body, the use of bronchoscopy in diagnostic and therapeutic intervention, complemented by machine learning.

Our study comprised 30 patients with suspected laryngo-tracheobronchial foreign bodies, who sought medical attention at the Casualty, Paediatric, and ENT departments of Government General Hospital, Guntur.

All patients underwent a comprehensive assessment including a detailed history, thorough clinical examination, chest radiographs, and chest CT scans as needed. The collected data encompassed patient age, presenting complaints, history of foreign body ingestion, clinical and radiological findings, time from surgical intervention to hospitalisation, lodgement location, type of foreign body, and any post-procedural complications.

In addition to conventional diagnostic techniques, we employed advanced computational tools for image analysis. Specifically, we utilised the U-Net architecture, a convolutional neural network (CNN) commonly used for semantic segmentation tasks in medical imaging. The U-Net model was trained in the detection and localization of laryngo-tracheobronchial foreign bodies and infective pathologies like pneumonia on chest CT scans, augmenting the diagnostic process by using it on the existing imaging data.

Surgical interventions, when required, were performed under general anaesthesia using a suitable rigid bronchoscope and jet ventilation. Various forceps were utilised for foreign body extraction. Three patients underwent tracheostomies, while one patient required a thoracotomy with right lobe posterior-basal segmentectomy due to complications related to the foreign body.

Figure 1: Architecture of Unet.

Our study included 30 individuals suspected of having foreign bodies in the laryngo-tracheobronchial tree.

Patients' distribution across age groups is outlined in Table 1.

Among the patients, three were under one year old, four were aged between one and two years, eight belonged to the age group of two to three years, ten fell within the age range of three to four years, and five were above four years old. The youngest patient was eight months old, while the oldest was 53 years old.

Table 1: Distribution of patients across age groups.

 The time interval from the beginning of symptoms and the patient's arrival at our centre varied, ranging from four hours to under a month. 20% of cases manifested within 48 hours, 57% between two and seven days, and 23% between seven and one month.

The time between hospitalisation and intervention varied from four hours to seven days. 60% (18) of the patients had a history of foreign body ingestion, whereas 40% (12) denied any suspicion of foreign body ingestion. Choking incidents occurred in 10%(3) of the patients. 90% (27) of the patients had a cough, 40% (12) had a fever, and 30% (9) felt breathlessness.

Clinically, air entry was decreased on the right side in 60% (18), on the left side in 40% (12), and bilaterally in 3% (1). Crepitations were present in 66% (20).

Radiological results showed that 30% (nine cases) had collapse, 40% had consolidation, 3% had emphysema, and 30% had normal results. Out of all the patients, 80% (24) had a foreign body in the tracheobronchial channel, 17% (5) had a mucopus/mucus plug/crusting/mass lesion in the laryngo-tracheobronchial tree, and 3% (one case) had an intraoperatively normal-looking laryngo-tracheobronchial tree. Table 2 shows the distribution of foreign bodies in the laryngo-tracheobronchial tree among the cases.

Table 2:  Shows a table of the different lodgement places.

Figure 2:  Chest radiograph showing a pin in segmental bronchus of the right lower lobe.

Ten percent (3) of the recovered foreign bodies were non-vegetative, whereas the remaining ninety percent (27) were vegetative. In 90% (27) of the vegetative foreign body instances, groundnut was the most prevalent. The types of foreign bodies are charted in Table 3.

Tabel 3: Shows the types of foreign bodies found.

Rigid bronchoscopy was performed in all instances that required it. Complications during the recovery period included pneumonia, persistent cough, and fever. Table 4 shows the frequency of Post-Op complications.

Table 4: Different types of complications seen in the Post-Op period

In this retrospective study, we aimed to shed light on various aspects related to foreign body aspiration in the laryngo-tracheobronchial passage based on a cohort of 30 cases spanning a three-year period from 2016 to 2018. Our findings contribute valuable insights into the incidence, demographics, clinical presentations, diagnostic methods, and management strategies associated with this critical medical concern. This observation aligns with existing literature highlighting the prevalence of foreign body aspiration in the paediatric population, where the majority of cases fall between the ages of one and three years [4]. Timely recognition and intervention in this age group are crucial, given the potential life-threatening complications associated with foreign body aspiration.

The interval between symptom onset and presentation to our centre varied, emphasising the need for increased awareness among caregivers. A significant portion of cases presented within 48 hours, underscoring the acute nature of this condition. The varied presentation, including symptoms such as cough, fever, and breathlessness, highlights the challenge in diagnosing foreign body aspiration solely based on clinical signs.

Radiological findings provided valuable information in our study, with collapse and consolidation being prevalent.  However, a noteworthy proportion of cases presented normal radiographic results, emphasising the limitations of relying solely on imaging. This reinforces the necessity of a comprehensive diagnostic approach that integrates clinical findings with imaging studies, culminating in bronchoscopy, which emerged as the definitive diagnostic and therapeutic tool in our study. Our study demonstrated a diverse range of foreign bodies, with vegetative substances being the most common. Groundnut emerged as the predominant vegetative foreign body, aligning with the environmental exposure typical for the paediatric age group. The successful retrieval of foreign bodies via rigid bronchoscopy, without surgical complications, underscores the effectiveness and safety of this intervention.

The literature emphasises the severe complications associated with foreign body inhalation, including pneumonia, atelectasis, and abscess formation [5,6]. Our findings reinforce the urgency of timely diagnosis and intervention in preventing these potentially life-threatening consequences. Furthermore, parental awareness is paramount, considering foreign body inhalation is reported as a leading cause of mortality in children under five [7,8].

In the clinical management context, bronchoscopy plays a pivotal role in both diagnosis and removal of tracheobronchial foreign bodies, with studies highlighting its significance in the successful extraction of aspirated foreign bodies, particularly in paediatric cases [9-11]. The considerations of anaesthetic techniques and peri-interventional morbidity, particularly in the context of rigid bronchoscopy, were highlighted in our study, aligning with existing literature [5,12]. Moreover, the nature of the aspirated foreign body emerged as a crucial factor impacting the severity of complications, with organic foreign bodies being associated with more severe mucosal inflammation, bronchiectasis, scarring, and granulation tissue compared to inorganic foreign bodies [13].

Exploration of Image Segmentation: In addition to the core analysis, an exploratory effort was made to evaluate the potential of machine learning applications in clinical settings. A radiologist applied an image segmentation model, specifically the U-Net, to segment foreign bodies in chest X-rays. This trial aimed to understand the practical utility of such advanced technologies in enhancing the accuracy of radiological diagnostics for respiratory tree foreign body cases. While preliminary, these findings contribute to the growing body of knowledge on the integration of machine learning in medical diagnostics.

Furthermore, machine learning algorithms have the potential to be leveraged to predict post-procedural complications, such as pneumonias, based on a combination of clinical variables and imaging data. These algorithms can facilitate early identification of at-risk patients and provide informed timely intervention strategies.

In conclusion, our study provides a comprehensive overview of foreign body aspiration, emphasising the importance of a multidimensional diagnostic approach and timely intervention. The insights gleaned from this study contribute to the evolving understanding of this critical medical concern, with potential implications for clinical practice and caregiver education.

In summary, our three-year retrospective study of 30 cases shedding light on laryngo-tracheobronchial foreign body aspirations underscores the acute nature of this medical emergency, particularly in the paediatric population. The prevalence of cases within 48 hours of symptom onset highlights the need for heightened caregiver awareness and prompt medical consultation. While radiological assessments and clinical signs play essential roles in diagnosis, bronchoscopy emerged as the definitive and successful diagnostic and therapeutic tool, ensuring the safe removal of foreign bodies.

For the removal of foreign bodies within the respiratory tract, rigid bronchoscopy is often the preferred method, especially upon confirmation of their presence. Negligence and hurried eating contribute to a significant number of inhaled foreign bodies. Diagnosis confirmation is facilitated through chest X-rays, careful history-taking, and clinical examination. In cases of doubt, flexible bronchoscopy, particularly for non-radio-opaque foreign bodies, proves valuable. Immediate tracheostomy is occasionally performed as a preliminary measure for removing foreign bodies lodged in the trachea. Recent advancements in endoscopic techniques, coupled with safe anaesthetic procedures like ventilating bronchoscopes, have transformed the removal of foreign bodies from the tracheobronchial tree into a relatively safe procedure. Following removal, antibiotic and steroid treatments are administered as needed.

Furthermore, as advancements in endoscopically assisted bronchoscopy contribute to reduced mortality rates, our findings underscore the ongoing significance of caregiver education and swift medical intervention in preventing adverse outcomes. The study emphasises the critical role of interdisciplinary collaboration among paediatricians, radiologists, and otorhinolaryngologists in formulating timely and effective management plans. This coordinated effort proved instrumental in minimising the time interval between intervention and symptom onset to less than 24 hours, thereby improving overall patient prognosis. Overall, our study contributes significantly to the discourse on optimising patient outcomes in laryngo-tracheobronchial foreign body aspirations.

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