Tracheobronchial Foreign Bodies*

Presentation and Management in Children and

Adults
Farhad Baharloo, MD; Francis Veyckemans, MD; Charles Francis, MD, FCCP;
Marie-Paule Biettlot, RN; and Daniel O. Rodenstein, MD, PhD

Study objectives: To compare the clinical and management aspects of tracheobronchial aspirated
foreign body (AFB) removal in children and adults; to assess the influence of the operators
experience on the outcome of the procedure.
Design: A retrospective review of a 20-year experience (from 1976 to 1996).
Setting: A 900-bed university hospital.
Patients: Eighty-four children up to 8 years old (the child group) and 28 adult patients (the adult
group).
Results: The peak incidence of foreign body aspiration occurred during the second year of life in the
child group and during the sixth decade in the adult group. The symptoms at presentation were
similar in both age groups, but the diagnosis was significantly delayed in the adults. The AFBs were
lodged preferentially in the right bronchial tree only in the adults; a central location was predominant
(but not at all exclusive) in the children. Atelectasis was more common in the adults, and air trapping
was more common in the children. The most frequent procedure was rigid bronchoscopy; when a
flexible bronchoscope was used, it was always in the adult patients. When the operator was less
experienced, a failed first attempt at bronchoscopy and the need for a second procedure were
significantly more frequent.
Conclusions: At presentation, the symptoms seen with AFBs do not differ according to the age of the
patient; however, the delay to diagnosis, the location of the AFBs, and the radiographic images differ
between child and adult populations. The removal of AFBs in patients of all ages can be performed
by the same operators. Because the outcome associated with these procedures improves when the
operator is experienced, the removal of AFBs should be performed in medical centers that are
capable of acquiring and maintaining the necessary expertise.
(CHEST 1999; 115:13571362)
Key words: aspiration; bronchoscopy; foreign bodies, removal
Abbreviation: AFB 5 aspirated foreign body

body aspiration can be a life-threatening

F oreign
emergency requiring immediate intervention; however, symptoms can also go unnoticed for years with
serious sequelae.1,2 The removal of a foreign body in
the respiratory tract generally leads to a rapid recovery.
Most bronchoscopists are skilled in performing procedures on adult or pediatric patients, but not both; most
of the published series to date specifically address
either adult or child patient populations. A comparison
of these two age groups with regard to the symptoms,
*From the Departments of Pneumology (Drs. Baharloo, Francis,
Rodenstein, and Ms. Biettlot) and Anesthesiology (Dr. Veyckemans), Saint-Luc University Hospital, Universite Catholique de
Louvain, Brussels, Belgium.
Manuscript received July 15, 1998; revision accepted December
18, 1998.
Correspondence to: Daniel O. Rodenstein, MD, PhD, Service de
Pneumologie, Cliniques Universitaires Saint Luc, Avenue Hippocrate 10, 1200 Brussels, Belgium; e-mail: rodenstein@pneu.
ucl.ac.be

signs, and management of foreign body aspiration is

made difficult by the shortage of comprehensive data.
At our institution, a referral tertiary university hospital
of 900 beds, a team of pneumologists who are familiar
with both flexible and rigid bronchoscopy for adult and
pediatric patients (including transcarinal or transtracheal biopsies, laser therapy, and stent placement and
removal) have acquired a unique and extensive experience in the removal of endobronchial foreign bodies in
patients of all ages. For the present report, we reviewed
all procedures performed between 1976 and 1996. We
compare the clinical and technical aspects seen in both
age groups, and we assess the influence of the operators experience on procedure outcome.
Materials and Methods
From 1976 through 1996, the physicians in our clinic performed and recorded the removal of aspirated foreign bodies
CHEST / 115 / 5 / MAY, 1999

1357

(AFBs) from the respiratory tracts of 170 children and adult

patients. The patients who required the removal of suture
threads, necrotic or Aspergillus-related material, blood clots, and
plugs were excluded from the study. The series was arbitrarily
divided into two groups according to age. The first group
included patients # 8 years old (the child group); the second
group included patients $ 8 years old (the adult group). The case
files were retrospectively reviewed for gender, age, symptom
distribution, radiographic findings, foreign body type, respiratory
tract localization, eventual complications, and delay in diagnosis.
We also identified the operator and the type, outcome, and
eventual complications of each procedure. The foreign body was
identified based on the clinical history, an endoscopic inspection,
and, on occasion, a histopathologic examination. When it was
difficult to differentiate between peanuts or other nut varieties,
the preference was given to peanuts.
The statistical analysis was performed using the Students t test
for independent samples or x2 for statistics as needed. The
statistical significance level was fixed at a p value , 0.05.

Results
After excluding the patients who did not meet the
study criteria, a total of 112 patients and 121 procedures were retained for analysis. The great majority
of the patients had been referred to us from another
hospital for the removal of a suspected or diagnosed
foreign body in the respiratory tract. In two patients,
an unsuccessful first attempt to remove the foreign
body had been made at the referring hospital. Our
series included 84 patients # 8 years old and 28
patients $ 8 years old. The 121 procedures were
performed over a 20-year period by a total of nine
pneumologists, and the great majority of the interventions were done by two of these nine physicians.
Gender and Age
There were 68 male patients (60%) and 44 female
patients (40%). The gender distribution was the
same in both age groups. The patients ranged in age
from 2 months old to 90 years old (Fig 1), and the
child group represented 75% of the total study

population. The mean age (6 SD) in the child group

was 2.6 6 1.3 years, and the peak incidence of
foreign body aspiration occurred during the second
year of life, accounting for 48% of the total. There
was a rapid decline in the number of incidents that
occurred after the age of 3 years. The mean age
(6 SD) in the adult group was 48 6 24 years old,
and the peak incidence of foreign body aspiration
occurred during the sixth decade of life, with incidents occurring in every decade of life (Fig 1). No
debilitating factors were found in the adult group
that would predispose these patients to foreign body
aspiration, such as a swallowing disorder, or a neuromuscular or neurologic disease. The only exception was an aspirated dislocated tooth in a 37-yearold woman who, after suffering trauma and loss of
consciousness after a severe fall, underwent emergency endotracheal intubation (we ignore whether
the tooth was aspirated before or during intubation).
Signs and Symptoms
The signs and symptoms associated with AFBs are
outlined in Table 1. The most frequent symptom was
what we called the penetration syndrome, defined
as a sudden onset of choking and intractable cough
with or without vomiting, as seen in 48 patients
(49%). Other presenting symptoms that occurred in
isolation or in association were cough, fever, breathlessness, and wheezing. Eight patients presented
with cyanosis. Two patients (2%) had no symptoms
at the time of diagnosis, and they had no history of
penetration syndrome. One of these two patients was
a 9-year-old boy with an aspirated needle that was
visible on radiograph; the other patient was a 59year-old man from whom a peanut was extracted by
flexible bronchoscopy performed for persistent atelectasis. The distribution of symptoms was similar in
the two age groups.

Figure 1. The age distribution of patients with tracheobronchial AFBs. Left: the child group. Right:
the adult group. Note the different scale in the two graphs.
1358

Clinical Investigations

Table 1Incidence of Symptoms and Signs Isolated or

in Association and Their Relative Frequencies After
Foreign Body Aspiration
Symptoms

No. of Patients

% of Patients

Penetration syndrome*
Cough
Fever
Breathlessness
Wheezing
No symptoms

48
36
30
25
25
2

49
37
31
26
26
2

*The penetration syndrome is defined as a sudden onset of choking

and intractable cough with or without vomiting coinciding with the
foreign body aspiration.

Types of AFBs
The nature of seven of the AFBs (6%) could not
be established. Seventy-two of the AFBs (91%)
found in the child group and 16 of the AFBs (59%)
found in the adult group were organic in nature.
More than half of the organic AFBs in the child
group were peanuts. A list of the various AFBs that
were found in both groups is shown in Table 2.

Table 2The List of Aspirated Foreign Bodies in the

Two Age Groups
Child Group*
Organic
Peanut
Organic material
Walnut
Carrot
Apple
Sunflower seed
Chickpea
Peach tail
Tangerine tail
Coffee bean
Orange pip
Crystallized fruit
Coconut
Pistachio
Almond
Dried cereal
Soya
Popcorn
Nonorganic
Plastic
Toy wheel
Plastic peg
Plastic pearl
Pin

Unidentified

No. of AFBs
39
8
5
4
2
2
1
1
1
1
1
1
1
1
1
1
1
1
3
1
1
1
1

*Includes patients # 8 years old.

Includes patients $ 8 years old.

Adult Group
Food
Garden peas
Mushroom
Apple
Stewed apple
Peanut
Meat
Organic material
Tablet

No. of AFBs
5
4
1
1
1
1
1
1
1

Location of AFBs
The distribution of AFBs in the different parts of
the respiratory tract at the time of removal was as
follows: in the child group, 63 AFBs (74%) were
found in the proximal airways (larynx, trachea, and
right and left main bronchi); in the adult group, only
13 AFBs (43%) were lodged in the proximal airways.
This difference was significant by x2 test (p , 0.005).
Only seven AFBs were found in the upper lobe
bronchi, and these were all in the child group. In the
child group, 42 AFBs (52.5%) were located in the
right bronchial tree and 38 AFBs (47.5%) were in the
left bronchial tree (no significant difference). In the
adult group, 20 AFBs (69%) were located in the right
bronchial tree, and 9 AFBs (31%) were in the left
bronchial tree (significant by x2 test [p , 0.05]). In
four patients (3.6%), AFBs were found in both the
right and the left main bronchi.
Radiographic Findings
There were no chest radiographs available for 7
patients in the child group and for 10 patients in the
adult group. Of the available radiographs, the main
radiographic findings and their distribution in the
two age groups are shown in Table 3. Atelectasis was
significantly more common in adults, and air trapping was significantly more common in children
(significant difference between the groups by x2 test
[p , 0.005 for both radiograph findings]). One patient (1.3%) in the child group had a case of pneumomediastinum. No relationship was found between
the radiographic findings and the delay in diagnosis
or the nature of the AFB.
Fever was present in 77% of the patients with
radiographic signs of pneumonia and in 31% of
patients without radiographic signs of pneumonia,
respectively: 10 of 13 vs 22 of 70 patients (significant
difference by x2 test [p 5 0.016]).
Delay in Diagnosis
The delay in diagnosis ranged from 3 h to 11
months. The mean delay (6 SD) in the adult group
Table 3Radiographic Findings in Patients With
Foreign Body Aspiration*

Dental file
Tooth and amalgam
Pin
Drawing pin
Toy wheel
Chicken bone
Pen cap
Plastic
Swab
Unidentified

2
2
1
1
1
1
1
1
1
2

Atelectasis
Air trapping
Pneumonia
Visible foreign body
Normal radiograph

Child Group, No.

of Radiographs
With Diagnosis
(% Relative
Frequency)

Adult Group, No.

of Radiographs
With Diagnosis
(% Relative
Frequency)

11 (14)
49 (64)
10 (13)
3 (4)
9 (12)

9 (50)
3 (17)
3 (17)
2 (11)
2 (11)

*For significant differences, see text.

CHEST / 115 / 5 / MAY, 1999

1359

was significantly longer than in the child group:

40.3 6 87 vs 9.5 6 16.4 days, respectively (p , 0.005
by Students t test). In the child group, the average
delay (6 SD) was noticeably shorter in infants under
the age of 1 year old than in the rest of the patients
in that group, respectively: 3.6 6 3.5 vs 10.3 6 17.2
days (p , 0.005). The overall average delay (6 SD)
was shorter for patients with nonorganic AFBs than
for patients with organic AFBs, respectively: 4.2 6 5
vs 16.8 6 48 days (p , 0.0001 by Students t test).
No correlation was found between the delay in
diagnosis and the location of the AFB or its associated symptoms.
Instrumentation and Complications
In 103 patients (92%), the AFB was removed
under general anesthesia using appropriate-size (2.5
to 8.5 mm) rigid bronchoscopes (Karl-Storz; Tuttlingen, Germany) equipped with a telescopes (Hopkins
Straight Forward Telescope; Karl Storz). Alligatoror peanut-type forceps (Karl Storz) were used as
needed to grasp the AFBs. In the child group,
general anesthesia was almost always administered
by one of two pediatric anesthesiologists who assisted
during pediatric endoscopic procedures.
A flexible bronchoscope (Olympus; Tokyo, Japan)
was used in the remaining nine patients, all of whom
were in the adult group. Biopsy- or tripod-type forceps
were used in this group under local anesthesia.
There were no immediate or late complications.
The great majority of the patients were followed up
for at least 3 months after the removal of the AFB,
and they were all symptom free. However, in nine
patients, the procedure had to be repeated the
following day because of ongoing symptoms due to
the incomplete removal of the AFB (one tablet
fragment, one tooth fragment, and seven nuts debris). These nine patients were compared with the
rest of the patients for age, gender, AFB location,
and delay in diagnosis; no significant differences
were found. It was observed, however, that the
pneumologists who were experienced in foreign
body removal were more successful in removing the
AFB on the first attempt. The two most experienced
pneumologists performed 85 of the procedures, and
only 3 of these 85 procedures required a repeat
bronchoscopy. In contrast, of the 27 procedures
performed by the seven other physicians, 6 procedures had to be repeated because of persisting
symptoms due to the incomplete removal of the AFB
(significant difference by x2 test [p , 0.005]).
Discussion
In our series, we found that foreign body aspiration was more common in children than in adults. All
1360

of the patients except one presented with symptoms

and/or a history that suggested an AFB. It was rare to
discover serendipitously AFBs in the respiratory
tract without any clinical signs. The most frequently
reported symptom was the penetration syndrome,
found in 49% of the patients. This syndrome occurred either as an isolated event, as was the case in
19% of the patients, or in association with ongoing
symptoms such as persistent cough, breathlessness,
and wheezing. Fever was significantly more common
when pneumonia was present; however, up to 33%
of the patients without radiographic signs of pneumonia presented with fever, thus making fever an
unreliable sign in diagnosis.
We found a significantly greater proportion of
organic AFBs in children, accounting for 91% of the
AFBs in this group. Although the nature of AFBs
reported in various studies37 differs according to
lifestyle and eating habits, nuts in general and peanuts in particular remain the most commonly found
AFBs in children. Although the aspiration of fish or
chicken bones is prevalent in previous studies of
adults,8 such cases were relatively rare in our series.
We found AFBs resulting from dental surgery accidents to be more common.
In contrast to the adult group, the majority of the
AFBs in the child group were lodged in the proximal
airways, probably because of the smaller bronchial
tree diameter in this age group. However, 26% of the
AFBs in the child group were localized in the more
distal and lobar bronchi. Moreover, all seven patients
with AFBs lodged in the two upper lobes were in the
child group; therefore, during bronchoscopy, it is
important to thoroughly examine the more distal
sites in all patients suspected of having an AFB.
It is usually believed that AFBs are lodged preferentially in the right bronchial tree because of its
more vertical disposition.6,9 Our data show that this
was the case only in the adult group; in the child
group, the AFBs were found on either side.
Air trapping was the predominant roentgenographic finding in the child group; in the adult group,
atelectasis was more common. The prevalence of
atelactasis might be a result of the longer delay in
diagnosis in the adult group, a delay that allows
enough time for the complete closure of the airway
and retrostenotic atelectasis.9 It is interesting to note
that in both age groups, just over 10% of the chest
radiographs were normal. The proportion of normal
radiographs reported in the literature varies from 8%
to . 80%, depending on the study and the location
of the foreign body.3,4,6,8 In a patient with a high
clinical suspicion, a normal chest radiograph should
not rule out the possibility of an AFB. It should be
noted that AFBs usually are indicated by radiographic abnormalities. Nevertheless, during bronClinical Investigations

choscopy, it is essential to thoroughly explore the

entire bronchial tree to search for fragments lodged
contralaterally, as was seen in four patients in the
present series with AFBs lodged in both the right
and left main bronchi.
The mean time to diagnosis was significantly
shorter in the child group than in the adult group.
This was particularly true in infants , 1 year old.
Our results are in agreement with those of Lan,8 who
described a group of 47 adult patients with nonasphyxiating foreign body aspiration in whom only 6
patients presented with a retention of the AFB for
, 1 week. In contrast, Limper and Prakash10 found
a median delay of only 10 days in adults. The shorter
time to diagnosis in children must be partly due to
parental alertness in infants and children, but it
could also be related to the more central location of
the AFBs in the child group. Indeed, AFBs lodged in
the trachea are probably more prone to be symptomatic than AFBs located in more peripheral airways,
although we did not find any relationship between
the location of the AFBs (ie, central vs peripheral)
and the delay in diagnosis. The shorter time to
diagnosis in the child group cannot be attributed to
the presence of nonorganic AFBs (that were diagnosed much earlier), because nonorganic AFBs were
relatively uncommon in this age group. Contrary to
al-Majed et al,2 we did not find more frequent
complications at presentation in patients with longer
delays in diagnosis, perhaps because in our series the
longest delay was only 11 months.
By comparing the complication rates associated
with bronchial foreign bodies in two separate 5-year
periods before and after the advent of Hopkins
telescopes, Inglis and Wagner5 found a significant
reduction in the overall complication rates from 44%
in the early cohort to 15% in the late cohort, with a
particularly marked reduction in missed or incompletely removed foreign bodies. This improvement
was attributed essentially to the better visualization
provided by the Hopkins telescope. The same researchers also found a trend of increased complications with an increased duration of retention of the
foreign body and lesser operator experience. We
report no complications in our series; however, the
procedure had to be repeated in nine patients the
following day because of ongoing symptoms due to
the incomplete removal of the AFB. The distinctive
feature of this subgroup is that only 3 of 85 procedures were carried out by either one of the two
physicians most experienced in the removal of endobronchial foreign bodies; 6 of 27 procedures were
performed by the less experienced physicians. Because foreign body aspiration is a relatively rare
phenomenon, opportunities for acquiring skill in
removal procedures are inherently scarce. This prob-

lem is made more complex because rigid bronchoscopy in children is quite a different matter from
flexible bronchoscopy in adults; therefore, only referral centers can gain enough experience to ensure
proficiency in the management of foreign body
aspiration.
Over the years, most of our procedures were
performed using rigid bronchoscopes. This does not
mean that flexible bronchoscopes cannot be used for
the removal of foreign bodies. In fact, many of the
procedures that were excluded from this study that
removed nonaspirated foreign bodies (mainly from
adult patients) such as clots, plugs, and suture
threads were performed using flexible bronchoscopes under local anesthesia.
Three additional issues merit some comment.
After the removal of the AFB, some of the patients
were put on a regimen of antibiotics, bronchodilators, or corticosteroids and chest physiotherapy for
short periods (usually 48 h), depending on the
presence of purulent endobronchial secretions or an
inflammatory aspect of the airway mucosa. This
might have contributed to the absence of complications reported in this series. However, there were
too many missing data in this respect in the charts to
allow for a rigorous analysis. The second issue concerns the absence of predisposing factors in this
series. Because this was a retrospective analysis, we
cannot be entirely sure that there were no predisposing factors. The intake of alcohol, for example, is
not always accurately recorded when patients arrive
in respiratory distress. Indeed, alcohol could have
easily been missed. The third issue refers to the
team characteristic of AFB management, especially in the child group. A proficient coordination
among the pneumologist, the anesthesiologist, and
the instrumentation nurse is essential in making the
procedure safe, fast, and efficacious. Although no
hard data support this observation (to our knowledge), most of the procedures in our series that were
performed by the usual team of experienced physicians and nurses were believed to take less time
and involve less stress for the participants, thus
reinforcing our view that tracheobronchial AFB removal is best performed in specialized centers.
We conclude that foreign body aspiration, although more frequent in infants and small children,
can occur at any age and in the absence of any
predisposing factors. The old notion that AFBs are
lodged preferentially in the right bronchial tree is
true in adults but not in children. Air trapping on
chest radiograph was more common in the child
group, and atelectasis was more common in the adult
group. However, if the history is suggestive, a normal
chest radiograph does not rule out a diagnosis of
foreign body aspiration. The removal procedure is
CHEST / 115 / 5 / MAY, 1999

1361

safe and rewarding if it is carried out with the right

instruments in the hands of experienced physicians
in specialized centers.
ACKNOWLEDGMENT: We gratefully acknowledge the physicians who performed the procedures described in this article, and
we thank Giuseppe Liistro, MD, for statistical assistance.

5
6

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Clinical Investigations