44 AJTCCM VOL. 30 NO. 2 2024
ORIGINAL RESEARCH: ARTICLES
Background.Airway foreign bodies are a common cause of accidental death in children. Tracheobronchial foreign body aspiration (FBA)
can result in severe immediate and long-term complications if the foreign body is not identied and removed. Little is known about the
burden of tracheobronchial FBA in the Soweto area, south of Johannesburg, South Africa.
Objectives. To describe the burden and clinical characteristics of tracheobronchial FBA in hospitalised children in a tertiary-level hospital
in Johannesburg.
Methods.is was a retrospective, single-centre, descriptive study of children aged <10 years who presented to Chris Hani Baragwanath
Academic Hospital from 1 January 2011 to 31 December 2020. Children with FBA were identied from the paediatric pulmonology and
paediatric surgery databases using the relevant International Statistical Classication of Diseases and Related Health Problems, 10th revision
(ICD-10), codes (T17.4 and T17.5). Clinical and radiological data were extracted from medical records and the databases.
Results.Forty-seven children with FBA were identied during the study period. Overall, the incidence of FBA among children aged <10
years of age was 1.42 per 100000 person-years (95.0% condence interval 1.04 - 1.88). FBA occurred more commonly in males (66.0%;
n=31), and the mean (standard deviation) age at presentation was 68 (28.2) months. Most of the children (42.6%) were in the 7 - <10-year
age group, followed by the 5 - <7-year age group (27.7%). Chronic respiratory symptoms were reported in one-third of the children, and a
history of witnessed FBA was reported in only 59.6% of cases. Inorganic foreign bodies (n=29; 61.7%) were aspirated more commonly than
organic foreign bodies; these included metal objects such as pins or springs (21.3%), toy parts (17.0%), pen or pencil lids/stoppers (12.8%)
and plastic objects (6.4%).
Conclusion. Our study highlights the fact that tracheobronchial FBA is prevalent in school-aged children, and public safety campaigns
targeted at this age group are warranted. Furthermore, to prevent sequelae, a high index of suspicion in required in children with respiratory
symptoms that fail to respond to appropriate therapy.
Keywords. Aspiration, foreign body, tracheobronchial.
Afr J Thoracic Crit Care Med 2024;30(2):e1145. https://doi.org/10.7196/AJTCCM.2024.v30i2.1145
Tracheobronchial foreign body aspiration
inchildreninSoweto,South Africa: A retrospective
descriptivestudy
A Moola,1,2 MB BCh, DA (SA); C Ver we y,1,3 MB ChB, FC Paed (SA), MMed (Paed), Cert Pulmonology (SA) Paed, PhD ;
T Mabaso,1 BSc, MB ChB, MMed (Paed); K Mopeli,1 MB BCh; A Withers,4 MB BCh;
J Loveland,4 MB BCh, FCS (SA), Cert Paed Surg; N Patel,4 BA Hons, MA, MB BCh, MMed (Paed Surg), FC Paed Surg (SA);
Z Dangor,1,3 MB BCh, FC Paed (SA), MMed (Paed), Cert Pulmonology (SA) Paed, PhD
1 Department of Paediatrics and Child Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
2 Department of Anaesthesia, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
3 South African Medical Research Council Vaccines and Infectious Diseases Analytics Research Unit, Faculty of Health Sciences, University of the Witwatersrand,
Johannesburg, South Africa
4 Department of Paediatric Surgery, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
Corresponding author: A Moola (ayeshamoola0@gmail.com).
Study synopsis
What the study adds. Our study demonstrated that tracheobronchial foreign body aspiration (FBA) was most prevalent in school-aged
children (7 - <10 years of age), which is in contrast to studies that have reported a high prevalence in children aged <3 years. Chronic
respiratory symptoms were reported in only a third of the children, and a history of witnessed FBA was reported in only 59.6%. Chest
radiographs were normal in a high proportion of cases in which a chest radiograph was done (56.3%). Inorganic foreign bodies were
aspirated more commonly than organic foreign bodies.
Implications of the ndings. Public safety campaigns should be targeted at school-aged children in Soweto, South Africa. Clinicians should
investigate children with respiratory symptoms suggestive of FBA, even if a history is not forthcoming. Furthermore, to prevent long-term
respiratory sequelae, a high index of suspicion in required in children with respiratory symptoms that fail to respond to appropriate therapy.
AJTCCM VOL. 30 NO. 2 2024 45
ORIGINAL RESEARCH: ARTICLES
Airway foreign bodies are the third most common cause of death due
to unintentional injury in children aged <1 year in the USA, where
they have been reported to occur in 0.43 per 100 000 children aged
<5 years.[1,2] Survivors of tracheobronchial foreign body aspiration
(FBA) who are not timeously managed may suer severe immediate
and long-term complications. ere are no local data on the scale and
scope of FBA.
The most common presenting symptoms of tracheobronchial
FBA are cough, wheezing, and choking followed by cough, with a
history of witnessed FBA.[2-4] e most common clinical signs of FBA
are decreased air entry and wheezing in the aected hemithorax.[5]
Radiologically, air trapping or hyperination (35%) and/or atelectasis
(16%) on a plain radiograph of the chest may be observed.[6] Common
complications of tracheobronchial FBA are recurrent pneumonia,
pneumothorax, lung abscess, bronchiectasis, pneumomediastinum
and granuloma formation.[7] Furthermore, in-hospital complications
may arise from instrumentation of the airway during foreign body
retrieval, as well as from the need for mechanical ventilation, and
prolonged admission in the intensive care unit (ICU).[8]
Studies from low- and middle-income countries (LMICs) report a
relatively high prevalence of organic nut tracheobronchial FBA (40%),
whereas studies from high-income countries report a relatively high
prevalence of inorganic magnet foreign body aspiration (34%).[2] Types
of material aspirated also dier by age; children aged <5 years aspirate
food particles more commonly than older children.[9] In South Africa
(SA), foreign body aspiration and ingestion of coins (30%), followed
by beads (8%) and pellets (7%), were described in a Cape Town study
in 2016, with the majority of aspirated/ingested foreign bodies being
of a metallic nature (44%).[9]
Little is known about the burden of tracheobronchial FBA
in Johannesburg, SA. Identifying demographic and clinical
characteristics of children with FBA is essential to make public health
recommendations and develop local management guidelines. We
describe the burden and clinical characteristics of tracheobronchial
FBA in hospitalised children in a tertiary-level hospital in
Johannesburg.
Methods
is was a retrospective, single-centre, descriptive study of children
aged <10 years who presented to Chris Hani Baragwanath Academic
Hospital (CHBAH) from 1 January 2011 to 31 December 2020.
CHBAH is the third largest hospital in the world, situated in the
periurban township of Soweto, south of Johannesburg. ere are ~400
medical and surgical paediatric beds, 9 paediatric ICU beds, and 10
000 medical and 2 300 surgical admissions annually.[10]
We searched the paediatric pulmonology and paediatric surgery
databases to identify children with tracheobronchial FBA according
to the relevant International Statistical Classication of Diseases and
Related Health Problems, 10th revision (ICD-10), codes (T17.4 and
T17.5). Clinical and radiological data for children who presented with
conrmed tracheobronchial FBA were extracted from medical records
and the databases (Fig.1).
Data were analysed using Jamovi statistical software (version
2.3.21, developed by Jonathon Love, Damian Dropmann and Ravi
Selker in Sydney, Australia). Categorical variables were reported as
proportions, and the mean or median was reported for continuous
variables. Incidence was calculated as the number of cases divided
by the estimated mid-year population estimates for regions D and G
in the Johannesburg metropolitan area as per Statistics South Africa.
e study was approved by the University of Witwatersrand Human
Research Ethics Committee (ref. no. M211195).
Results
Forty-seven children were identied with FBA during the 10-year
study period. Overall, the incidence of FBA among children aged <10
years was 1.42 per 100000 person-years (95.0% condence interval
1.04 - 1.88). ere were 31 males (66.0%), and the mean (standard
deviation) age at presentation was 68 (28.2) months (Fig.2). Most
children (42.6%) were in the 7 - <10-year age group, followed by the
5 - <7-year age group (27.7%).
A history of witnessed FBA was reported in 28 children (59.6%).
Sixteen children (34.0%) presented with cough, 6 (12.8%) with
wheezing, 6 (12.8%) with dyspnoea and 4 (8.5%) with recurrent
pneumonia (Table1). irteen children (27.7%) presented with more
than one symptom. Seven children (14.9%) required admission to the
ICU and 5 (10.6%) required ventilatory support. No child was recorded
as having died. A foreign body was visible on 6 chest radiographs
(37.5%). One child (6.3%) had air trapping on the radiograph and
2children (12.5%) had atelectasis (Table1).
Inorganic foreign bodies (n=29; 61.7%) were aspirated more
commonly than organic foreign bodies (n=4; 8.5%) (Fig.1). The
type of aspirated object was unspecied/not recorded in 14 cases
(29.8%). Of the inorganic foreign bodies aspirated, 10 (21.3%) were
metal objects. ese metal objects were pins (n=6; 12.8%), springs
(n=2; 4.3%), or unspecied (n=2; 4.3%). e next most common were
toy parts, which were aspirated in 8 cases (17.0%). Pen and pencil
parts, lids and stoppers were aspirated in 6 cases (12.8%). Aspirated
organic foreign bodies were nuts (n=1; 2.1%), fruit and vegetables
(n=1; 2.1%) and other organic or unspecied objects (n=2; 4.3%).
Table1. Presenting clinical signs and symptoms and
radiological signs in children with tracheobronchial foreign
body aspiration (N=47)
n (%)
Clinical signs/symptoms*
Known history of aspiration 28 (59.6)
Cough 16 (34.0)
Wheezing 6 (12.8)
Dyspnoea 6 (12.8)
Recurrent pneumonia 4 (8.5)
Other†4 (8.5)
Radiological signs*
Radiographic ndings documented 16 (34.0)
Normal radiograph 9/16 (56.3)
Foreign body visible 6/16 (37.5)
Atelectasis 2/16 (12.5)
Air trapping/hyperination 1/16 (6.3)
No radiograph 7 (14.9)
Unknown‡24 (51.1)
*Some patients had more than one clinical sign/symptom or radiological sign.
†Other clinical signs included 1 child with drooling, 1 with sweating, and 2 with audible whistling
while breathing.
‡No data available on whether a radiograph was done or the radiological ndings.
46 AJTCCM VOL. 30 NO. 2 2024
ORIGINAL RESEARCH: ARTICLES
None of the children in the 7 - <10-year age
group aspirated organic material, and most
organic aspirations (n=35; 75.0%) occurred
in children <3 years of age.
Discussion
The incidence of tracheobronchial FBA in
hospitalised children at CHBAH is higher
than reported in high-income settings, and
more than double the incidence reported in
the late 1990s in the USA (0.66 per 100 000
person-years).[11,12] Children from LMICs
may be at increased risk of tracheobronchial
FBA and its complications because of lower
socioeconomic status, limited access to
healthcare, and less awareness of the risks
of aspiration.[13] A eld study in this setting
noted that children are often left to play
unsupervised.[14] Apostulated reason for this
lack of supervision is that both parents in the
household work, with escalated risk during
school holidays when children are at home
unsupervised for longer periods of time.
The present study also demonstrated a
high proportion of tracheobronchial FBA
in older children, particularly aspiration of
inorganic foreign bodies. Aspirated items
vary across the world, and their nature is
largely socioeconomically or culturally
related.[6] Our ndings raise concerns that
local schoolchildren may tend to keep foreign
objects in their mouths, and that these could
be aspirated during activities such as laughing,
coughing or talking.[15] is risky behaviour
provides an opportunity for education around
injury prevention in schools, and prevention
strategies targeted to this age group and their
teachers and guardians.
Previous studies have reported a high
prevalence (72 - 92%) of tracheobronchial
FBA in children aged <3 years, because
toddlers explore the environment through
their mouths.[5,6,16,17] In addition to anatomical
factors such as absent molars, immature
chewing mechanisms and a floppy tongue
and epiglottis, children of this age may be
unable to distinguish between edible and
inedible items.[6] In contrast, the prevalence
of tracheobronchial FBA in the present study
was 29.8% in children aged <5years.
A male predominance of FBA has been
described in previous literature. e reason
for this has been postulated as male children
having a more adventurous and impulsive
nature than females.[11]
Radiolucent foreign bodies are difficult
to detect, so other radiological signs such
as air trapping/hyperination or atelectasis
should alert the clinician to the need for
bronchoscopy, particularly if symptoms
are chronic.[6] Reported sensitivities and
Age (years)
Proportion of patients, %
30
25
20
15
10
5
0
Males Females
<1
n=1
n=0
1 - <3
n=5
n=2
3 - <5
n=3 n=3
5 - <7
n=10
n=3
7 -<10
n=12
n=8
Fig.2. Bar graph showing age and gender distribution of children with tracheobronchial foreign
body aspiration (N=47).
Unknown,
n=14 (29.8%)
Inorganic,
n=29 (61.7%)
Organic,
n=4 (8.5%)
0000
Nut,
n=1 (2.1%)
Seed,
n=0
Fruit/
vegetable,
n=1 (2.1%)
Unspecied
or
other organic,
n=2 (4.3%)
Toy parts,
n=8 (17.0%)
Pen and
pencil parts,
n=6 (12.8%)
Magnet,
n=1 (2.1%)
Glass,
n=1 (2.1%)
Metal
objects,
n=10 (21.3%)
Plastic
objects,
n=3 (6.4%)
FBAs,
n=47
Exclusions,
n=11
Total FBAs
(ltered from databases
using ICD-10 codes T17.4 and T17.5),
N=58
Fig.1. Flow chart depicting the study population of patients with FBA. (FBA = foreign body aspiration; ICD-10 = International Statistical
Classication of Diseases and Related Health Problems, 10th revision; *Children aged ≥10 years and those hospitalised outside the study period
were excluded.)
AJTCCM VOL. 30 NO. 2 2024 47
ORIGINAL RESEARCH: ARTICLES
specicities of plain radiography in the detection of FBA range from
66% to 88% and 30% to 71.4%, respectively.[6] The presence of a
normal chest radiograph does not exclude the diagnosis of FBA, as
was highlighted in our study, in which 9/16 children (56.3%) had a
reportedly normal chest radiograph.
A proposed new scoring system for predictors of FBA has been
described.[3] Features include new-onset, recurrent or persistent
wheeze (93.3% specicity), noisy breathing/stridor/dysphonia (89%
specicity), unilateral reduced air entry (81.5% specicity), abnormal
ndings on the chest radiograph (47.6% specicity), and a witnessed
episode of choking (36% specicity).[3] Despite the availability of
scoring systems, clinicians should nevertheless have a high index of
suspicion for FBA in children with chronic respiratory symptoms.[18,19]
Study limitations
A limitation of this study was that it was retrospective and there were
missing data. Furthermore, the study ndings cannot be generalisable to
primary- and secondary-level hospitals. Children may have presented
to primary healthcare clinics and other hospitals without being
referred to CHBAH, and would therefore not be included in the study
sample. In addition, we could not ascertain whether some children had
neurological, cognitive or psychiatric disorders that may have placed
them at increased risk for aspiration and its complications.[20]
Conclusion
e risk of serious respiratory sequelae following tracheobronchial
FBA is largely avoidable through prevention and prompt intervention.
Tracheobronchial FBA, particularly of metallic and plastic objects,
is prevalent in school-aged children. Public safety anti-choking
campaigns should not only be directed at parents of toddlers but
at teachers and at schoolchildren themselves, encouraging children
to keep items such as pins, pens and pencils out of their mouths.
Children with acute and chronic respiratory symptoms that fail to
respond to appropriate therapy require referral for investigations such
as computed tomography or bronchoscopy, even if a history is not
forthcoming.
Declaration. CV is a member of the editorial board.
Acknowledgements. None.
Author contributions. All authors contributed to the study conception
and design. Material preparation, data collection and analysis were
performed by AM, ZD and NP. e rst dra of the manuscript was
written by AM, ZD and NP. All authors commented on all versions of
the manuscript, and all authors read and approved the nal manuscript.
Funding. None.
Conicts of interest.None.
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Received 6 January 2024. Accepted 25 March 2024. Published 4 July 2024.
