AJTCCM VOL. 30 NO. 2 2024 35
EDITORIAL
Foreign body aspiration (FBA) in children remains a problem worldwide,
but with dierent challenges in developed and resource-poor settings.
What gets aspirated, the length of time before medical advice is sought,
expertise available and methods of removal vary across the world.
Most textbooks and articles refer to rigid bronchoscopy as the
preferred method for foreign body (FB) extraction, but this practice
has changed signicantly over the past decade, with many FBs being
removed using exible bronchoscopy with the option of converting
to rigid bronchoscopy if necessary. e latter is now possible owing to
newer-generation bronchoscopes with larger working channels, as well
as more advanced instruments. ese include forceps, tripod forceps and
baskets. Recently, cryotherapy has also been added as a possible treatment
option.
[1]
Moola etal.
[2]
report on FBA in the Johannesburg region of South Africa
(SA). Many of their ndings are similar to those reported previously, but
they also highlight some important dierences from articles published
in other resource-poor settings. e rate of FBA was highest in an older
age group, with the majority of children (42.6%) aged 7 - <10 years,
which diers from previous studies. is is interesting, as one would not
expect FBA to occur so commonly in this age group. e reasons for
this nding are uncertain, but may in part reect lack of supervision in
a resource-poor setting where both parents are likely to be working, and
aer-school care may be lacking. Another reason may be neurological
or developmental abnormalities, which were not evaluated in this study.
Öztürk etal.
[3]
have reported that on screening, younger children with
FB ingestion had a signicantly higher prevalence of behavioural and
emotional problems compared with controls. Hyperactivity was an
important predictor for FB ingestion.
[3]
Moola etal.
[2]
report that inorganic material, including plastic, was
aspirated more commonly than organic material. is is also seen in
other parts of SA, and the plastic material aspirated is commonly small
plastic whistles found in inexpensive toys.
[4]
Radiographic ndings were only available in 34.0% of patients in this
study (n=16), with 56.3% of radiographs reported as normal. is is an
important point, as in many cases children present to a health facility with
a history suggestive of FBA and then have a radiograph that is reported
as normal, which can lead to missed or delayed diagnosis followed by
complications. Furthermore, many radiographs will be read by junior
doctors and not radiologists, which may result in subtle radiological
changes being missed. It is debatable whether all children with FBA should
be referred to a tertiary facility for review and bronchoscopy. Although
FBA is taught in most curricula, it may be important to emphasise that
the history overrules radiographic ndings. ere is also sometimes
confusion about whether an FB was ingested rather than aspirated, as the
history may be overlapping and confusing. Bronchoscopy will be negative
in a number of these cases, but the risk/benet ratio is much lower than
that of a delayed diagnosis caused by failing to perform bronchoscopy.
ere is value in repeating radiographs within 24 hours if tertiary medical
services are not easily accessible, as changes may be visible at follow-
up with development of airway oedema and swelling, causing airway
obstruction with an air-trapping eect.
New algorithms and scoring systems have been created to improve
the diagnosis of FBA. A proposed new scoring system for prediction
of FBA with the features 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) may be helpful, but the diagnosis still relies on clinical
and radiological experience.
[5,6]
e article by Moola etal.
[2]
has limitations such as small numbers,
absent radiological ndings in a large number of cases, and, probably the
most important, the method of FB removal.
Task forces of the European Respiratory Society
[7]
and the American
Thoracic Society
[8]
have recommended rigid bronchoscopy for FB
removal in children; in contrast to these recommendations, there is an
increasing number of publications reporting on, or even propagating,
exible bronchoscopy as the primary method for FB removal in children.
Schramm etal.
[9]
reported on a survey in Germany with a total of
259 participants. e majority of them were experienced doctors, with
65% working in the eld of paediatric bronchoscopy at centres that
performed ≥20 paediatric bronchoscopies per year. About 40% of the
respondents indicated that they had been formally trained in a course in
exible bronchoscopy, 15% had been trained in rigid bronchoscopy, and
42% had never attended formal training. Seventy percent of the facilities
treated ≤15 cases of paediatric FBA per year, and 30% treated >15 cases.
Twenty percent primarily used exible bronchoscopy as the method of
choice for FB removal, 48% preferred rigid bronchoscopy, and 30% used
a systematic combination of the exible and rigid techniques. About a
quarter of respondents reported that they had experienced situations
requiring ICU admission.
Swanson etal.
[10]
retrospectively described a group of 40 children
with FBA. Of the FBs, 60% were successfully removed with exible
bronchoscopy alone. In 35% of cases, the initial method was exible
bronchoscopy, but conversion to rigid bronchoscopy was required.
Wiemers etal.
[11]
reported on complication rates of rigid and exible
bronchoscopy in FB removal. e overall rate of complications was
similar in rigid v. exible bronchoscopy (19.1% v. 24.2%; p=0.232), but
respiratory complications occurred signicantly less frequently during
rigid bronchoscopy (9.2% v. 16.3%; p=0.025).
e situation in SA is less clear with regard to the method used, and this
varies from institution to institution, depending on who is responsible for
the management of children with suspected FBA. It seems that at many
institutions rigid bronchoscopy is still the preferred choice, as removal is
mostly done by cardiothoracic or ear, nose and thoat surgeons. However,
in an increasing number of cases, flexible bronchoscopy is used by
paediatric pulmonologists.
FBA can be complicated by many factors, including location of the FB,
length of delay in diagnosis, parenchymal and pleural complications, and
the degree of airway obstruction.
FBA can have a signicant mortality rate, both before hospital admission
and during attempted removal. e real risk of removal is mostly unknown,
as negative outcomes are typically not reported. Delayed diagnosis with
Foreign body aspiration in children: Challenges, insights, and
pathways forward
36 AJTCCM VOL. 30 NO. 2 2024
EDITORIAL
complete bronchus obstruction may have a high risk of complications due
to suppurative lung disease, which can lead to pus formation and release
once the FB is removed or moved.
Many countries in Africa, including certain areas of SA, have a shortage
of bronchoscopy services, especially for paediatric patients. is shortage
results in delays in the resolution of obstructions and can lead to long-
term complications. It is important that pulmonology societies develop
a plan to improve this situation, or at least create pathways of referral to
centralised units.
In conclusion, the management of FBA is inuenced by a variety of
factors including technological advancements, resource availability,
healthcare provider expertise and regional dierences. Addressing these
challenges requires a multifaceted approach involving medical education,
resource allocation, and collaboration among healthcare providers and
organisations.
Pierre Goussard, FC Paed (SA), PhD
Head of Clinical Unit: Paediatric Pulmonology and Paediatric Intensive
Care, Department of Paediatrics and Child Health, Faculty of Medicine
and Health Sciences, Stellenbosch University and Tygerberg Hospital,
Cape Town, South Africa
pgouss@sun.ac.za
Ernst Eber, MD
Head of Division of Paediatric Pulmonology and Allergology and Chair of
Department of Paediatrics and Adolescent Medicine, Medical University
of Graz, Austria
1. Schramm D, Freitag N, Kötz K, etal. Cryotherapy in the paediatric airway: Indications, success
and safety. Respirology 2022;27(11):966-974. https://doi.org/10.1111/resp.14353
2. Moola A, Verwey C, Mabaso T, etal.
.
Tracheobronchial foreign body aspiration in children
in Soweto, South Africa: A retrospective descriptive study. Afr J oracic Crit Care Med
2024;30(2):e1145. https://doi.org/10.7196/AJTCCM.2024.v30i2.1145
3. Öztürk B, Güngör A, Yoldaþ TÇ, etal. Social, emotional and behavioral problems in children
with foreign body ingestion: A case control study. Indian Pediatr 2024;61(5):447-451 (epub
26 February 2024).
4. Webster I, Goussard P, Gie R, Janson J, Rossouw G. e indications and role of paediatric
bronchoscopy in a developing country, with high prevalence of pulmonary tuberculosis and
HIV. Expert Rev Respir Med 2017;11(2):159-165. https://doi.org/10.1080/17476348.2017.12
80397
5. Janahi IA, Khan S, Chandra P, etal. A new clinical algorithm scoring for management of
suspected foreign body aspiration in children. BMC Pulm Med 2017;17(1):61. https://doi.
org/10.1186/s12890-017-0406-6
6. Pozailov S, Goldbart A, Aviram M, etal. Foreign body aspiration score (FOBAS) – aprospectively
validated algorithm for the management and prediction of foreign body aspiration in children.
Eur J Pediatr 2024;183(2):815-825. https://doi.org/10.1007/s00431-023-05347-9
7. Eber E, Antón-Pacheco JL, de Blic J, etal. ERS statement: Interventional bronchoscopy in
children. Eur Respir J 2017;50(6):1700901. https://doi.org/10.1183/13993003.00901-2017
8. Faro A, Wood RE, Schechter MS, etal.; American oracic Society Ad Hoc Committee
on Flexible Airway Endoscopy in Children. Ocial American oracic Society technical
standards: Flexible airway endoscopy in children. Am J Respir Crit Care Med 2015;191(9):1066-
1080. https://doi.org/10.1164/rccm.201503-0474ST
9. Schramm D, Ling K, Schuster A, Nicolai T. Foreign body removal in children: Recommendations
versus real life – a survey of current clinical management in Germany. Pediatr Pulmonol
2017;52(5):656-661. https://doi.org/10.1002/ppul.23609
10. Swanson KL, Prakash UB, Midthun DE, etal. Flexible bronchoscopic management of
airway foreign bodies in children. Chest 2002;121(5):1695-700. https://doi.org/10.1378/
chest.121.5.1695
11. Wiemers A, Vossen C, Lücke T, etal. Complication rates in rigid vs. exible endoscopic
foreign body removal in children. Int J Pediatr Otorhinolaryngol 2023;166:111474. https://doi.
org/10.1016/j.ijporl.2023.111474
Afr J Thoracic Crit Care Med 2024;30(2):e2380. https://doi.org/10.7196/
AJTCCM.2024.v30i2.2380
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