The majority of foreign bodies (FBs) aspirated into the airways
of children are removed by means of respiratory endoscopy, with
endoscopic instruments introduced through the mouth. However, on
rare occasions when the FB is too large to pass the subglottic region,
or is sharply pointed and risks perforating the airway, the removal
of the FB may be performed by opening the trachea.
Below we report on three clinical cases of children who aspirated
FBs into their airways, in which FB removal was performed with an
endoscopic instrument inserted by tracheostomy or tracheotomy.
F.P.P., 6 years old, female, diagnosed with Central Alveolar Hypoventilation
Syndrome idiopathic ("Ondina's Curse"), having been tracheostomized
during the neonatal period for apnea and requiring prolonged mechanical
ventilation. While interned in the Intensive Care Unit she presented
sudden respiratory dysfunction after the PVC tracheostomy tube (Portex
®) was accidentally dislodged. The initial assessment revealed
that the tube had broken at the junction with the horizontal plate
used for fixation to the throat, and that the distal portion had
been aspirated. Radiography of the thorax confirmed that a portion
of the tube was located in the distal trachea. The child underwent
respiratory endoscopy, with a rigid bronchoscope introduced through
the tracheostoma and the aspirated portion of the tube was removed.
The patient had an excellent post-endoscopic evolution.
A.S.J., 8 years old, male, asthmatic, referred to our hospital due
to acute respiratory dysfunction with suspicion of having aspirated
vomit. Presented severe respiratory difficulties requiring tracheal
intubation. On internment presented radiography of the thorax showing
atelectasis of the whole right lung. Fibrobronchoscopy performed
at the ICU, by means of the endotracheal tube, revealed an inorganic
FB, blue in color and plastic in aspect at the ostium of the main
right bronchus. The patient then underwent rigid bronchoscopy at
the Outpatients Surgery Unit of the HCPA, under general anesthetic,
with a rigid bronchoscope with 0º optics connected to video
equipment. It was observed that the FB completely occluded the main
right bronchus. This was secured with endoscopic forceps and tractioned.
The FB came easily as far as the subglottic region, but would not
pass this point. As the FB in the trachea obstructed breathing and
was provoking oxygen desaturation, it was pushed into the right
bronchus with the bronchoscope. The child was ventilated, and, after
ventilation was established, a further attempt was made to remove
the FB. After a third attempt without success, during which the
patient presented severe oxygen desaturation, with cardiac arrhythmia,
the decision was taken to use an endotracheal tube and perform a
tracheotomy. The trachea was exposed with a cervical incision and
prepared for opening. The tracheal tube was then removed, and the
bronchoscope inserted into the airway once more. Endoscopic forceps
were used to pull the FB to the subglottic region. At this point
a transverse opening was made in the trachea, at the third tracheal
ring, and the FB removed through the tracheotomy with hemostatic
forceps. It was a pen lid. After the child's ventilation had been
established, the bronchoscope was removed and nasotracheal intubation
put in place. The trachea was closed with separate stitches using
PDS 5-0, and next the cervical incision was closed by planes. The
cervical opening was closed without tracheostomy tube insertion.
The child remained with the tracheal tube inserted for 3 days when
he was extubated in the Pediatric ICU. He continued to present stridor
and mild intercostal retraction for 02 days, improving thereafter.
A follow-up 1 month after the procedure showed an absence of respiratory
symptoms and radiography of the thorax revealed both lungs expanded.
C.S., 4 years old, female, carrying a tracheostomy due to severe
subglottic stenosis, resulting from prolonged intubation in the
past. Consulted the emergency service because of fever, tachypnea
and yellow secretions from the tracheostomy. Under examination presented
myiasis of the tracheostoma, and radiography of the thorax showed
bronchopneumonia. Antibiotics were started, and, under general anesthetic
the tracheostoma was cleaned, and innumerable larvae were removed.
Respiratory endoscopy with a rigid bronchoscope inserted through
the tracheostoma revealed larvae in the intrathoracic trachea and
a foreign body (a wooden toothpick/cocktail stick) in the main left
bronchus. The foreign materials were removed with endoscopic forceps
introduced through the bronchoscope. The child recovered well and
was later referred to the Child Protection Service (Serviço
de Proteção da Criança).
The presence of foreign material within the airways of children
continues to be a significant cause of morbidity and mortality.
In some countries FBs are even the most common cause of accidental
death among children less than one year old ().
Soon after inspiration of the foreign material, the child may present
intense coughing, wheezing, vomiting, pallor, cyanosis or brief
episodes of apnea. After these initial dramatic manifestations,
the clinical status generally attenuates or even disappears completely.
This short interval during which the child does not present overt
symptoms can give an observer the false impression that the FB may
have been expelled by the cough or even swallowed. This is why it
is important that doctors are always alert to this diagnostic possibility
The treatment for children who have aspirated FBs is their endoscopic
removal with either rigid or flexible equipment. However, in rare
situations, certain materials cannot be removed by endoscopy, and
must be removed through an opening in the airway. A revision undertaken
by Marks et al. (),
studying 6.393 patients with FBs in the airway showed that when
open surgery is indicated for the removal of the FB, thoracotomy
(2.5 %) is more commonly required than tracheostomy (2 %). Of the
104 patients who needed tracheostomy, 52 were because of laryngeal
edema after bronchoscopy, 12 as a route for the introduction of
a bronchoscope, 11 in order to permit assisted ventilation, and
only 10 to enable the removal of large objects which would not pass
the subglottic region ().
In 19 patients the indications for tracheostomy were not commented
It is important to note that tracheotomy indication for removal
of tracheobronchial FBs, as described for one of our patients, is
reported in only 11 cases in the literature (),
suggesting that this is an extremely rare event. Despite our patient
having been described in an earlier international publication (),
we judged its inclusion in this series of cases to be important
since, while rarely necessary, it is important that doctors removing
FBs from the airways of children be familiarized with the possibility
of tracheotomy in order that it may be performed when necessary.
As the subglottic region is the narrowest part of the airway of
a child, any edema caused by the passage of a large caliber FB can
reduce even further the caliber of this area and make it impossible
for the FB to pass a second time when removed. This is a dramatic
moment during the performance of an endoscopic procedure, since
an FB which does not pass the subglottic region completely obstructs
the trachea with hypoxemia, bradycardia and cardiac arrest resulting.
Before this catastrophic event can occur it is important that the
surgeon pushes the FB with the bronchoscope into one of the main
bronchi, in order to allow respiration with at least one of the
lungs. This is a life-saving maneuver and is indispensable.
During removal of a tracheobronchial FB, the removal of such an
object through a tracheal opening is indicated when the FB is overly
wide and will not pass the subglottic region, as was observed with
one of our patients. Other indications for opening the trachea are
the removal of sharply pointed FBs whose points lodge in the subglottis
or in the vocal cords and when the FB impacts the subglottic region
and provokes an acute obstruction ().
Furthermore, in patients who have had previous tracheostomies, as
in the cases reported in this study, the introduction of endoscopic
equipment through the tracheostomy facilitates the removal of large
objects which have been aspirated into the airway.
When the removal of FBs from the airway requires a tracheal opening,
it is important that two trained teams work together: one for the
cervical approach, tracheal opening and removal of the FB viewed
directly: and the other for the bronchoscopy, to grip the FB and
to pull it up to the tracheotomy region. That these teams act in
synchronization and quickly is fundamental to the removal of the
FB and to ensure sufficient ventilation of the child.
Reports in the scientific literature describe the necessity of performing
a tracheostomy after a tracheotomy for the removal of an FB of the
airway. However, this is not necessarily an absolute indication
for tracheostomy, as may be seen with one of our patients. If it
is possible to suture the trachea firmly without leakage, it is
only necessary to maintain tracheal intubation for between 2 and
5 days. This is sufficient time to reduce the local edema and allow
safe extubation ().
Aspiration into the airway or a fragment of a tracheostomy canola
is an uncommon event ().
The first case of aspiration of a fractured metallic tracheal cannula
was in 1960 ();
and aspiration of part of a PVC canola (Portex ®) by one child
was reported by Sood (),
and by three others by Bhatia et al. ().
The aspiration described here is the third history published in
the literature. In all cases, as in our patient, the cannula fractured
at the union between the tube and the horizontal plate used to fix
the cannula in the throat ().
The authors attribute the breakage to prolonged use or to a defect
in the connection of the tracheostomy tube with the external horizontal
portion used for cervical fixation. While PVC cannulae (Portex ®)
do not have joints at this point, wear makes the fracture more likely
to occur ().
We conclude that a minority of child FB aspirations cannot be removed
by endoscopy alone, even when performed by an experienced surgeon.
The concomitant performance of a tracheotomy, or even the use of
a previously created tracheostoma, is indicated for patients who
have aspirated particularly wide FBs, which do not pass the subglottic
region, sharply pointed FBs whose points lodge in the subglottis
or in the vocal cords, or FBs which impact the subglottic and provoke
acute respiratory obstruction.