Multiple factors responsible for fatal outcome in 14-month-old child with 4.5cm right angled metallic nail in the bronchus

1. Introduction 

Foreign body aspiration is a common problem in infants and young children and can be a life-threatening event. Almost 2.5 million children are affected each year in the United States. However, we do not have a reliable statistics for Nepal. Annual death frequencies from such incidents range from 350 to 2000 children and the mortality rate of tracheo-bronchial foreign body aspiration is approximately 1% [1], [2], [3], [4]. The maximum incidence of inhalation of foreign body occurs in children under 4 years’ age [5]. Peanuts, seeds, beans, toys parts and other smooth surface objects are the most common aspirated foreign bodies [6]. Among sharp foreign bodies safety pins, straight pins and fish bones are common. Here, we report an unusual case of a 14-month-old child who presented with a right angle curved metallic nail inside his trachea and right bronchus.

2. Case 

A 14-month-old boy was brought to emergency room in a critical condition with acute respiratory distress. There was a history of difficulty in breathing lasting 12 days which had a sudden onset. He was treated outside as a case of bronchial asthma and as his condition suddenly worsened, he was referred to our hospital. On presentation, he was unconscious and showed response only to painful stimulus. His respiratory rate was 54/min, pulse rate 160/min, and SPO2 80% in room air. Accessory muscles of respiration were prominent and there was severe bronchospasm but minimal stridor. Immediately upon arrival in emergency room the child was evaluated, given oxygen by mask and an X-ray chest was performed. In a meanwhile the patient developed cardiac arrest and emergency doctor decided to attempt laryngoscopy and intubate the child. The child was intubated with some difficulty but the air entry was still not adequate. The child was revived from cardiac arrest. By this time the X-ray film arrived which showed radio-opaque foreign body (90° curved nail) in neck region occupying trachea and larynx (Fig. 1). As the air entry did not improve on intubation, a repeat urgent chest X-ray was taken. It showed that the foreign body had now shifted in the chest (Fig. 2). Patient suffered cardiac arrest once again from which he was again revived. An immediate ENT consultation was sought at this stage. It was difficult to explain the location of foreign body as seen on plain chest X-ray. It was also difficult to confirm if the foreign body was inside trachea and bronchus or had pierced these structures to lie in the mediastinum. At this stage the patient's pupils were dilated and sluggishly reacting to light. After explaining the condition and prognosis to parents and taking their informed consent the child was transferred to the operation theatre for endoscopic assessment and endoscopic or open removal under general anaesthesia. Bronchoscopy using ventilating bronchoscope size 3 (Karl Storz, Tuttlingen, Germany) and 2.9mm Hopkin's telescope (Karl Storz, Tuttlingen, Germany) revealed an impacted right angle curved metallic nail almost completely occupying the trachea and going into the right bronchus. Initially, this bronchoscopy was performed with gases delivered via a ventilating bronchoscope. But in the middle of the procedure, because of increasing airway oedema around foreign body which had been manipulated, the ventilation became difficult. By this time one limb of nail was partly out of the larynx but the other limb with a nail head was stuck in trachea. At this stage immediate tracheostomy was undertaken to allow ventilation from below the impacted foreign body. After tracheostomy the nail was finally removed via the larynx.

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Fig. 1. Nail seen at laryngeal level on X-ray.

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Fig. 2. Nail as seen on chest X-ray and later confirmed to be in trachea and right bronchus on bronchoscopy.

The rusted nail was curved at right angle and its two limbs measured 2.5 and 2cm (Fig. 3). There was no significant bleeding but the patient suffered an episode of severe bradycardia while bronchoscopy was underway. The patient was shifted to pediatric intensive care postoperatively but expired on 10th day of admission.

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Fig. 3. Nail after removal.

3. Discussion 

Often the patients with airway foreign body are first misdiagnosed and treated for bronchial asthma. Diagnosis of an aspirated foreign body mainly depends on clinical suspicion. History as always, is the best determinant of how suspicious one should be of a potential aspiration but proper history is not always available especially in cases of small children. In our case, there was no such history. It was a very uncommon foreign body and the history was atypical. The treating physician outside did not suspect any foreign body in this child for 12 days and treated it as bronchial asthma. Even when the history of foreign body aspiration is negative, the presence of an inhaled foreign body must be suspected by the key signs and symptoms. These signs and symptoms will vary according to the site of impaction of such foreign body [7].

Airway foreign bodies should thus be ruled out in any stridulous child. Laryngeal foreign bodies as such are very rare as most inhaled objects pass into the bronchus [8]. One commonly seen metallic foreign body in the larynx is the safety pin [9]. Vian et al. described the use of high frequency jet ventilation to maintain gaseous exchange in a 16-month-old child with an impacted open safety pin in the larynx, which could be removed by a tracheostomy [10]. Bhat and Oates reported an unusual foreign body in the larynx in an 18-month-old baby without any history of foreign body inhalation and radiological findings [11].

From the second chest X-ray in our case it was difficult to ascertain and explain the location of the nail. After its removal from the trachea and bronchus, an attempt was made to understand how this could get lodged in such location within the bronchus and trachea. We tried to pass this nail through a flexible plastic Y shaped tube. It was found that it is possible to push such right angle curved nail into one of the sidearm of the ‘Y’ tube by manipulating the axis of nail and the main arm. And since in children the trachea and bronchus are very pliable, it is possible for a bent nail to reach the bronchi if it gets pushed during intubation from above.

The removal of impacted foreign bodies like this in a small child where a small sized bronchoscope is used is sometimes better manoeuvred using standard forceps and a telescope, as in this case, than an optical forceps [12].

On the issue of attempting laryngoscopy and endotracheal intubation in cases with foreign body lodged at laryngeal level, it is probably safer and more appropriate in many cases to carry out emergent tracheostomy if a foreign body is at a laryngeal level. This decision will however depend on the nature and type of foreign body, condition of the patient on presentation, level of emergency and the expertise of emergency doctor. However, in our case there was no history of foreign body ingestion and there was misleading history of the child being treated for bronchial asthma for 12 days, which led the emergency doctors to attempt urgent intubation as the child developed cardiac arrest while his X-ray was awaited.