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 Table of Contents  
CASE REPORT
Year : 2016  |  Volume : 3  |  Issue : 2  |  Page : 50-51

Migratory foreign body in the airway manifesting as recurrent cardio-respiratory arrest: A rare case report


1 Assistant Professor, Department of Pediatrics, Dr S N Medical College, Jodhpur, India
2 Professor, Department of Pediatrics, Dr S N Medical College, Jodhpur, India
3 PG Resident, Department of Pediatrics, Dr S N Medical College, Jodhpur, India

Date of Submission03-Apr-2016
Date of Acceptance16-May-2016
Date of Web Publication18-May-2016

Correspondence Address:
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Room No. 214 PG Doctors Hostel, Umaid Hospital, Jodhpur
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Source of Support: None, Conflict of Interest: None


DOI: 10.21304/2016.0302.00114

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  Abstract 


Foreign body aspiration in children commonly presents with coughing, dyspnea, wheezing, cyanosis and stridor. Our case presented with cardio-respiratory arrest (CRA), and was successfully revived, but suffered recurrent CRA, and finally betel nut was retrieved from the airway. Here clinical course of the patient favours migration of foreign body leading to recurrent cardio-respiratory arrest. Foreign body migration in airway is an unusual phenomenon, and its presentation as recurrent cardio-respiratory arrest is very rare.

Keywords: Migratory foreign body, recurrent cardio-respiratory arrest


How to cite this article:
Goyal V K, Singh A, Nagar R, Singh S. Migratory foreign body in the airway manifesting as recurrent cardio-respiratory arrest: A rare case report. J Pediatr Crit Care 2016;3:50-1

How to cite this URL:
Goyal V K, Singh A, Nagar R, Singh S. Migratory foreign body in the airway manifesting as recurrent cardio-respiratory arrest: A rare case report. J Pediatr Crit Care [serial online] 2016 [cited 2023 Feb 3];3:50-1. Available from: http://www.jpcc.org.in/text.asp?2016/3/2/50/282019




  Introduction Top


Foreign body in the airway is an important cause of morbidity and mortality in pediatric age group and poses diagnostic as well as therapeutic challenges [1]. Coughing, dyspnea, wheezing, cyanosis and stridor are the classical manifestations of foreign body aspiration. In atypical cases, it may present with aphonia, massive subcutaneous emphysema, bronchial asthma, hemoptysis and bronchiectasis, but presentation in cardiac arrest is rare [2],[3],[4].

We report a one and half years female child, who presented to us in cardio-respiratory arrest and was successfully revived. During post-resuscitation period, she again developed cardio-respiratory arrests twice on ventilator support, and every time was revived with cardio-pulmonary resuscitation (CPR). She had none of the typical features of foreign body aspiration at admission but recurrent episodes of sudden cardiac arrests on ventilator support prompted us to conduct a bronchoscopy, which revealed betel nut in the right main bronchus. Recurrent cardiac arrests per se is rare in children, and mainly results from arrhythmias either primary (mostly channelopathies) or secondary to myocardial injury or electrolyte imbalance. Migration of foreign body in the airway manifesting recurrent cardiac arrest is very rare [5],[6].


  Case Top


A one and half year old female child was brought to emergency department in cardio-respiratory arrest. History obtained from the mother revealed that about 15 minutes back child was sleeping comfortably, and then she noticed abnormal movements followed by unresponsiveness. On arrival child was in cardio- respiratory arrest and immediate CPR was started beginning with chest compressions. ECG revealed asystole. Return of spontaneous circulation was achieved after 2 minutes of CPR. No foreign body was visualized during endotracheal intubation. Patient was placed on ventilator support. Patient was afebrile and was not tachycardic. SpO2 was 98 percent on FiO2 of 30 percent. Peripheral pulses were good and blood pressure was 98/68 mm Hg without any inotropic support. She was encephalopathy with Glassgow coma scale - E2, M4 and VET. Chest rise was adequate, and bilateral air entry was equal with no added sounds. Rest of the systemic examination was normal. Investigations including arterial blood gas, blood sugar, serum electrolytes, hemogram, liver function test, renal function test and ECG did not reveal anything specific for the underlying cause. Chest Radiograph was also normal with no evidence of regional atelectasis or hyperinflation.

At 6 hours and 16 hours of admission child had 2nd and 3rd episode of cardio-respiratory arrest respectively with successful revival. Both the episodes were preceded by bouts of cough. When 24 hour Sp02 (pulse oximeter saturation) record was reviewed it was seen that there was a sudden steep fall in SP02 just prior to cardiorespiratory arrest. Bouts of cough and sudden fall in saturation leading to cardiorespiratory arrest prompted us to evaluate for the presence of endotracheal foreign body. Subsequently, the child underwent rigid bronchoscopy and a piece of betel nut was retrieved from the right main bronchus.

After that child was successfully extubated and had no further episodes of cardio-respiratory arrest, but had developed hypoxic encephalopathy. At day 7 she was discharged on symptomatic treatment.


  Discussion Top


Foreign body aspiration is frequently encountered in pediatric age group particularly in children less than 3 years of age because of inadequate chewing resulting from absence of molar tooth [7]. Males remain more susceptible because of their overactive nature in comparison to females. In children organic foreign bodies like nuts and seeds are more commonly encountered [7],[8].

Majority of foreign bodies pass through the larynx and trachea and lodge in the more peripheral airways, mostly right bronchus in 40-50 % cases. These lower aspirations are more likely to be missed because of partial obstruction and lesser significant symptomatology in children. Uncommonly the aspirated foreign body may lodge in the larynx and trachea also, leading to sudden and complete airway obstruction and cardiovascular collapse, but this phenomenon known as ‘cafe coronary’ is more common in elderly persons [4].

Migration of aspirated body is a rare phenomenon. Inorganic smooth materials like electric bulb and nail in the airway may be displaced by high flow generated by coughing, but is not common. Organic foreign bodies because of their irregular shape, tendency to absorb water and swell up, and induction of more mucosal inflammation, immobilize early in the airway and do not migrate [1],[9].

In the case of our child, the foreign body was probably initially located in the more peripheral airways, leading to mild symptoms missed by the parents. Coughing episodes on awakening might have displaced it from the peripheral airways to trachea, resulting in complete airway obstruction and ultimately cardiovascular collapse. CPR might have resulted in re-migration of foreign body in to more peripheral airways leading to better air entry and successful revival.

In non-life threatening cases of suspected foreign body, a detailed radiological evaluation including CT scan chest is required, as chest X-ray may be normal if the aspirated material is radiolucent, like in our case. But in potentially fatal situations rigid bronchoscopy should be considered as the primary diagnostic and therapeutic choice [1],[2],[4].

Source of Funding: None

Conflict of Interest: None



 
  References Top

1.
Singh RB, Gangopadhyay AN, Gupta DK, Pandey V. Migrating Foreign Body Bronchus: An Unusual Case of Foreign Body Aspiration. Case Reports in Clinical Medicine 2014; 3: 407-409.  Back to cited text no. 1
    
2.
Fidkowski CW, Zheng H, Firth PG. The anesthetic considerations of tracheobronchial foreign bodies in children: a literature review of 12,979 cases. Anesth Analg. 2010; 111(4): 1016-25.  Back to cited text no. 2
    
3.
Oliveira CF, Almeida JFL, Troster EJ, Vaz FAC. Complications of tracheobronchial foreign body aspiration in children: Report of 5 cases and review of the literature. Rev. Hosp. Clin. Fac. Med. S. Paulo. 2002; 57(3):108-111  Back to cited text no. 3
    
4.
Kruif HF, Innemee G, Giezeman A, Spoelstra-de Man AME. Collapse due to acute aspiration of a foreign body. Nehterland Journal of Critical Care 2013; 17(2): 23-26  Back to cited text no. 4
    
5.
Modi S, Krahn AD. Sudden cardiac arrest without overt heart disease. Circulation 2011; 123(25):2994-3008  Back to cited text no. 5
    
6.
Crotti L, Johnson CN, Graf E, De Ferrari GM, Cuneo BF, Ovadia M, Papagiannis J et al, Calmodulin mutations associated with recurrent cardiac arrest in infants. Circulation 2013;127(9):1009-17  Back to cited text no. 6
    
7.
Saki N, Nikakhlagh S, Rahim F, Abshirini H. Foreign body aspirations in infancy: a 20-year experience. Int J Med Sci. 2009; 6(6):322-8  Back to cited text no. 7
    
8.
Rovin JD, Rodger MB. Paediatric Foreign Body Aspiration. Paediatric Review 2000; 21:86-90  Back to cited text no. 8
    
9.
Kikuchi, R, Isowa, N, Tokuyasu, H, Kawasaki Y Intraoperative Migration of a Nail from the Left B 10b to the Main Bronchus. Interactive Cardiovascular and Thoracic Surgery 2007; 6:92-93.  Back to cited text no. 9
    




 

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