기도이물의임상적고찰 전남대학교의과대학호흡기내과학교실, 화순전남대학교병원폐식도종양클리닉, 이비인후과학교실, 서남대학교의과대학내과학교실 손창영, 위정욱, 김수옥, 오인재, 박창민, 김규식,, 김유일, 임성철, 임상철, 김영철,, 박경옥 A Retrospective Review of Tracheobronchial Foreign Bodies Chang-Young Son, M.D., Jeong-Ook Wee, M.D., Soo-Ock Kim, M.D., In-Jae Oh, M.D., Chang-Min Park, M.D., Kyu-Sik Kim, M.D.,, Yu-Il Kim, M.D., Sung-Chul Lim, M.D., Sang-Chul Lim, M.D., Young-Chul Kim, M.D.,, Kyung-Ok Park, M.D. Division of Pulmonology and Critical Care Medicine, Department of Otolaryngology & Head and Neck Surgery, Chonnam National University Medical School Lung and Esophageal Cancer Clinic, Chonnam National University Hwasun Hospital, Internal Medicine, Seonam University Medical School, South Korea Background : The development of bronchoscopic equipment along with the precision of radiographic techniques had reduced the mortality rate of patients with tracheobronchial foreign bodies but has been no change in the incidence of tracheobronchial foreign bodies since their introduction. The aim of this study was to assess the clinical characteristics of a tracheobronchial foreign body aspiration and to evaluate the efficacy of the treatment modality in children and adults. Methods : This is a retrospective review of 6 patients who underwent bronchoscopic procedures for the treatment of aspirated foreign bodies from December 99 through March at the Chonnam national university hospital. Results : There were 7 males and 7 females, aged from month to 78 years. Most of the patients had no underlying illness except for one patient with a cerebrovascular accident that contributed to the foreign body aspiration. The most common symptom was cough, which was noted in patients (8.%). The other presenting symptoms were dyspnea (8.8%), fever (.%), sputum (%), vomiting (7.8%), and chest pain (.6%). Those whose tracheobronchial foreign bodies were diagnosed more than days after the aspiration ( patients) were more likely to have pneumonia than those whose foreign bodies were diagnosed within days (p =.9). Foreign bodies were visualized in the plain chest radiographs in cases (8.8%), while others showed air trapping (,.8%), pneumonia (,.%), atelectasis (7,.9%), and normal findings (9,.%). The foreign bodies were more frequently found in the right bronchial tree (6) compared with the left bronchial tree (, p =.). In order to remove the foreign bodies, twenty (.%) cases were removed using flexible bronchoscopy, while (6.6%) and (.%) cases required rigid bronchoscopy and surgery, respectively. Conclusions : Tracheobronchial Foreign body aspiration had a bimodal age distribution in the infancy and old age around 6 years. They were found more frequently in the right bronchial tree. In addition, patients whose foreign bodies were diagnosed more than days after the aspiration were more likely have a infection. Rigid bronchoscopy is the procedure of choice for uncooperative children and for those with foreign bodies lodged deeply in the small bronchial tree. (Tuberc Respir Dis ; 8: 6-66) Key words : Airway, Foreign body, Bronchoscopy 서 기도이물은즉각적인처치를시행하지않으면생 론 Address for correspondence : Kyu-Sik Kim, M.D. Lung and Esophageal Cancer Clinic Department of Pulmonology and Critical Care Medicine Chonnam National University Hwasun Hospital Jeollanamdo, Hwasun, Ilsim-ri 6, 9-89 Phone : 8-6-79-76 Fax : 8-6-79-766 E-mail : Cyberkks@cnuh.com Received : Jan. 7. Accepted : May. 7. 명을위협할수도있는응급질환으로써 때로는수개월에서수년동안자각하지못하여반복적인객혈, 기도폐쇄, 심한육아종형성으로인한비가역적인손상등의심각한부작용을초래할수있다. 기도이물은대개성인보다소아에서호발하는것으로알려져있으며, 998년미국에서총,건의치명적인기도이물환자가발생하여 Un-intentional injury 사망률이 위에이르렀고매년 만명당.명이사망하였다. 세이하의소아의경우에는사망의가장흔한원인을차지하여기도이물에대한진단및치료가중요 6
Tuberculosis and Respiratory Diseases Vol. 8. No. 6, Jun. 함을알수있다. 897년 Killian 6 이식도경을이용한기도이물을제거한이후로최근까지새로이개발되는기관지내시경장비들과세밀해진영상기술로써점차사망률이감소하고는있으나그이환율에차이는없음을보여주고있다. 저자들은전남대학교병원에서기도이물로진단및치료를받은환자 6예를대상으로기도이물환자들의임상상, 이물들의유형, 치료법들을조사하여향후진단및치료방법에있어서문제점과개선점을찾아보고자하였다. 연구대상및방법 99년 월부터 년 월까지전남대학교병원에서기도이물로진단및치료를받은환자 6예를대상으로하였다. 의무기록을기초로하여굴곡성내시경, 경직성내시경과수술을통해제거된기도이물환자들의성, 나이, 기저질환, 증상분포, 방사선학적소견, 이물의종류, 기도이물의위치, 치료방법, 시술후발생된부작용및실패원인을분석하였으며 일미만으로조기발견된군과 일이상으로늦게발견된군을서로비교분석하였다. 모든자료는평균 ± 표준편차로표기하였고, 통계분석은 MS Window SPSS- PC.을이용하여 p 값이. 미만인경우에유의한것으로판정하였다. 결과총 6예환자에서연령분포는 세부터 7세까지분포하였다. 그림 에서보이는것과같이영유아기에높은분포를보이고소아기를지나서감소하다가 6 세주변에또다른호발연령층을보이고있었다. 기저질환으로의식장애나흡인이호발할수있는원인이동반되어있었던경우는 예있었으나특별한기저질환이없는정상인들이대부분이었다 ( 표 ). 주증상은대부분기침 (8.%) 을보였고, 호흡곤란 (6.8%), 발열 (.%), 가래 (%), 구토 (7.8%), 흉통 (.6%) 등을보였으나, 예 (.6%) 에서는아무런증상도없었다 ( 표 ). Figure. The Age distribution of the patients with tr acheobronchial foreign bodies Table. Patients characteristics Variable N=6 Age (year) ~76 Male/Female 7/7 Underlying illness Cerebrovascular accident Delay in Diagnosis days > days Table. Incidence of symptoms and signs of endobronchial foreign bodies coughing, choking dyspnea fever sputum vomiting wheezing chest pain No symptom No. of patient 9 8. % 6.8 %. %. % 7.8 % 7.8 %.6 %.6 % 방사선적으로치아, 뼈, 압정, 못, 보철물, 핀, 담배파이프등 예 (8.7%) 에서이물의확인이가능하였고, 예 (.8%) 에서 air trapping, 예 (.%) 에서폐렴, 7예 (.9%) 에서무기폐를보였으며정상소견을보인경우도 9예 (.%) 가있었다 ( 표 ). 그림 는땅콩을흡인한후내원한 세의여아의흉부방사선사진으로흡인된좌측폐가과팽창되어있는소견이다. 기도이물은우측주기관지에서 7예로가장빈발하였으며기관내 6예, 좌측주기관지 예, 우상엽기관분지 예, 우중엽기관분지 9예, 우하엽기관분지 6
CY Son, et al.: A retrospective review of tracheobronchial foreign bodies Table. Radiographic findings of patients with foreign body aspiration Air trapping Pneumonia Visible foreign body Atelectasis Normal radiograph Number of patient 7 9.8 %. % 8.8 %.9 %. % Figure. Chest X ray of a year old girl who had an aspirated nut in her left main bronchus. Note the hy perinflated left lung, which is shifting the mediasti num to the right side. 9예, 좌상엽기관분지 예, 좌하엽기관분지 7 예로좌측 (.%) 보다우측 (6.%) 에서더호발하였다 (p=.). 기도내에서발견된이물의종류는 8예 (9.7%) 에서확인이가능하였고땅콩 예, 음식물 7예, 치아 6예, 플라스틱류 예, 뼈, 치과보철물, 핀이각각 예, 압정, 못, 담배파이프, 꽃씨가각각 예, 돌이 예로확인되었으며그성상을확인할수없었던경우가 6예 (9.%) 가있었다 ( 표 ). 이물의제거를위해사용한방법은 예 (.%) 에서굴곡성기관지내시경 (Fiberoptic flexible broncho scopy, FFB) 을경유하여 rat tooth, tripode, basket snare 등의 forcep으로제거가가능하였고 예 (6.6%) 는경직성기관지내시경을, 예 (.%) 는개흉술을이용한제거가필요하였다 ( 표 ). 다양한증상등을보여 일내에기도이물을발견한경우가 예이었고, 이물의흡인을자각하지못하고흡인후 일이후에발견된경우가 예 ( 그림 ) 로양군간에연령등임상적특성등에차이는없었다. 단지조기발견한군에비하여지연되어진단된군에서폐렴이더자주관찰되었다 (.6 vs..%, p=.9) ( 표 6). 굴곡성기관지내시경을처음시도하였던환자들중 예에서는이물을제거하지못하고결국경직성내시경으로이물을제거하였는데, 그원인으로협조가되지않아실패한경우가 예가있었으며이물이깊숙이위치한경우가 예가있었다. 수술적으로이물을제거한 예는모두이물이작고깊숙이박혀있어내시경적제거가불가하였기때문이었다 ( 표 7). 치료후최고 년 8개월까지 6예의환자에서부작용을추적관찰하였으며추적관찰도중유의한증상발현이나부작용은보이지않았다. 하지만처음시도 Table. The list of aspirated foreign bodies in the three age groups No. of Foreign bodies < years ~ years > years Nuts Tooth Bone Food Nail Tack petal plastic implant pin stone pipe paper unknown 6 7 6 7 6
Tuberculosis and Respiratory Diseases Vol. 8. No. 6, Jun. Table. Treatment methods of aspirated foreign bodies Fiberoptic bronchoscopy Rigid bronchoscopy Surgical treatment (lobectomy) No. of patient (*) (*). % 6.6 %. % * Number of cases whose foreign body removal had failed by fiberoptic bronchoscopy. 한기관지내시경으로완전한기도이물의제거가이루어지지않은 예에서는 차례의기관지내시경적시술및수술을시행해야했다. 이 명의환자군과나머지환자군의연령 (p=.), 성비 (p=.), 기도이물의위치 (p=.), 진단의지연 (p=.) 등에서유의한차이점은발견할수없었다. 고 찰 Figure. The distribution of time elapsed from the events of the aspiration of the foreign bodies to the diagnosis (W : week, M : month) Killan 6 이 897년기도이물을식도경으로제거하였고 96년 Jackson 이기도이물환자의 98% 에서이물 Table 6. Comparison between those with an early and late diagnosis Number Duration (range) Age (Median, range, years) Sex (M/F) Underlying illness Complications Removal Methods FFB FFB Lobectomy Rigid bronchoscopy * p <.9 FFB : Flexbile fiberoptic bronchoscopy : Rigid bronchoscopy Early group ( days) hr ~ day (~76) / none Pneumonia () 7 Late group (> days) day ~ months (~69) /7 CVA () Pneumonia ()* bleeding () 8 Table 7. Causes of Failure from the Flexible Bronchoscopic Removal of the Foreign Body age(year) location material duration cause treatment 6 6 RML RML RLL Rt main LLL Rt main Nail Food Implant Tack Petal Petal M hr hr hr w 6hr poor cooperation deep impaction deep impaction poor cooperation deep impaction,small deep impaction,small : Rigid bronchoscopy RML : Right middle lobe RLL : Right lower lobe Rt main : Rt main bronchus LLL : Lefit lower lobe lobectomy lobectomy 6
CY Son, et al.: A retrospective review of tracheobronchial foreign bodies 제거에성공과함께사망율을 % 에서 % 로감소시켰다. 최근까지새로이개발되는굴곡성혹은기관지내시경들과영상기법으로사망률은더욱감소되어 년에 Hsu등은 99% 의이물제거율과.% 미만의사망률을보고하였다 7-9. 보고된성적들에따르면기도이물은어른보다소아에서더욱흔히관찰된다고한다. 특히 세이전의어린이에게흔히발생하는데이시기가이물을입으로가져가는성장환경으로기인한다고본다 9,. 또한성인에게서는 6대이후가흔하며기도의방어기전의약화가이물의흡인을쉽게한다고설명되고있다,. 본연구에서도마찬가지로기도이물은성인보다 세이하의소아에서호발하였으며성인에서는 6세주변에서호발함을보여주었다. 특히고령의성인들에서는대부분특별한기저질환이없는정상인들이어서이물의흡인이특별한원인질환없이도발생이가능함을알수있었다. 기도이물의임상양상은부피가큰이물이후두에흡인되었을때심한기침, 음성변화, 청색증등의증상이빈번히관찰됨을알수있으며 998년미국에서이러한흡인으로 명이질식사하였다. 그러나이물이후두와기관을지나하부기관지에서위치할수록이러한증상은소수에서만관찰되게되고장기간자각하지못한채로발견되는경우가많아지게된다,. 본연구의 6예의환자중대부분이호흡기적증상을관찰할수있었고이중 예가 일이내에조기발견이가능하였다. 가장흔한증상으로기침과숨막힘이 8.% 에서발생하였고호흡곤란, 천명음, 발열, 가래, 구토증상과동반된경우도있었다. 폐렴이발생하였을때발열이가장흔한증상이지만방사선소견상폐렴이의심된환자중 6% 에서는발열이없어서이물로인한폐렴이발생되는초기에진단된경우들로사료된다. 일반적으로소아들은기도의직경이성인에비해상대적으로작기때문에기관지근위부에이물이호발하는것으로생각되며일부에서원위부에위치하는경우도있었으므로기관지내시경을시행할때에기도의원위부까지잘관찰하여야할것이다. 기도이물이가장흔하게위치하는부위는우측하부기관지로알려져있는데이는기관분지에서보이는해부학적 차이에의한것으로우기관지가좌기관지에비해좀더완만한각도를유지하기때문이다. 기도이물의종류는매우다양하였는데, 이는환자들의생활습관및음식습관과관련되어있다,-7. 가장흔한이물은땅콩이었는데, 이는기도이물이소아환자에서많이발생하고땅콩이소아환자에서가장많은이물이었기때문이다. 방사선소견에서는공기폐색 (air trapping) 이.8% 로가장흔히관찰되었으며폐렴이.% 에관찰되었다. 방사선소견으로기도이물이확인되었던경우는여러연구에서 8~8% 에서다양하게발표되었지만,-7 본연구에서는 8.8% 에불과하였다. 또한.% 에서정상적인방사선소견을보이기도하였으므로방사선사진만으로기도이물의가능성을배제할수없었다 ( 표 ). 조기발견된군에비해늦게발견된군 (일초과 ) 에서연령분포 (P >.) 및성별 (P >.) 에서유의한차이는보이지않았다. 신경학적장애가있는경우는 % 에불과하였으며이는특별한기저질환으로인해기도이물이더호발한다거나발견이지연되지는않았을것으로생각된다. 그러나폐렴은진단이늦어치료가지연된군에서유의하게높은빈도로발생하였다. 치료가지연될수록이물이감염의원인이되어폐렴을초래하였을것으로생각되며이중몇예에서는이물주위로육아종이자라종양으로오인된경우도있었다. 기도이물의진단에있어 6 예의환자중 예에서 일이후에진단이되어조기진단에어려움이있었다. 이는기도이물의경우기침과숨막힘, 호흡곤란, 천명음, 발열, 가래, 구토등비특이적인호흡기적증상들만이관찰되어임상양상으로타질환과감별이어려웠고방사선학적으로이물질이확인된경우는 8.8% 에불과하여지연진단이되었다. 또한이렇게지연진단이되었던군은폐렴발생률이높아기도이물이잘발생하는 세미만, 6세전후에서임상적으로기도이물이의심되는경우혹은비특이적인증상이라할지라도한번쯤은기관지내시경등의적극적인방법을고려해볼필요가있겠다. 본연구에서 6 예의환자중 6 예에서기관지내시경으로기도이물을제거할수있었고 예에서만수술적치료가필요하였으며방사선학적으로확인된 6
Tuberculosis and Respiratory Diseases Vol. 8. No. 6, Jun. 예를제외하고나머지예에서는기관지내시경으로진단이가능하였다. 따라서임상적으로기도이물이의심되는경우적극적인기관지내시경술을시행하여기도이물의진단이이루어져야할것으로사료되며이는곧치료로연결될수있어기도이물의진단및치료를위해서는기관지내시경검사가필수적임을시사한다. 기관지내시경제거술은연령이나환자의상태에따라경직성기관지내시경또는굴곡성기관지내시경을적용하였으나, 협조가되지않은소아이거나기관지내에깊숙이박혀있는경우는결국경직성내시경또는수술적치료로제거하였다. Inglis 와 Wagner 는홉킨스기관지경 (Hopkins tele scope) 의개발전과후의 년간의기도이물의부작용발생율의비교분석에서 % 에서 % 로부작용발생율감소와함께불완전한제거및실패율도감소되었으며의료진의경험이부족한경우에부작용발생율이높음을보고하였다 8. 본연구에서는기도이물의제거후최고 년 8개월까지추적관찰을시행하였고특별한부작용을관찰할수없었다. 이는본연구에서비교적경험있는의료진만이기관지내시경을시행하여부작용발생율이적었을것으로사료된다. 또한처음시도한기관지내시경으로완전히기도이물의제거가이루어지지않은 예에서는 차례의기관지내시경적시술및수술이필요하였으나 명의환자군과나머지환자군의연령 (p=.), 성비 (p=.), 기도이물의위치 (p=.), 진단의지연 (p=.) 등에서유의한차이점을발견할수없었다. 비록경험있는의료진이시술을하더라도모든환자에서단한번의기관지내시경시술만으로모든기도이물을제거할수는없음을알수있었고기관지내시경으로기도이물의제거가이루어졌다하더라고의료진의세심한추적관찰이필요하리라생각된다. 결론기도이물은 6세주변의고령층과영유아기에높은분포를보였고다양한임상증상과함께방사선학 적으로는이물을확인할수없는경우가많았으며정상적인소견을보인경우도있어조기진단에어려움이있었다. 또한발병후 일이지난뒤에진단된경우에는폐렴합병증의발생가능성이높아졌다. 따라서임상적으로기도이물이의심되는경우에는경험있는의료진의적극적인기관지내시경술이필요하며협조가되지않은소아나기관지내에깊숙이박혀있을것으로의심되는경우들에서는경직성기관지내시경을초기부터고려하는것이필요하리라사료된다. 참고문헌. Massachusetts General Hospital. Case records of the Massachusetts General Hospital: weekly clinicopath ological exercises: case 997: a 7-year-old man with chest pain, hemoptysis, and a pulmonary lesion. N Engl J Med 997;7:-6.. al-majed SA, Ashour M, al-mobeireek AF, al-hajjaj MS, Alzeer AH, al-kattan K. Overlooked inhaled fo reign bodies: late sequelae and the likelihood of re covery. Respir Med 997;9:9-6.. Rafanan AL, Mehta AC. Adult airway foreign body removal: what's new? Clin Chest Med ;:9-.. Nonfatal choking-related episodes among children: United States,. MMWR Morb Mortal Wkly Rep ;:9-8.. Burton EM, Brick WG, Hall JD, Riggs W Jr, Houston CS. Tracheobronchial foreign body aspiration in children. South Med J 996;89:9-8. 6. Killian G. Meeting of the Society of Physicians of Freiburg. Münch Med Wochenschr 989;:78. 7. Cohen SR, Herbert WI, Lewis GB Jr, Geller KA. Foreign bodies in the airway: five-year retrospective study with special reference to management. Ann Otol Rhinol Laryngol 98;89:7-. 8. Oguzkaya F, Akcali Y, Kahraman C, Bilgin M, Sahin A. Tracheobronchial foreign body aspirations in child hood: a -year experience. Eur J Cardiothoracic Surg 998;:88-9. 9. Hsu WC, Sheen TS, Lin CD, Tan C, Yeh T, Lee S. Clinical experiences of removing foreign bodies in the airway and esophagus with a rigid endoscope: a series of 7 cases from 97 to 996. Otolaryngol Head Neck Surg ;:-.. Baharloo F, Veyckemans F, Francis C, Biettlot MP, Rodenstein DO. Tracheobronchial foreign bodies: pre sentation and management in children and adults. Chest 999;:7-6. 6
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