Airway Foreign Bodies


Article Author:
David Rose


Article Editor:
Laurence Dubensky


Editors In Chief:
Jason Nagle


Managing Editors:
Avais Raja
Orawan Chaigasame
Carrie Smith
Abdul Waheed
Khalid Alsayouri
Kyle Blair
Trevor Nezwek
Radia Jamil
Erin Hughes
Patrick Le
Anoosh Zafar Gondal
Saad Nazir
William Gossman
Hassam Zulfiqar
Navid Mahabadi
Hussain Sajjad
Steve Bhimji
Muhammad Hashmi
John Shell
Matthew Varacallo
Heba Mahdy
Ahmad Malik
Sarosh Vaqar
Mark Pellegrini
James Hughes
Beata Beatty
Daniyal Ameen
Altif Muneeb
Beenish Sohail
Nazia Sadiq
Hajira Basit
Phillip Hynes
Komal Shaheen
Sandeep Sekhon


Updated:
6/3/2019 7:47:51 PM

Introduction

The presentation of foreign body aspiration in the emergency department varies greatly and can suffer from incorrect diagnosis. Factors affecting the acuity of the problem include the object that is aspirated, the location of the aspirate, as well as timeframe in which aspiration occurred. Acute upper airway compromise may present with classic symptoms of choking including significant respiratory distress, while a more distal obstruction may present with mild wheezing, cough, a complaint of discomfort, or general shortness of breath. 

Foreign body aspiration is the fourth leading cause of death in preschool and younger age children.[1] It accounts for a significant number of emergency department visits in the United States. As such, it is a leading concern for both prevention and public health as well as critical recognition and treatment. The Consumer Product Safety Commission placed restrictions on items that may confer a choking hazard, and in 1973, federal regulation 15 CFR 1501 introduced the Small Parts Test Fixture which provides measurements for toys designed for children three years and younger.[2]

Although several federal guidelines have been implemented to reduce choking in young children, which include, package labeling with warnings for small parts, warnings on television and internet advertisements regularly make the public aware of the choking hazards of toys. In the United States, no regulations exist on food items with a potential risk for choking, which is unfortunate because many aspirations are organic food material. Peanuts, seeds, and fruits with round shapes are the most often aspirated food in children. With hotdogs and candy accounting for a majority of deaths from choking.[3] Public education of parents, babysitters, teachers, and caregivers remains an essential factor in preventing airway foreign body aspiration.

Etiology

Upon aspiration of a foreign body into the larynx or proximal trachea, there is always the potential for respiratory compromise or aspiration into the distal airways causing subacute symptoms including shortness of breath or coughing. Causes of a foreign body aspiration include many items like food and non-organic items. Peanuts are the most frequently ingested object in the West, with hotdogs causing the most morbidity. Male children are more likely to aspirate than female children.[3] A common feature of most aspirated objects is their round/oval shape. 

Epidemiology

Children, males, more often than females, and developmentally delayed individuals are more likely to aspirate foreign bodies. In the West, food objects are most commonly aspirated, with peanuts being the most commonly aspirated food, followed by hotdogs and hard candy. Outside of food, other smooth and round objects like marbles and rubber balls are often aspirated. The lack of molars to chew food is also a contributing factor in children.[3]

Statistical data predominantly derives from single-center studies. Larger cohorts and nationwide analysis have just started to analyze the data.[7] These studies estimate the incidence of foreign body airway obstruction (FBAO) to be 0.66 per one hundred thousand.[8] In the USA, seventeen thousand emergency visits in children under 14 years were linked to foreign bodies inhalation in 2000.[9] Foreign body aspiration is the primary cause of accidental infantile deaths and the fourth cause of death among preschool children less than five years old.[10]

Airway foreign bodies have unique demography; 80% of cases are below three years of age, with a peak frequency occurring in the one to two years old age group.[11] In a case review of 81 cases, Asif et al. found that children under five years aspirate 77.8% of foreign bodies, 16% by children between five to fifteen years, and 6.2% by those above fifteen years. Similarly, Reilly et al. highlighted that children four years or younger are more vulnerable to inhaling foreign bodies as they are driven by oral exploration using their molar-free mouths and their lack of well-coordinated swallowing reflex.[12]

Pathophysiology

Complete obstruction can lead to distal infection; partial obstruction may lead to inflammation of local tissue. Food may lead to more inflammatory effects than a metal or plastic object, and also may swell leading to incomplete to complete obstruction.[3] Medications like iron tablets have led to distal airway stenosis and severe airway inflammation.[4]

History and Physical

History of aspiration or suspected aspiration is sometimes enough to warrant a full workup including a rigid bronchoscopy.

Presentation of aspiration may present different ways. Acute large airway obstruction presents with severe obvious clinical distress, stridor, choking sign, drooling. Chronic shortness of breath related to the foreign body, especially in children and developmentally delayed individuals who are unable to articulate the event reliably, is more likely to be in the smaller airways. The patient may have several weeks of coughing, shortness of breath or even a complaint of chest discomfort.  

Airway anatomy in children differs from anatomy in adults. The smallest diameter area is the cricoid area of trachea inferior to the vocal cords due to the funnel shape of the trachea. In adults, the narrowest portion is the glottic opening, and the trachea is cylindrical shaped.

The most likely place for a proximal obstruction is the trachea; this will likely cause apparent respiratory distress, stridor, and possibly airway trauma if the object is sharp. Children have a slight right side predominance for right main-stem obstruction, but not as high as adults. Patients with a distal obstruction may present with subacute symptoms.

The physical exam may show tripoding, drooling, stridor, focal wheezing. History may be suggestive of aspiration, even from several weeks prior.[3]

Evaluation

Evaluate with chest X-rays, PA, and lateral inspiratory-expiratory films, if possible. Unilateral expansion with diaphragm flattening of the affected side with mediastinal pushing away will indicate obstruction on that side. Obtain IV access with bloodwork including CBC, type, and screen if the patient will go the OR, develop a treatment for pain management, and administer empiric antibiotics in a patient who is febrile or toxic appearing.

Treatment / Management

For an active upper airway obstruction, airway control is paramount. Do NOT blindly sweep the airway, perform direct visualization of the airway with whatever blade you are most comfortable using, and possible extraction with Magill forceps. Sedation will likely be necessary unless the patient is unresponsive. Intubating past the obstruction or forcing the blockage into one of the mainstems may be required. Emergent ED cricothyroidotomy may be indicated if there is no other avenue to ventilate the patient. 

For a possible lower airway obstruction, a good history and physical exam are always important. If the patient has been treated and symptoms have not resolved is an indication to evaluate more aggressively. There may be focal findings on auscultation, there may be a potential choking episode weeks ago, and the patient may have infectious symptoms if the object is causing bronchiectasis or abscess. The definitive treatment is rigid bronchoscopy, and at some centers, a rigid bronchoscopy will be performed based on history or suspicion alone as up to 15% of aspirations have a normal physical exam and imaging.[1]

Definitive management of known radiopaque or suspected radiolucent foreign body is rigid bronchoscopy under anesthesia. If the object has acutely been aspirated then retrieval and normal post-op recommendations are sufficient. If there have been clinical signs of infection, then antibiotic treatment for post-obstructive infection can be initiated.[5]

Differential Diagnosis

Diseases that may present with clinical findings similar to foreign body aspiration are asthma, pneumonia, tuberculosis, epiglottitis, retropharyngeal abscess, peritonsillar abscess, postviral pericarditis or pleuritis, and bronchiolitis. Traumatic injuries with localized pulmonary, airway or even diaphragmatic injury may present similarly to foreign body aspiration.

Prognosis

In children with foreign body aspiration, the prognosis is good if removed early and without complications. Aspiration of iron and potassium can cause airway stenosis. These will need to be retrieved emergently. In a study of 94 children who all presented three days after aspiration, all recovered fully from any complications aside from one who died of respiratory failure.[6]

Complications

During management, there is about a 25% complication rate with the majority of these being mild with early intervention. Late intervention brings more severe complications such as hypoxia or anoxic brain injury, bronchial injury, airway stenosis, abscess formation, pneumothorax. Aside from death from respiratory compromise, children will likely recover with treatment for the mentioned complications.[6]

Consultations

  • Interventional pulmonology, otolaryngology, ENT, cardiothoracic surgery

Deterrence and Patient Education

  • Consumer Product Safety Commission
  • Federal regulations on packaging and warnings
  • Education of parents and others who may supervise children on the risks of hard round food items - to watch and encourage slow mastication to ensure safe eating habits

Pearls and Other Issues

  • Peanuts are the most commonly aspirated foods, followed most often by items like marbles, and small rubber balls
  • Hotdogs and hard candies are the most common food items, and latex balloons are the most common non-food items to cause fatal aspiration
  • Rapid diagnosis and retrieval lead to the best outcomes in these patients
  • Less likely to have upper airway (laryngeal or tracheal) obstruction than lower, however, emergent airway control is required with upper obstruction due to the potential for complete ventilatory compromise
  • Lower airway obstruction necessitates a good history and physical especially in children and developmentally delayed individuals, and suspicion for foreign body aspiration - inspiratory-expiratory chest x-ray, pre-op labwork, otolaryngology consultation, and antibiotics based on clinical picture and timeframe
  • Definitive management of known radiopaque or suspected radiolucent foreign body is rigid bronchoscopy under anesthesia.
    • If the object has acutely been aspirated then retrieval and normal post-op recommendations are sufficient
    • If there have been clinical signs of infection, then antibiotic treatment for post-obstructive infection can be initiated

Enhancing Healthcare Team Outcomes

Foreign body aspiration frequently creates a diagnostic dilemma. Such patients may exhibit non-specific signs and symptoms such as a cough, shortness of breath without a medical history or diagnosed medical problems, unclear-onset, and vague discomfort. The cause of these complaints may be due to an infectious, allergic, traumatic, reactive, or foreign body etiology. While physical examination may reveal that the patient has a focal lung finding, the cause will likely correlate with a history of possible aspiration.

While the pulmonologist is almost always involved in the care of patients with a foreign body aspiration, it is essential to consult with an interprofessional team of specialists that include an ENT, otolaryngologist, and possibly a cardiothoracic surgeon. The nurses are also vital members of the interprofessional group as they will monitor the patient's vital signs, help with family members, and keep patients and family calm. In the postoperative period for pain, possible infection, and possible airway lesions; the pharmacist can ensure that the patient is taking the right analgesics, bronchodilators, and appropriate antibiotics. The radiologist also plays a crucial role in delineating the cause. Without a proper history, the radiologist may not be sure what to look for or what additional radiologic exams may be necessary. This problem gets even more involved with radiolucent objects. CT is recommended in the ACR–ASER–SCBT-MR–SPR PRACTICE PARAMETER FOR THE PERFORMANCE OF PEDIATRIC COMPUTED TOMOGRAPHY (CT), Indications section 4 Tracheobronchial abnormalities.  The American College of Radiology Appropriateness Criteria represents evidence-based guidelines for specific clinical disorders that undergo review by an interprofessional expert committee every 3 years. The current guidelines were developed following an exhaustive review of the current medical literature from peer-reviewed journals to determine the appropriateness of radiographic imaging and therapy procedures by the committee. In instances where evidence is not definitive or is minimal, expert opinion from specialists may be utilized for recommendations of the type of imaging or treatment.

The outcomes of a foreign body aspiration are usually good. However, to optimize outcomes, prompt consultation with an interprofessional group of specialists is recommended.[7][8]


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Airway Foreign Bodies - Questions

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Which of the following statements regarding airway foreign bodies is not true?



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Aspirated foreign bodies most typically become lodged in which region of the lung?



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A previously healthy 2-year-old female presents with a cough that started 3 days ago. She is afebrile. No one else in the family is sick. There is wheezing in the left lower lung field but no other findings. What is the most probable diagnosis?



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Which of the following is a poor choice for fiber-optic bronchoscopy?



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Which of the following forceps may be used to remove a visible foreign body obstruction?

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What should be done for an adult patient with a suspected partial airway obstruction who appears unable to cough?

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A 2-year-old female without significant past medical history has had a cough for five weeks. She has been treated at a couple of emergency rooms with different antibiotics for pneumonia. On exam, the right lung is clear but breath sounds are decreased on the left. Chest x-rays taken after inspiration and expiration show air trapping on the left only. Select the next step in management.



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A mother brings her 4 year old child. She says he has always been fine but today developed some funny sounds from his chest. He also appears to have a dry cough. Auscultation reveals presence of a right sided wheeze. What should be done?



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A 2 year old is suspected of having aspirated a radiolucent foreign body. Select the most appropriate radiographs in a cooperative child.



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An 18-month-old girl is brought by her mother with inspiratory stridor. The mother mentions that her child was playing with small toy after which she suddenly started coughing and having this noisy breathing. The mother denies any fever, cough, or difficulty breathing before this episode. What is the most likely diagnosis?



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A 16-year-old with an intellectual disability possibly aspirates an unknown object. He is brought to the emergency department by his parents. A chest x-ray is ordered. Even if no radiopaque object is noted, what abnormality on the chest x-ray is most commonly seen in patients who aspirate foreign bodies?



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Which intubation method is preferred if a foreign body is suspected?



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A 3-year-old boy with a temperature of 101.5 F is brought for evaluation. The mother states that he has been coughing for two weeks but only recently developed a fever. A chest x-ray shows that the patient has a radiopaque object in the right lung field and distally there appears to be consolidation. What is the likely nature and course of treatment of these findings?



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Airway Foreign Bodies - References

References

Tsang JE,Sun J,Ooi GC,Tsang KW, Endobronchial Foreign Body Presenting as Exacerbation of Asthma. Case reports in emergency medicine. 2017;     [PubMed]
Salih AM,Alfaki M,Alam-Elhuda DM, Airway foreign bodies: A critical review for a common pediatric emergency. World journal of emergency medicine. 2016;     [PubMed]
Lim SY,Sohn SB,Lee JM,Lee JA,Chung S,Kim J,Choi J,Kim S,Yoo AY,Roh JA,Park H,Kim WS,Sim JK,Shim JJ,Min KH, Severe Endobronchial Inflammation Induced by Aspiration of a Ferrous Sulfate Tablet. Tuberculosis and respiratory diseases. 2016 Jan;     [PubMed]
Milkovich NM,Milkovich SM,Harty MP,Kecskemethy HH,Briddell JW,Levi JR,Reilly JS, Computerized Tomography Analysis of Young Children for Prevention of Aspiration Injuries. The Laryngoscope. 2018 Oct 3;     [PubMed]
Steen KH,Zimmermann T, Tracheobronchial aspiration of foreign bodies in children: a study of 94 cases. The Laryngoscope. 1990 May;     [PubMed]
Ezer SS,Oguzkurt P,Ince E,Temiz A,Çalıskan E,Hicsonmez A, Foreign body aspiration in children: analysis of diagnostic criteria and accurate time for bronchoscopy. Pediatric emergency care. 2011 Aug;     [PubMed]
Ramos-Rossy J,Cantres O,Torres A,Casal J,Otero Y,Arzon-Nieves G,Rodríguez-Cintrón W, Flexible Bronchoscopic Removal of 3 Foreign Objects. Federal practitioner : for the health care professionals of the VA, DoD, and PHS. 2018 Sep     [PubMed]
Cheng J,Liu B,Farjat AE,Routh J, National estimations of airway foreign bodies in children in the United States, 2000 to 2009. Clinical otolaryngology : official journal of ENT-UK ; official journal of Netherlands Society for Oto-Rhino-Laryngology & Cervico-Facial Surgery. 2018 Nov 18     [PubMed]

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