Foreign bodies in the airway

- Choking is a leading cause of morbidity and mortality among children, especially those younger
than age 4 year, largely because of the developmental vulnerabilities of a young child’s airway
and the underdeveloped ability to swallow food
- Most victims of foreign-body aspiration are older infants and toddlers. Children, younger than 3
year of age, account for 73% of cases, with the peak incidence between one and two years of
age
- At this age, most children are able to stand, are apt to explore their world via the oral route, and
have the fine motor skills to put a small object into their mouths, but they do not yet have
molars to chew food adequately
- Additional predisposing factors to FBA in this age group include access to improper foods or
small objects, activity while eating, and older siblings (who may place food or objects into the
mouths of infants or toddlers).
- Most common objects they choke on are food, coins, balloons, toys
- Food items are the most common items aspirated by infants and toddlers, whereas nonfood
items (eg, coins, paper clips, pins, pen caps) are more commonly aspirated by older children
- One-third of aspirated objects are nuts, particularly peanuts
- Factors that make foreign bodies more dangerous include roundness (round objects are most
likely to cause complete airway obstruction and asphyxiation), failure to break apart easily,
compressibility, and smooth, slippery surface
- An infant is developmentally able to suck and swallow and is also equipped with involuntary
reflexes (gag, cough, glottis closure) that help to protect against aspiration
- Despite a strong gag reflex, a young child’s airway is more vulnerable to obstruction than an
adult’s airway in several ways
- Smaller diameter. Mucus and secretions may form a seal around the FB, making it more difficult
to dislodge by forced air. The force of air generated by a cough in an infant to young child is less
effective in dislodging airway obstruction
- Young children less than 5 years should avoid hard candy, chewing gum and raw fruits and
vegetables should be cut into small pieces
- The most serious complication is complete obstruction. Globular items like hot dogs, grapes,
nuts and candies are the most common
- Complete airway obstruction is recognized in the conscious child as sudden respiratory distress
followed by inability to speak or cough

Clinical manifestations

- Three stages
- Initial event – violent paroxysms of coughing, choking, gagging, airway obstruction
- Asymptomatic interval – FB becomes lodged, reflexes fatigue, immediate irritating symptoms
subside
- This stage accounts for a large percentage of delayed diagnoses. No symptoms reassure the
physician there’s no foreign body
- Complications stage – obstruction, erosion, infection cause fever, cough, hemoptysis,
pneumonia, atelectasis
Diagnosis

- Presentation and diagnosis within 24 hours of aspiration occurs in approximately 50 to 75

percent of cases
- The classic triad of wheeze, cough, and diminished breath sounds is not universally present
- Don’t ignore positive history, but negative history can be misleading
- A witnessed episode of choking, defined as the sudden onset of cough and/or dyspnea and/or
cyanosis in a previously healthy child, has a sensitivity of 76 to 92 percent for the diagnosis of
FBA
- Choking or coughing episodes accompanied by new onset wheezing highly suggestive
- Ask about nuts because they are the most common. Bronchoscopy if so
- Most FB lodge in a bronchus (right in 58%), larynx or trachea in 10%. The sites are as follows:
Larynx: 3 percent, Trachea/carina: 13 percent, Right lung: 60 percent (52 percent in the main
bronchus, 6 percent in the lower lobe bronchus, and <1 percent in the middle lobe bronchus),
Left lung: 23 percent (18 percent in the main bronchus and 5 percent in the lower bronchus),
Bilateral: 2 percent
- Occasionally, fragments of a FB may produce bilateral involvement or shifting infiltrates if it
moves from lobe to lobe
- An esophageal foreign body can compress the trachea and be mistaken for airway foreign body
- The patient is asymptomatic and the radiograph normal in 15-30% cases
- Opaque foreign bodies occur only in 10-25% cases
- In children with lower airway FBA, the most common radiographic findings in lower airway FBA
are hyperinflated lung, atelectasis, mediastinal shift, and pneumonia
- CT can help with radiolucent objects like fish bones
- If there is high index of suspicion, do bronchoscopy despite negative imaging
- The diagnosis of FBA is easily established with plain radiographs when the object is radioopaque
(about 10 percent of foreign bodies). However, most objects aspirated by children are
radiolucent (e.g., nuts, food particles), and are not detected with standard radiographs unless
aspiration is accompanied by airway obstruction or other complications. As a result, the clinical
history, and not radiographs, is the main determinant of whether to perform a bronchoscopy.
- The treatment is prompt endoscopic removal with rigid instruments (rigid bronchoscopy)
- Bronchoscopy deferred only until preoperative studies have been obtained and the patient has
been prepared by adequate hydration and emptying of the stomach

Laryngeal FB

- Asphyxiation if complete unless relieved with Heimlich maneuver

- Partially obstructive objects are usually flat and thin. They lodge between the vocal cords in a
sagittal plane, causing symptoms of croup, hoarseness, cough, stridor and dyspnea

Tracheal FB

- Choking and aspiration occurs in 90%, stridor in 60%, wheezing in 50%

- PA and lateral soft tissue neck radiographs are abnormal in 92%, CXR only in 58%

Bronchial foreign body

 - Posteroanterior and lateral chest radiographs are standard in the assessment of infants and
children suspected of having aspirated a foreign object. The abdomen is included
- During expiration the bronchial foreign body obstructs the exit of air from the obstructed lung,
producing obstructive emphysema, air trapping, with persistent inflation of the obstructed lung
and shift of the mediastinum toward the opposite side
- Air trapping is an immediate complication, in contrast to atelectasis, which is a late finding
- Lateral decubitus chest films or fluoroscopy can provide the same information but are
unnecessary. History and physical examination, not radiographs, determine the indication for
bronchoscopy.

Complications

- When FBA is diagnosed soon after the event, there is usually little damage to the airway or lung
parenchyma. The longer the foreign body is retained, the more likely are complications (eg,
atelectasis, postobstructive pneumonia).
- A foreign body that causes chronic or recurrent distal infection may lead to bronchiectasis. This
complication should be treated after the foreign body is removed.
- Cultures obtained during bronchoscopy guide the initial antibiotic choice in treating infected
areas of bronchiectasis.
- Failure to promptly diagnose the FBA may also cause complications from the use of
nonindicated treatments, such as steroids, antibiotics, or bronchodilators.