Indian J Pediatr (November 2011) 78(11):1401–1403
DOI 10.1007/s12098-011-0488-8
SYMPOSIUM ON PGIMER PROTOCOLS ON RESPIRATORY EMERGENCIES
Airway Foreign Body Aspiration
Sudhanshu Grover & Arun Bansal & Sunit C. Singhi
Received: 23 April 2011 / Accepted: 11 May 2011 / Published online: 26 May 2011
# Dr. K C Chaudhuri Foundation 2011
Abstract Foreign body aspiration into the airway is one of
the dramatic pediatric emergencies. It is more common in
children aged 6 months to 5 years. Pea nuts and food items
account for most cases. Right main stem bronchus is the
most common site involved. The initial cough and choking
like episodes may be followed by a symptomless interval
before leading to further complications. Chest radiograph
findings may vary from normal to hyperinflation, obstruc-
tive emphysema or pneumothorax. Removal by rigid
bronchoscopy is the definitive treatment.
Keywords Foreign body . Choking . Bronchoscopy
Introduction
Foreign body aspiration is one of the common emergency
problems encountered in pediatric age group. At PGIMER,
it is responsible for approximately 0.6% of admissions in
pediatric emergency [1]. A male preponderance has been
noted. Delay in identification can lead to complications
including death. Most common age group affected is
6 months to 5 years. Most common objects inhaled are
pea nuts and food items. Organic objects may cause local
inflammation and swelling and convert partial obstruction
to complete obstruction. According to various studies, the
right main stem bronchus is the most common site of
obstruction [2, 3]. The larynx is the least common site.
S. Grover : A. Bansal : S. C. Singhi (*)
Department of Pediatrics, Advanced Pediatrics Centre,
Postgraduate Institute of Medical Education and Research,
Chandigarh 160012, India
e-mail: sunit.singhi@gmail.com
The following factors make the children more prone to
foreign body aspiration:
1) Absence of molars—inadequate chewing
2) In-coordinated swallowing mechanism
3) Curiosity / carelessness
Pathophysiology
The pathophysiology (and clinical picture) depends upon
the type of foreign body and location in the airway. The
object itself may cause obstruction. Foreign body causing
total obstruction at trachea/larynx may cause respiratory
failure/arrest and death within minutes. Acute obstruction
of the level of carina or main bronchus may cause lung
collapse and hypoxemia. Overtime, pooled secretion
caused by partial obstruction may get infected and
present with pneumonia. A sharp foreign body (FB)
may lead to erosion, as is the case with battery cells.
Vegetable matter may swell over hours or days leading to
obstruction. Organic foreign bodies (nuts) may produce
inflammation and edema.
Clinical Features
There may be definite history of foreign body aspiration
in 40–70% cases [4, 5]. The initial symptoms may include
cough, gagging, choking, wheezing, dyspnea, cyanosis,
hoarseness, and drooling. Partial obstruction at larynx may
present with inspiratory stridor, drooling and voice
change.
Partial obstruction at trachea often presents with chok-
ing, cough, whereas partial obstruction at bronchus presents
1402 Indian J Pediatr (November 2011) 78(11):1401–1403

Fig. 1 Flowchart showing Man-

Evaluate and maintain ABC (Airway, Breathing, Circulation)
agement of suspected airway for-
eign body aspiration in children Examine throat for visible foreign body

Start oxygen (if distress) and antibiotics (if suspected infection)

X-ray chest

Definitive history
Doubtful history
Strong suspicion of foreign body

Foreign body removal by rigid Check bronchoscopy

bronchoscopy

Observe for 12-24 h after

bronchoscopy till respiratorydistress
settles*

*Note: Even after removing the foreign body, inflammatory changes and edema may persist for
some time leading to persistence of the symptoms.

with wheezing (localized/ generalized) cough and lateraliz- Investigations

ing finding.
Initial symptoms may resolve (symptomless interval)
due to adaptation of the surface sensory receptors to
pressure. After a few hours to weeks, it is followed by
complications such as airway obstruction and infection. In
up to one-third of cases, there may be no history of foreign
body inhalation.
Overall, cough is the most common symptom seen in
76%, followed by wheezing (50%), respiratory distress
(36%), and history of cyanosis (30%) [4, 5]. Classical
physical finding of unilateral decrease of air entry on the
affected side is seen in 61% cases.
Differential Diagnosis
In absence of typical history of choking, sometimes it may
be difficult to differentiate wheeze and respiratory distress
caused by airway foreign body from bronchial asthma and
pneumonia. In asthma, there is often a history of recurrent
symptoms with good response to bronchodilators and a
positive family history. The wheeze is generally audible all
over the chest. Patients with pneumonia have history of
fever and respiratory distress but no history of choking or
acute onset symptoms. Ausculation reveals crackles. How-
ever, sometimes it may be difficult to differentiate;
pneumonia may occur as a complication of a foreign body
inhalation.
All cases suspected of foreign body aspiration presenting to
the pediatric emergency should be thoroughly examined
and evaluated based on the clinical status (Fig. 1).
Blood Investigations
Total leukocyte count and blood cultures may be
required in cases of suspected infection/pneumonia.
Blood gas analysis may be required in patients with
respiratory distress.
Chest Radiograph
A chest radiograph must be obtained in all the cases of
suspected foreign body aspiration even in the absence of
clinical symptoms. Plain radiographs during inspiration and
expiration are useful to identify the hyperinflation or other
pathological findings (Fig. 2a and 2b).The following
findings may be noted [4]:
& Hyperinflation or loss of volume on the affected side
& Obstructive emphysema.
& In 8–10% cases, foreign bodies are visible on X-ray
(some foreign bodies being organic are radiolucent).
& Infiltrates
& Atelectasis
& Air leak or pneumothorax .
Indian J Pediatr (November 2011) 78(11):1401–1403
Fig. 2 a Chest radiograph of 1- year- old, showing loss of volume on
left side, caused by small pieces of pea-nut in left main bronchus. b
Chest radiograph of a one and half year old showing hyperinflation on
left side. Bronchoscopy reveled piece of groundnut just at the opening
of left main bronchus
The chest radiograph may be normal in about 30% of the
cases.
Bronchoscopy
For confirmation and removal of the foreign body, definitive
investigation is rigid bronchoscopy. In case of doubt, one can
consider a fibreoptic bronchoscopy to confirm the diagnosis.
Other Investigations
Fluoroscopy, lung scan or CT scan do not improve
diagnostic accuracy compared to history, physical
examination and chest radiograph.
CT virtual bronchoscopy may be helpful in cases of
large foreign body in main airways. It may not be
1403
useful if foreign body is small and lodged beyond main
stem bronchi [6].
Figure 2a shows chest radiograph of a 1- year- old boy
admitted with episodes of fever (mild/undocumented),
cough, noisy, fast breathing, last one being 3 months ago.
He was on oral and IV medications and nebulization. On
Initial Examination, respiratory rate was 62 /min, wheeze +
++, with moderate subcostal and intercostals retractions.
Initially he was managed as a case of acute asthma with
nebulized salbutamol, Budesonide, IV hydrocortisone,
MgSO4 infusion, but without significant responses. On
review there was differential air entry (Left side > Right
side), but no clear history of foreign body aspiration was
forthcoming. Chest radiograph showed loss of volume on
left side. A possibility of neglected foreign body was
considered. Rigid Bronchoscopy revealed small pieces of
pea nut in left main bronchus. Post- Bronchoscopy
respiratory distress settled.
Treatment
Pediatric surgeon or ENT surgeon should be consulted for
rigid bronchoscopy; bronchoscopic removal is the defini-
tive treatment.
Conflict of Interest None.
Role of Funding Source None.
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