Description

  • Unintentional inhalation of a foreign body (objects or food) into the airway resulting in respiratory obstruction
  • Children < 3 years old are most affected (more often boys), with a second smaller peak at 10 years old
  • In adults, most aspirations occur after age 50
  • 7% of all accidental deaths in children < 4 years old attributed to foreign body aspiration in United States

Likely Risk Factors

  • Infants and children
    • Behavioral factors
      • Oral exploratory habits
      • Inability to distinguish between edible/inedible objects
      • Tendency to perform other activities with objects in their mouth
    • Anatomical factors
      • Immature swallowing coordination
      • Lack of dentition and decreased ability to chew food
      • Small diameter airway
      • Less ability to generate forced air through airway and relieve obstruction


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  • Commonly aspirated objects
      • Round, ovoid, cylindrical shapes with a diameter similar to child’s airway
      • Most common aspirated foreign bodies include:
        • Organic objects
          • Hotdogs (most common food associated with fatal choking among children)
          • Peanuts
          • Popcorn
          • Candy
          • Seeds
          • Bones
        • Inorganic objects
          • Coins
          • Toy parts (balloons most commonly associated with fatal choking)
          • Crayons or pen tops
          • Tacks, pins, nails, or screws
          • Bullets and casings

  • In adults, foreign body aspiration most often caused by inadequate airway protective mechanisms in the sixth and seventh decades of life including
    • Poor dentition/swallowing
    • Senility
    • Primary neurological disorders with impaired mental status
    • Intellectual disability
    • Alcohol intoxication, sedative, or hypnotic drug use
    • Seizure
    • General anesthesia

Pathogenesis

  • Most foreign bodies are spontaneously expelled through protective reflexes such as coughing and spitting
  • Foreign body aspiration may include several clinical phases
    • Initial stage or impaction phase occurs when a foreign body partially or fully obstructs the airway often resulting in reflexive choking, gagging, and paroxysms of coughing to relieve the obstruction
    • Second stage or asymptomatic phase may occur hours to weeks following aspiration event, when muscle reflexes fatigue and foreign body becomes lodged in airway
    • Third stage or complications stage may occur if foreign body impaction causes obstruction, erosion, and/or infection
  • 80%-90% of foreign bodies in the airway are located in the bronchus
  • Organic material may cause a severe mucosal inflammatory reaction and development of granulation tissue within hours of aspiration
  • Materials that may absorb water such as beans, seeds, and corn may swell after aspiration and cause more severe airway obstruction

Clinical Presentation

  • Common clinical presentation includes:
    • Acute choking episode with coughing, wheezing, or stridor in a previously healthy child
    • Patient or caregiver report of history of eating or playing with a small object
    • Possible painful or difficulty swallowing and/or fever
  • Severity of presentation depends on the characteristics of the aspirated foreign body and the site of impaction
    • Laryngeal impaction characterized by choking and/or gagging followed by hoarseness, aphonia, and cyanosis
    • Tracheal impaction characterized by inspiratory stridor and periods of coughing
    • Bronchial impaction characterized by coughing, wheezing, hemoptysis, dyspnea, chest pain, and decreased breath sounds
  • Less common presentations of foreign body aspiration may include subcutaneous emphysema, pneumothorax and/ or pneumomediastinum, and unresolving or recurrent pneumonia

Making the Diagnosis

  • Diagnosis usually presumed based on choking or coughing in otherwise healthy children and recent history of eating/playing with small objects
  • Testing to confirm suspected foreign body aspiration
    • Radiograph
      • Obtain posteroanterior and lateral chest x-rays 
      • May not detect radiolucent foreign bodies or any foreign body within 24 hours of aspiration
      • Findings may include
        • Atelectasis
        • Air trapping
        • Pulmonary infiltrates
        • Mediastinal shift
        • Presence of double contour image which may suggest button battery foreign body (batteries require urgent removal)
    • Rarely, chest computed tomography (CT) and magnetic resonance imaging (MRI) may also be used
    • Bronchoscopy may be used for both diagnosis and treatment
      • Most definitive method for diagnosis 
      • Rigid bronchoscopy under general anesthesia is recommended method in children
      • Flexible and fiberoptic bronchoscopy is more often used in adults
  • Diagnosis may also be made after successful removal of foreign body by Heimlich maneuver or by endoscopy

Management Overview

  • Perform Heimlich maneuver in emergency cases, such as complete airway obstruction or suspected battery aspiration, followed by emergency endoscopy in cases of persistent obstruction
  • No emergency measures indicated for children who can speak, cry, or cough following aspiration episode
  • Closely monitor patients with suspected aspiration of beans and seeds as this type of foreign body may expand and block airway
  • Endoscopic removal by bronchoscopy is preferred treatment in most cases of foreign body aspiration
  • Emergency tracheotomy or thoracotomy may be indicated in cases of failed bronchoscopic removal
  • Activities that are not recommended for treatment of foreign body aspiration include:
    • Exploration of hypopharynx using fingers
    • Chest physical therapy
    • Bronchodilators
    • Use of tenderizer substances to dissolve meat aspirations

Surgical Management

  • Endoscopic removal by bronchoscopy indicated in cases of suspected foreign body aspiration
    • If patient is not in respiratory distress, they should fast prior to procedure to prevent aspiration
    • Perform procedure under general anesthesia
    • In children, a rigid bronchoscope with ventilation recommended to perform extraction
  • Tracheotomy and bronchotomy may be indicated in emergency situations such as
    • Complete airway obstruction
    • Suspected battery ingestion
    • Failed attempts at endoscopic removal
  • Postoperative management
    • Antibiotic and steroids may be indicated for patients with significant airway damage
    • Chest physical therapy may be used to clear secretions in patients with chronic pneumonia, atelectasis, or purulent bronchitis
    • Routine follow-up chest x-ray not needed unless symptoms persist/progress

Complications

  • Complications of a retained foreign body may include
    • Lung abscess
    • Recurrent hemoptysis
    • Lung fibrosis
    • Atelectasis
    • Pulmonary infection
    • Stricture
    • Bronchial tree perforation and fistula formation (rare)

Prevention

  • Prevention of choking in children should include education for parents and caretakers on how to
    • Check for warning labels and recalls on children’s toys
    • Recognize acute pulmonary obstruction
    • Perform cardiopulmonary resuscitation or choking first aid
  • Food safety education for parents and caregivers regarding selection, processing, and supervising appropriate foods for children < 3 years old to make them safer for this highest-risk population

Kendra Church MS, PA-C, is a physician assistant at Dana-Farber Cancer Institute/Brigham & Women’s Hospital, and is also a senior clinical editor for DynaMed, an evidence-based, point-of-care database.

Sources:

  1. Rodríguez H, Passali GC, Gregori D, et al. Management of foreign bodies in the airway and oesophagus. Int J Pediatr Otorhinolaryngol. 2012;76 Suppl 1:S84-91. doi:10.1016/j.ijporl.2012.02.010
  2. Dikensoy O, Usalan C, Filiz A. Foreign body aspiration: clinical utility of flexible bronchoscopyPostgrad Med J. 2002;78(921):399-403. doi:10.1136/pmj.78.921.399
  3. Rovin JD, Rodgers BM. Pediatric foreign body aspirationPediatr Rev. 2000;21(3):86-90. doi:10.1542/pir.21-3-86