Foreign body aspiration

Background

  • Most common in young children (1-3 years old)
  • Consider in any child with respiratory symptoms
  • Object can be lodged in upper airway (20% of cases) or bronchus (80%)

Clinical Features

  • History of eating or handling a small object (or being unsupervised near one) followed by sudden onset coughing, dyspnea
    • Onset of respiratory symptoms may sometimes be delayed >24 hours
  • Dyspnea, tachypnea, respiratory distress, hypoxia
  • Sudden collapse, cardiac arrest
  • Cough, gagging
  • Stridor, dysphonia (if stuck at level of larynx)
  • Wheezing, decreased breath sounds (If lower airway)
    • Wheezing not responsive to bronchodilators
  • Fever, pneumonia symptoms if retained

Differential Diagnosis

Stridor

Trauma

  • Larynx fracture
  • Tracheobronchial tear/injury
  • Thyroid gland injury/trauma
  • Trachea injury
  • Electromagnetic or radiation exposure
  • Burns, inhalation

Infectious Disorders

Abscesses

Neoplastic Disorders

  • Neoplasms/tumors

Allergic and Auto-Immune Disorders

Metabolic, Storage Disorders

  • Cerebral Gaucher's of infants (acute)
  • Tracheobronchial amyloidosis

Biochemical Disorders

  • Tetany

Congenital, Developmental Disorders

Psychiatric Disorders

  • Somatization disorder

Anatomical or Mecanical

  • Foreign Body Aspiration
  • Acute gastric acid/aspiration syndrome
    • Airway obstruction
    • Neck compartment hemorrhage/hematoma

Vegetative, Autonomic, Endocrine Disorders

  • Esophageal free reflux/GERD syndrome
  • Laryngospasm, acute
    • Bilateral vocal cord paralysis
  • Hypoparathyroidism

Poisoning

Chronic Pediatric Conditions

  • Laryngomalacia
  • Tracheomalacia[1]
  • Subglottic stenosis or prior intubation
  • Vascular ring (double aortic arch)
  • Vocal cord dysfunction/paroxysmal vocal fold movement

<6mo

Evaluation

  • CXR
    • Useful to confirm diagnosis, does not rule out
    • Negative in >50% of tracheal foreign bodies, 25% of bronchial foreign bodies[2], and may be missed if very small and/or radiopaque
    • Inspiratory/expiratory films may show relative hyperinflation proximal to obstruction on end-expiration
    • Consider lateral decubitus films on right and left side

Management

Complete Airway Obstruction

  • If conscious: Heimlich maneuver, chest thrusts (obese or pregnant patients), back-blow/chest thrust (infants)
  • If object visible, remove manually (don't push it further into airway!)
  • Laryngoscopy, remove visualized object with Magill forceps
  • If unsuccessful, bag-valve mask or intubate (may dislodge object and improve situation to partial or more distal obstruction)
  • If unable to intubate, may need cricothyrotomy (though will not help if obstruction distal to cricothyroid)

Partial Obstruction

  • Supplemental O2
  • Allow patient to assume position of comfort
  • Monitor closely
  • May need rigid bronchoscopy to remove
  • Consider consulting ENT, anesthesia (inhalational induction will decrease risk of pushing foreign body into harder-to-reach area)
  • Post-removal: consider dexamethasone, bronchodilators and/or racemic epinephrine, and antibiotics for pneumonia

Disposition

See Also

External Links

References

  1. Ernst A, Feller-Kopman D, Becker HD, Mehta AC. Central airway obstruction. Am J Respir Crit Care Med 2004
  2. Zerella JT, Dimler M, McGill LC, Pippus KJ: Foreign body aspiration in children: value of radiography and complications of bronchoscopy. J Pediatr Surg 33: 1651, 1998.