Aspirated foreign body

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
• Tracheal injury
• Electromagnetic or radiation exposure
• Burns, inhalation injury

Infectious Disorders

• Bacterial tracheitis
• Diphtheria
• Tetanus
• Tracheobronchial tuberculosis
• Poliomyelitis, paralytic, bulbar, or acute
• Fungal laryngitis

Abscesses

• Retropharyngeal abscess
• Epiglottitis, acute
• Peritonsillar abscess
• Laryngotracheobronchitis (croup)
• Retropharyngeal abscess

Neoplastic Disorders

• Neoplasms/tumors

Allergic and Auto-Immune Disorders

• Spasmodic/tracheobronchitis
• Angioedema/Angioneurotic edema

Metabolic, Storage Disorders

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

Biochemical Disorders

• Tetany

Congenital, Developmental Disorders

• Angioedema/Angioneurotic edema, hereditary

Psychiatric Disorders

• Somatization disorder

Anatomical or Mechanical

• Foreign body aspiration
• Acute gastric acid/aspiration syndrome
• Airway obstruction
• Neck compartment hemorrhage/hematoma
• Paradoxical vocal fold motion

Vegetative, Autonomic, Endocrine Disorders

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

Poisoning

• Smoke inhalation
• Chemical burn/esophagus

Chronic Pediatric Conditions

• Laryngotracheomalacia
• Subglottic stenosis or prior intubation
• Vascular ring (double aortic arch)
• Vocal cord dysfunction/paroxysmal vocal fold movement

<6mo

• Laryngotracheomalacia
• Vocal cord paralysis (weak cry)
• Subglottic stenosis (previous intubation)
• Airway hemangioma (usually regresses by age 5)
• Vascular ring/sling

Evaluation

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

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

See Also

• Respiratory distress
• Stridor, Stridor (Peds)
• PALS (Main), Newborn resuscitation
• Difficult airway algorithm, Airway sizes (peds)
• Aspiration pneumonia and pneumonitis
• Esophageal foreign body, Nasal foreign body