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%)

Foreign Body Types

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

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 ^[1]

Vegetative, Autonomic, Endocrine Disorders

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

Poisoning

Chronic Pediatric Conditions

Laryngotracheomalacia^[2]
Subglottic stenosis or prior intubation
Vascular ring (double aortic arch)
Vocal cord dysfunction/paroxysmal vocal fold movement

Pediatric stridor

<6 Months Old

Laryngotracheomalacia
- Accounts for 60%
- Usually exacerbated by viral URI
- Diagnosed with flexible fiberoptic laryngoscopy
Vocal cord paralysis
- Stridor associated with feeding problems, hoarse voice, weak and/or changing cry
- May have cyanosis or apnea if bilateral (less common)
Subglottic stenosis
- Congenital vs secondary to prolonged intubation in premies
Airway hemangioma
- Usually regresses by age 5
- Associated with skin hemangiomas in beard distribution
Vascular ring/sling

>6 Months Old

Croup
- viral laryngotracheobronchitis
- 6 mo - 3 yr, peaks at 2 yrs
- Most severe on 3rd-4th day of illness
- Steeple sign not reliable- diagnose clinically
Epiglottitis
- H flu type B
  - Have higher suspicion in unvaccinated children
- Rapid onset sore throat, fever, drooling
- Difficult airway- call anesthesia/ ENT early
Bacterial tracheitis
- Rare but causes life-threatening obstruction
- Symptoms of croup + toxic-appearing = bacterial tracheitis
Foreign body (sudden onset)
- Marked variation in quality or pattern of stridor
Retropharyngeal abscess
- Fever, neck pain, dysphagia, muffled voice, drooling, neck stiffness/torticollis/extension

Evaluation

Chest x-ray of an adult with obstructive pneumonia in the right lung evidenced by hypodense area. This is from a blockage in the respiratory tract leading to an infection distal to the obstruction.

CXR showing focal pneumonia in lower right lung lobe classic for aspiration.

CXR
- Useful to confirm diagnosis, does not rule out
- Negative in >50% of tracheal foreign bodies, 25% of bronchial foreign bodies^[3], 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

External Links

References

↑ Vocal Cord Dysfunction on Internet Book of Critical Care https://emcrit.org/ibcc/vcd/
↑ Ernst A, Feller-Kopman D, Becker HD, Mehta AC. Central airway obstruction. Am J Respir Crit Care Med 2004
↑ 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.

Authors:

[1] Vocal Cord Dysfunction on Internet Book of Critical Care https://emcrit.org/ibcc/vcd/

[2] Ernst A, Feller-Kopman D, Becker HD, Mehta AC. Central airway obstruction. Am J Respir Crit Care Med 2004

[3] 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.

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