Foreign-Body Aspiration: A Pediatric Airway Emergency

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Foreign-body aspirations are potential life-threatening emergencies and are the leading causes of unintentional injury in children less than one year old.1,2 Infants and toddlers are particularly at risk for several reasons: they explore their world by placing objects in their mouths, they are very playful and active when eating, and they do not have developed dentition in order to chew food properly. Delayed diagnosis at any age can lead to significant morbidity and mortality. In the United States in 2007 alone, there were 3,700 deaths related to aspiration or ingestion of food or other objects ultimately causing airway obstruction.3 Suspected foreign-body aspiration in a child with respiratory symptoms requires immediate medical evaluation.

The longer a foreign-body aspiration goes undiagnosed, the more likely there will be secondary complications.

Commonly aspirated foods by infants and toddlers include peanuts, sunflower seeds, carrots, raisins, grapes, and hot dogs. In preschoolers, nonfood items such as coins, paper clips, pins, and pen caps are more commonly aspirated. 3

Presentation

Patients presenting with a foreign body aspiration are often stable. Nonetheless, a sudden onset of coughing and choking in an otherwise healthy child is highly suspicious for aspiration. Symptoms at presentation include cough, stridor, dyspnea, stupor, cyanosis, and respiratory arrest.4 The classic triad of new-onset cough, wheezing, and asymmetric breath sounds is only seen in 16-40% of cases and is neither sensitive nor specific for foreign-body aspiration.2,4-6 In general, patients with tracheal foreign bodies present with dyspnea and are more easily diagnosed. Bronchial foreign bodies, which account for 80-90% of aspirations, are more likely to cause decreased breath sounds, and children usually have a delayed diagnosis (Table 1).7 Partial or insignificant obstructions can make the diagnosis difficult and are often misdiagnosed as URIs, bronchiolitis, pneumonia, or asthma. In a child with chronic cough, recurrent pneumonias, persistent croup, or “asthma” that fails standard medical therapy, one should always have “retained foreign body” on the differential diagnosis.

Table 1. Location incidence of aspirated foreign bodies in children.

Location of Aspirated Foreign Body Percentage Found
Larynx 3%
Trachea/carina 13%
Right lung 60% (52% main bronchus)
Left lung 23% (18% main bronchus)
Bilateral 2%

Evaluation

Chest radiographs are usually the first diagnostic study ordered and can be helpful to confirm the diagnosis of foreign body, but they cannot be used to exclude the diagnosis. The majority of foreign bodies aspirated are radiolucent — chest radiographs are normal in more than 50% of tracheal foreign bodies and 25% are normal in bronchial foreign bodies.2,4,6 End-inspiratory and end-expiratory films can be helpful in the older or more cooperative child. Decubitus radiographs are of little diagnostic value.8 There are several secondary signs on chest radiograph that can be seen with aspiration (Table 2).2 Fluoroscopy and CT have also been used as alternatives for diagnosis, with CT sensitivity reaching 100%.2,5 However, if clinically suspected, a foreign body aspiration must be ruled out by bronchoscopy.

Table 2. Characteristics of subsets of airway obstruction.

Type of Obstruction Physiology of Obstruction Radiographic Findings
Bypass valve Partial obstruction of inspiration and expiration; there is aeration beyond the obstruction, even if diminished Normal
Check valve Air entry on inhalation, but little air escape on expiration Hyperinflation of the affected lung
Ball valve Partial obstruction in which the object intermittently prolapses Mediastinal shift toward involved lung and early atelectasis and collapse
Stop valve Complete bronchial obstruction with no aeration on inspiration or expiration Consolidation of the involved segment with possible collapse

Management

Children with respiratory distress require immediate intervention and basic life support measures to ensure airway, breathing, and circulation are intact. Blind sweeping of the mouth is not recommended. Infants require back blows and chest compressions, and children older than one year require abdominal thrusts. In severe cases of complete airway obstruction, direct laryngoscopy and foreign body removal with Magill forceps should be attempted emergently. If the foreign body is not visualized, endotracheal intubation should be performed, which will potentially dislodge the foreign body and move it more distally. In the rare cases in which the patient cannot be ventilated after the measures above, needle cricothyroidotomy can be a temporizing life-saving procedure.4

Those patients without complete airway obstruction or severe respiratory distress should be placed in a quiet room in a position of comfort until rigid bronchoscopy can diagnose and relieve the obstruction. Bronchoscopy should be performed if foreign body aspiration is suspected, even if radiographic studies are normal. This should be performed under general anesthesia in a controlled setting such as the operating room. Depending on the institution, bronchoscopy can be performed by an otolarnyngologist, pulmonologist, or surgeon. Bronchoscopy complication rates are very low, ranging between 1-10% and the majority of patients are discharged within 24 hours of the procedure.2,5,6,9

Complications

The longer a foreign body aspiration goes undiagnosed, the more likely there will be secondary complications. Most common complications include atelectasis, bronchiectasis, and post-obstructive pneumonia. Airway granulomas, broncho­esophageal fistula, and pneumothorax are much less common.3,5,9

Conclusion

Foreign body aspirations account for several thousand emergency department visits annually.1,2 Timely diagnosis is critical, and current management algorithms are clear and well established. Educational and legislative efforts have been effective intervention strategies promoting prevention of this common pediatric emergency.3 Foreign-body aspiration is a fully preventable event, and age-specific anticipatory guidance should be reviewed with caregivers when appropriate.

REFERENCES

  1. Center for Disease Control Morbidity and Mortality Weekly Report. Nonfatal choking-related episodes among children – United States, 2001. Oct 25, 2002; 51(42): 945-948.
  2. Srivastava, G. (2010). Airway Foreign Bodies in Children. Clinical Pediatric Emergency Medicine, 11(2), 67-72.
  3. Ruiz, F. (2014, August 1). Airway Foreign Bodies in Children. UpToDate. Retrieved Sept. 17, 2014.
  4. Tintinalli, J. (2011). Pediatrics. In Tintinalli’s Emergency Medicine: A Comprehensive Study Guide (7th ed., pp. 792-793). New York: The McGraw-Hill Companies.
  5. Saki N, Nikakhlagh S, Rahim F, Abshirini H. Foreign body aspirations in infancy: a 20-year experience. International Journal of Medical Sciences. 2009; 6(6): 322-328.
  6. Svedstrom E, Puhakka H, Kero P. How accurate is radiography in the diagnosis of tracheobronchial foreign bodies in children? Pediatr Radiol. 1989; 19(8): 520-522.
  7. Eren S, Balci AE, Dikici B, et al. Foreign body aspiration in children: experience of 1160 cases. Ann Trop Paediatr 2003; 23:31.
  8. Assefa, D. (2007). Use of Decubitus Radiographs in the Diagnosis of Foreign Body Aspiration in Young Children. Pediatric Emergency Care, 23(3), 154-157.
  9. Ezer, S. (2011). Foreign Body Aspiration in Children: Analysis of Diagnostic Criteria and Accurate Time for Bronchoscopy. Pediatric Emergency Care, 27(8), 723-726.
Molly Wormley, MD

Molly Wormley, MD

Resident Physician, University of Arizona, Tucson, AZ
Molly Wormley, MD

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