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

Infectious Disorders

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

Congenital, Developmental Disorders

Psychiatric Disorders
  • Somatization disorder

Anatomical or Mechanical
  • Foreign body aspiration
  • Acute gastric acid/aspiration syndrome
  • Airway obstruction
  • Neck compartment hemorrhage/hematoma

Vegetative, Autonomic, Endocrine Disorders

Poisoning

Chronic Pediatric Conditions

Pediatric stridor
  • A minimal amount of edema or inflammation in the pediatric airway can result in significant obstruction
    • Can lead to rapid decompensation

<6mo
  • Laryngotracheomalacia
    • Accounts for 60%
    • Usually exacerbated by viral URI
    • Dx w/ flexible fiberoptic laryngoscopy
  • Vocal cord paralysis
    • Stridor associated w/ feeding problems, hoarse voice, weak and/or changing cry
    • May have cyanosis or apnea if bilateral (less common)
  • Subglottic stenosis
    • Congenital vs 2/2 prolonged intubation in premies
  • Airway hemangioma
    • Usually regresses by age 5
    • Associated w/ skin hemangiomas in beard distribution
  • Vascular ring/sling

>6mo
  • 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
    • Sx 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
  • 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

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.
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