The most common foreign bodies in the airway are food (peanuts are the most common) and coins. They are lodged most commonly at the right mainstem bronchus or subsegmental bronchi
Foreign body aspiration is characterised by the sudden onset of wheezing, choking, or cough in children who have access to risky objects. The most common location of obstruction is the right bronchus (58%). Incomplete obstruction is usually followed by an asymptomatic interval where the foreign body becomes lodged, reflexes are diminished, and the patient becomes more comfortable. This is when non-diagnosis or misdiagnosis is common. If the index of suspicion is high for foreign body aspiration, bronchoscopy should be performed.
Children < 3 years of age account for ~ 73% of all cases.
Clinical presentation
| Foreign body | Clinical features |
|---|---|
| Incomplete obstruction | Violent paroxysms of coughing, gagging, wheezing and drooling |
| Laryngeal foreign body | Leads to complete obstruction and asphyxiation (death) unless the Heimlich manoeuvre is performed. It is usually caused by a flat, thin object (coin) lodged sagitally between the vocal cords. presents with hoarseness, stridor, cough and dyspnea |
| Tracheal foreign body | Choking (90%), stridor (60%), wheezing (50%) |
| Bronchial foreign body | Unilateral wheeze |
- Most common aspirated objects
- Nuts (peanuts; 1/3 of cases)
- Raw carrot
- Apple
- Dried beans
- Popcorn
- Sunflower seeds
- Watermelon seeds
- Small toys/parts
- Risk factors for aspiration
- Children
- Molars are not yet developed before 2 years of age, hence children are not able to chew food into smaller children
- Natural curiosity
- Poor child protection
- Inappropriate food
- Children
- Patient History
- Sudden coughing, respiratory distress
- What was around the patient when signs and symptoms started?
- What has the patient been fed? (particularly ask about nuts)
- Differentials
- Angioedema
- Epiglottitis: drooling, dysphagia, stridor
- Accidental ingestion of very hot liquid
- Diphtheria
- Investigations
- CXR with inspiratory and expiratory phases: to evaluate for air trapping for non-radiopaque objects
- Air-trapping and Hyperinflation of the affected side (ball-valve effect) during the expiratory phase
- Hypoinflation of the affected side (atelectasis)
- Mediastinal shift to the affected side
- Chext X-ray left/right lateral decubitus phases, since the affected lung may not undergo normal collapse when dependent
- Neck X-ray
- Rigid bronchoscopy: for diagnosis and removal of the foreign body
- Flexible bronchoscopy: for follow-up
- CXR with inspiratory and expiratory phases: to evaluate for air trapping for non-radiopaque objects
- Treatment of complete obstruction
- Back-blows or Heimlich maneuver (older child) in complete obstruction
- Treatment of incomplete obstruction
- Obtain a description of the object and location to aid in removal
- Prepare for bronchoscopy
- Decompress stomach via NG tube (prevent aspiration)
- Provide IV fluids
- Perform rigid bronchoscopic extraction of a foreign body
- Intra-op corticosteroid may minimise edema
- Nebulization and chest physiotherapy after removal to treat bronchospasm and help clear mucus
- Oral corticosteroids for edema and prophylactic antibiotics
- Complications of incomplete obstruction
- Airway oedema
- Pneumonitis
- Post-obstructive pneumonia
- Pneumothorax
- Bronchiectasis
- Chronic lung infection
- Atelectasis
- Complications of complete obstruction
- Asphyxiation
- Sudden respiratory distress → inability to speak or cough
- Globular objects are more frequent offenders of complete obstruction
- Asphyxiation