Pediatric Airway Foreign Body 

Updated: Sep 06, 2018
Author: Emily Concepcion, DO; Chief Editor: Girish D Sharma, MD, FCCP, FAAP 

Overview

Background

The human body has numerous defense mechanisms to keep the airway free and clear of extraneous matter. These include the physical actions of the epiglottis and arytenoid cartilages in blocking the airway, the intense spasm of the true and false vocal cords any time objects come near the vocal cords, and a highly sensitive cough reflex with afferent impulses generated throughout the larynx, trachea, and all branch points in the proximal tracheobronchial tree. However, none of these mechanisms is perfect, and foreign bodies frequently lodge in the airways of children.[1]

Pathophysiology

Children are more prone to aspirate foreign material for several reasons. The lack of molar teeth in children decreases their ability to sufficiently chew food, leaving larger chunks to swallow. The propensity of children to talk, laugh, and run while chewing also increases the chance that a sudden or large inspiration may occur with food in the mouth. Children often examine even nonfood substances with their mouth.

More foreign body aspirations occur in children younger than 3 years than in other age groups, with a peak between the first and second birthdays. However, foreign bodies have been found in the airways of individuals of all ages and sizes. Even relatively immobile infants may aspirate foreign bodies, despite not having the ability to crawl and find things or the ability to pick up objects and put them in the mouth. They have less chewing capacity and higher respiratory rates, so any objects placed in their mouths are more likely to be aspirated than in older children. They also have well-meaning siblings, who may put the wrong foods in the baby's mouth in an attempt to help feed them.

The most common entities aspirated are small food items such as nuts, raisins, sunflower seeds, improperly chewed pieces of meat and small, smooth items such as grapes, hot dogs, and sausages. All of these should be avoided until the child is able to adequately chew them while sitting. Generally, this occurs around age 5 years, with most foreign body aspirations occurring in children younger than 3 years. Small items that are round, smooth, or both (eg, grapes, hot dogs, sausages, balloons) are more likely to cause tracheal obstruction and asphyxiation. Dried foods may cause progressive obstruction as they absorb water.

In a review of 1068 foreign body aspirations in children, the authors found 3% in the larynx, 13% in the trachea, 52% in the right main bronchus, 6% in the right lower lobe bronchus, fewer than 1% in the right middle lobe bronchus, 18% in the left main bronchus, and 5% in the left lower lobe bronchus; 2% were bilateral.[2] In a child in an upright position, the right-sided airways are direct entries from the trachea. The left main bronchus is smaller than the right main bronchus and is slightly angled. In a child in a supine position, material is more likely to enter the right main bronchus.

Epidemiology

Frequency

United States

In the year 2008, foreign body aspiration accounted for more than 17,000 emergency department visits and in 2009 caused 220 deaths in children aged 14 years or younger.[3] Airway foreign bodies are the third most common cause of death due to unintentional injury in children younger than 1 year.[3]

Mortality/Morbidity

Unfortunately, mortality occurs due to acute aspiration, and morbidity can occur due to acute hypoxia during the acute episode or due to chronic lung and airway damage from a long-standing aspirated foreign body. The National Safety Council estimates that 2900 deaths occur annually in the United States because of foreign body aspiration.[4]

Race

No racial predilections are noted.

Sex

Most reviews of foreign body aspiration in children show a slight male predominance.{ref17]

Age

The peak ages during which aspiration of foreign body occurs are the toddler through preschool ages, although foreign bodies have been found in the airways of people of all ages and sizes.

 

Presentation

History

Often, the child presents after a sudden episode of coughing or choking while eating with subsequent wheezing, coughing, or stridor. However, in numerous cases, the choking episode is not witnessed, and, in many cases, the choking episode is not recalled at the time the history is taken.

The most tragic cases occur when acute aspiration causes total or near-total occlusion of the airway, resulting in death or hypoxic brain damage.

The more difficult cases are those in which aspiration is not witnessed or is unrecognized and, therefore, is unsuspected.

In these situations, the child may present with persistent or recurrent cough, wheezing, persistent or recurrent pneumonia, lung abscess, focal bronchiectasis, or hemoptysis.

If the material is in the subglottic space, symptoms may include stridor, recurrent or persistent croup, and voice changes.

In one series, as many as one third of parents were unaware of the aspiration or remembered an event that occurred more than a week before the presentation.[5] In as many as 25% of cases, aspiration occurred more than one month before presentation. Consequently, a high index of suspicion in addition to the history may be necessary to reach the diagnosis. In another series of 280 foreign body aspirations, 47% were detected more than 24 hours after the aspiration.[5] However, 99% had signs or symptoms or abnormal plain radiographs before the bronchoscopy.

One of the author's cases involved a 9-year-old boy with persistent pneumonia and lung abscess. Upon bronchoscopy, a plastic toy was visualized in his left lower lobe bronchus. Neither he nor his family could recognize the toy and had no idea how long it had been since it might have been aspirated.

Physical

See the list below:

  • Major findings include new abnormal airway sounds, such as wheezing, stridor, or decreased breath sounds. These sounds are often, but not always, unilateral.

  • Sounds are inspiratory if the material is in the extrathoracic trachea. If the lesion is in the intrathoracic trachea, noises are symmetric but sound more prominent in the central airways. These sounds are a coarse wheeze (sometimes referred to as expiratory stridor) heard with the same intensity all over the chest.

  • Once the foreign body passes the carina, the breath sounds are usually asymmetric. However, remember that the young chest transmits sounds very well, and the stethoscope head is often bigger than the lobes. A lack of asymmetry should not dissuade the observer from considering the diagnosis.

  • Similarly, a lack of findings upon physical examination does not preclude the possibility of an airway foreign body.

 

DDx

 

Workup

Imaging Studies

Radiography

Most aspirated foreign bodies are food material and are radiolucent. Thus, one has to look indirectly for signs of the foreign body.

If the diagnosis is in doubt, pediatric radiologists can be helpful if they know the child is being evaluated for a foreign body.

See the image below.

Aspirated foreign body (backing to an earring) lod Aspirated foreign body (backing to an earring) lodged in the right main stem bronchus.

A plain radiograph can reveal an area of focal overinflation or an area of atelectasis, depending on the degree of obstruction.

If the material completely occludes the airway, the radiograph may reveal opacification of the distal lung as residual air is absorbed and no air entry is possible.

If the obstruction is partial, progressive ball valve obstruction results in focal overinflation in the area of the lung distal to the affected airway.

If the plain radiography findings are not diagnostic, remember that an affected lung portion does not completely empty. If the child cooperates, an anteroposterior expiratory radiograph may reveal trapped air in the affected portion of the lung. In those children who cannot cooperate with the maneuver, lateral decubitus radiographs may reveal the trapped air. An anteroposterior film with compression on the abdomen, mimicking a forced exhalation, can be helpful.

Fluoroscopy

Fluoroscopy of the chest may be helpful in showing focal air trapping, paradoxical diaphragmatic motion, or both.

CT scanning

Chest CT scanning may reveal the material in the airway, focal airway edema, or focal overinflation not detected using plain radiography.[6] If the index of suspicion is high, many physicians forgo CT scanning and proceed to the more definitive study, bronchoscopy. The use of CT scanning in managing the child with a foreign body in the airway has recently been questioned.

Even if no foreign body is evident on any of the radiographic studies, a foreign body may still be present, and a bronchoscopy should be performed if the suspicion is high.

Procedures

Bronchoscopy

If the history and physical findings are diagnostic, no workup is needed. The child should immediately be referred for rigid bronchoscopy. Guidelines for bronchoscopy have been established by the American Association for Respiratory Care.[7]

Although a flexible bronchoscopy is useful in detecting a foreign body, removing most foreign bodies using the currently available flexible bronchoscopes and their attachments is difficult. However, removal using a fiberoptic bronchoscope has been reported.[8] If the diagnosis is known or confirmed, rigid bronchoscopy is the procedure of choice.[9]

Flexible bronchoscopy is highly successful in detecting the foreign body.[10] The flexible bronchoscope has the advantage of being able to go deeper into the airways and to go into some of the more difficult airways, such as the upper lobes. However, if a foreign body is detected upon flexible bronchoscopy, the child should undergo rigid bronchoscopy to remove the material.

If the possiblity of foreign body is significant but has not been diagnosed by phyical examination or radiographic studies, flexible bronchoscopy should be strongly considered.

Heimlich maneuver

If the child has respiratory distress and is unable to speak or cry, complete airway obstruction is probable, and the likelihood of morbidity or mortality is high. In those cases, a Heimlich maneuver may be performed. If the child is able to speak, the Heimlich maneuver is contraindicated because it might dislodge the material to an area where it could cause complete airway obstruction.

 

Treatment

Medical Care

See the list below:

  • Bronchodilators and corticosteroids should not be used to remove the foreign body, and chest physical therapy with postural drainage may dislodge the material to an area where it may cause more harm, such as at the level of the vocal cords.

  • Medications are not necessary before removal, although the endoscopist may observe enough focal swelling after the material is removed to recommend a short course of systemic corticosteroids.

  • Unless the airway secretions are infected with organisms present, antibiotics are not necessary.

Surgical Care

See the list below:

  • Surgical therapy for an airway foreign body involves endoscopic removal, usually with a rigid bronchoscope.[11]

Consultations

See the list below:

  • If the diagnosis is in question or a flexible bronchoscopy is needed, a pediatric pulmonologist should be consulted.

  • A pediatric surgeon or pediatric otolaryngologist usually performs the rigid bronchoscopy if necessary.

 

Medication

Medication Summary

No medications are needed. If significant swelling is observed in the airway or if granulation tissue is present, a corticosteroid (eg, prednisolone, prednisone) may be administered. Unless airway secretions are infected, antibiotics are not helpful or necessary.

Corticosteroids

Class Summary

These agents elicit anti-inflammatory and immunosuppressive properties and cause profound and varied metabolic effects. They modify the body's immune response to diverse stimuli. If swelling in the airway or granulation tissue is present, a corticosteroid may help.

Prednisolone (FloPred, Millipred, Millipred DP)

Prednisolone is a corticosteroid which reduces inflammation

Prednisone (Prednisone Intensol, Deltasone, Rayos)

Prednisone is a corticosteroid which reduces inflammation.

 

Follow-up

Further Outpatient Care

In one series of 98 foreign body aspirations, 74.5% of the radiographs were normal within one week.[12] A longer time until clearing was associated with inflammatory changes on the initial radiograph or direct visualization, a procedure time longer than 50 minutes, and respiratory complications during the removal.

Further Inpatient Care

See the list below:

  • Endoscopy must be performed by a physician skilled in pediatric airway procedures. Ideally, an anesthesiologist skilled in the treatment of children should also be present in the operating room.

  • Once the foreign body has been removed and the patient is stable, the child may be discharged. This usually occurs the same day as the procedure.

Inpatient & Outpatient Medications

See the list below:

  • If swelling or granulation tissue was observed, a corticosteroid may be administered.

  • Unless airway secretions are infected, antibiotics are not necessary.

Deterrence/Prevention

The best prevention is avoidance.

Anticipatory guidance should include information about age-appropriate foods and instructing the child to sit at the table until all chewing is complete. Supervise children during eating.

Talking while chewing should also be discouraged.

Anticipatory guidance should also include information about age- and size-appropriate toys. Toys that often cause choking include marbles, balloons, batteries from toys, and balls with a diameter of less than 1.75 inches. Children younger than 3 years should not be allowed to play with toys with small pieces. Older children should be supervised when playing with these toys. Keep older children's toys out of the reach of younger children.

Cardiopulmonary resuscitation and choking first aid for children should be taught to parents, teachers, childcare providers, and others who care for children, especially children at high risk of choking such as children with swallowing disorders, neuromuscular disorders, developmental delay, traumatic brain injury, and other primary and secondary medical conditions that may adversely affect the complex neuromuscular coordination involved in the swallowing process.[13]

Complications

See the list below:

  • Atelectasis due to prolonged airway obstruction

  • Bronchiectasis due to chronic infection

  • Lung abscess

  • Pneumomediastinum and pneumothorax (rare complications of foreign body removal)

Prognosis

See the list below:

  • Once the foreign material is removed, the prognosis is excellent. The sooner it is removed, the quicker and more complete the recovery.

Patient Education

See the list below:

  • For excellent patient education resources, see eMedicineHealth's patient education articles, Choking and Swallowed Object.