Pediatric Airway Foreign Body Workup

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

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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.

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