II. Epidemiology

  1. Ages affected (typical range 1 to 4 years old)
    1. Age under 3 years old: 50%
    2. Age under 4 years old: 80%
    3. Age under 10 years old: 95%
  2. Increased Incidence at holiday time
  3. Known object aspiration in less than 40% of cases
  4. Choking deaths related to toy use 68% of time
  5. Foreign Body Aspirations and ingestions are responsible for 3000 deaths per year in the United States

III. Causes: Commonly aspirated objects (Choke Hazards)

  1. Children
    1. Latex Balloons (responsible for 29% of Choking deaths)
    2. Marbles, Balls (responsible for 19% of Choking deaths)
    3. Peanuts
    4. Popcorn
    5. Grapes
    6. Hot dogs
    7. Other foods
    8. Coins
    9. Plastic or metal small toys
    10. Button batteries (caustic)
  2. Adults
    1. Fish bones
    2. Meat and bone pieces
  3. Elderly
    1. Swallowed dentures or partials

IV. History

  1. Acute onset of Choking, coughing, Stridor or Wheezing
    1. Onset after eating or playing with potential Choke Hazards
  2. Up to one third of Foreign Body Aspirations are unwitnessed
    1. Foreign Body Aspiration diagnoses are delayed in up to 40% of cases
    2. Keep Foreign Body Aspiration on differential in a child with respiratory complaints
    3. Consider a second foreign body, when one is found (e.g. Nasal Foreign Body, Ear Canal Foreign Body)
  3. Consider Foreign Body Aspiration with subacute respiratory conditions
    1. Prolonged cough
    2. Unilateral Wheezing
    3. Persistent respiratory symptoms refractory to standard management (e.g. Albuterol)
    4. Persistent or recurrent Pneumonia in the same lung region

V. Symptoms

  1. Noisy Breathing with sudden onset and then persistent (variably present)
    1. Stridor
    2. Wheezing
  2. Symptoms may vary by foreign body size
    1. Small objects may produce only a cough
    2. Larger objects may cause sonorous rhonchi
  3. Location of pain indicates foreign body location
    1. Anterior jaw pain (pharynx)
    2. Neck Pain (cervical esophagus below cricopharyngeous)
    3. Chest Pain (thoracic esophagus)
  4. Initial Associated Symptoms or signs (may be asymptomatic)
    1. Cough
    2. Wheezing or Stridor
    3. Choking
    4. Dysphagia
    5. Dysphonia
  5. Chronic Symptoms or signs
    1. Acute or chronic Pneumonia

VI. Differential Diagnosis

VII. Precautions

  1. All pharyngeal and airway foreign bodies are medical emergencies
    1. Asymptomatic patients may abruptly transition to complete airway obstruction
      1. Foreign bodies migrate, incite local inflammation and cause distal Atelectasis
    2. Choking episodes with suspected foreign body, must be thoroughly evaluated before disposition
    3. Non-diagnostic imaging and exam does not exclude foreign body
  2. Emergently involve clinicians skilled in Advanced Airway management (e.g. Emergency Department, ENT, Anesthesia)
  3. Most throat foreign bodies require sedation and endoscopy

VIII. Imaging: Chest XRay

  1. Precautions
    1. XRays are normal in >50% of tracheal Foreign Body Aspirations
    2. XRays are normal in >25% of Bronchial Foreign Body Aspirations
    3. Foreign Body Aspirations are radiolucent in >75% of Foreign Body Aspirations in age 1 to 3 years old
  2. Object is uncommonly radiopaque and visible (10-20%)
    1. Flat foreign bodies may orient in a plane indicating their location
      1. Tracheal foreign bodies often orient in a median or sagittal plane (anterior-posterior)
        1. Coins appear as a circle on lateral films
      2. Esophageal foreign bodies often orient in a frontal or coronal plane (right-left)
        1. Coins appear as a circle on anterior-posterior films
        2. Mnemonic: "O Appearance" = Oesophagus (british spelling)
  3. Obtain right lateral decubitus and left lateral decubitus Chest XRays
    1. Mechanism
      1. Airway Foreign Body creates a ball-valve effect, in which air can enter, but is not expelled
    2. With the right lung down (right lateral decubitus xray), the right lung normally deflates
      1. However in right mainstem Bronchus foreign body, air is trapped and remains expanded
    3. With the left lung down (left lateral decubitus xray), the left lung normally deflates
      1. However in left mainstem Bronchus foreign body, air is trapped and remains expanded
  4. Secondary findings distal to the obstruction
    1. Segmental Atelectasis
    2. Pneumonia (post-obstructive)
    3. Pulmonary consolidation
    4. Air trapping, hyperinflation or hyperlucency
    5. Pneumothorax and other signs of Barotrauma

IX. Imaging: CT Neck Soft Tissue

  1. Avoid in children if at all possible due to CT-associated Radiation Exposure (consider endoscopy instead)
  2. May consider in a stable patient, with non-diagnostic xray and exam, but high clinical suspicion
  3. IV Contrast is not needed for foreign body visualization
    1. Consider IV Contrast for complication evaluation (e.g. abscess, Vascular Injury, Esophageal Perforation)
  4. Efficacy
    1. Test Sensitivity: 100%
    2. Test Specificity: 93-95%
  5. References
    1. Park (2014) Acta Radiol 55(1):8-13 +PMID:23884842 [PubMed]

X. Imaging: Other modailities to consider

  1. XRay of soft tissues of neck
  2. Expiratory chest film
    1. Difficult to obtain in children (lack of cooperation)
  3. Abdominal XRay
  4. Barium swallow or Gastrografin
    1. Indicated for suspected Esophageal Perforation

XI. Diagnostics

  1. Indirect or fiberoptic Nasolaryngoscopy
  2. Video Laryngoscopy (e.g. glidescope)
  3. Bronchoscopy

XII. Management: Alert patient able to maintain airway (can cough, cry or speak)

  1. Provide Supplemental Oxygen
  2. Keep patient as calm as possible and allow them to assume a comfortable position
  3. Do not perform back blows or blind finger sweeps (may completely obstruct airway)
  4. Avoid paralysis for Laryngoscopy as trachea may collapse around foreign body (use Conscious Sedation instead)
  5. Consult otolaryngology, general surgery or pulmonology for bronchoscopy
  6. Consider adjunctive and temporizing measures
    1. Racemic Epinephrine nebulization
    2. Ondansetron (Zofran)
    3. Heliox

XIII. Management: Complete airway obstruction

  1. ABC Management
    1. See Pediatric Resuscitation
    2. Cardiopulmonary Resuscitation if patient unresponsive
  2. Heimlich Maneuver
    1. Age <1 year old: Cycles of 5 back blows and 5 chest thrusts (with head down position)
      1. See Heimlich Maneuver in Infants
    2. Age >1 year old: Abdominal Thrusts
      1. See Heimlich Maneuver
  3. Attempt bag mask ventilation (Positive Pressure Ventilation)
  4. Failed bag mask ventilation
    1. Laryngoscopy and removal of foreign body with Magill forceps or suction
  5. Persistent airway obstruction
    1. Attempt Endotracheal Intubation
      1. If object visualized on Laryngoscopy, remove with Magill forceps or suction
      2. Push foreign body into one of the more distal Bronchi (with stylet within the tube)
      3. Attach suction to Endotracheal Tube and attempt to withdraw object with the suction
    2. Cricothyrotomy or Tracheostomy
      1. Needle Cricothyrotomy for age <12 years
      2. Cricothyrotomy for age >12 years
      3. Do not perform if obstruction is NOT visualized above the Vocal Cords
        1. If obstruction not visualized, obstruction is too low for Cricothyrotomy
        2. Perform Endotracheal Intubation and push object into right mainstem
        3. Pushing object distally allows for aeration of left lung to temporarily stabilize
    3. Other measures
      1. Consider Heliox

XIV. Management: Disposition

  1. See Precautions as above
  2. Consult if suspicion of retained Airway Foreign Body despite negative testing
    1. Laryngoscopy or bronchoscopy is often indicated
    2. Removal becomes more difficult with delayed removal (local inflammation and distal migration)
  3. Observe in emergency department with serial examinations
    1. Consider hospital admission even in the asymptomatic patient, if higher clinical suspicion
    2. If discharged, consider short interval scheduled follow-up with consultant
  4. Criteria for discharge
    1. Uncompelling history and child asymptomatic
    2. Normal imaging and exam
    3. Low clinical suspicion for retained Airway Foreign Body
  5. Return Indications
    1. Coughing spasms
    2. Chest Pain
    3. Shortness of Breath
    4. Wheezing
    5. Stridor
    6. Pneumonia symptoms (e.g. productive cough, fever)

XV. Prevention

  1. Parents of preschool children should keep them away from potential Choke Hazards (see above)
  2. Keep children from Running while eating
  3. Avoid hot dogs, seeds and peanuts in children under age 3 years old

XVI. References

  1. Claudius and Brown (2017) Crit Dec Emerg Med 31(12): 13-20
  2. Dahan, Campbell and Melville (2020) Crit Dec Emerg Med 34(11): 3-10
  3. Fuchs and Yamamoto (2011) APLS, Jones and Bartlett, Burlington, p. 53
  4. Gautam (1994) J Accid Emerg Med 11:113-5 [PubMed]
  5. Hughes (1996) Ann Otol Rhinol Laryngol 105:555-61 [PubMed]
  6. Lemberg (1996) Ann Otol Rhinol Laryngol 105:267-71 [PubMed]
  7. Rimell (1995) JAMA 274:1763-6 [PubMed]

Images: Related links to external sites (from Bing)

Related Studies

Ontology: Choking (C0008301)

Definition (MEDLINEPLUS)

Food or small objects can cause choking if they get caught in your throat and block your airway. This keeps oxygen from getting to your lungs and brain. If your brain goes without oxygen for more than four minutes, you could have brain damage or die.

Young children are at an especially high risk of choking. They can choke on foods like hot dogs, nuts and grapes, and on small objects like toy pieces and coins. Keep hazards out of their reach and supervise them when they eat.

When someone is choking, quick action can be lifesaving. Learn how to do back blows, the Heimlich maneuver (abdominal thrusts), and CPR.

Definition (NCI) A condition caused by blocking the airways to the lungs and interference with the respiration by compression or obstruction of the larynx or trachea.
Concepts Pathologic Function (T046)
MSH D000402
SnomedCT 69710001, 249489001
LNC LA17127-4
French ASPHYXIE, Étouffement, Etouffement
Spanish AHOGO, Ahogo, ahogo (hallazgo), ahogo (concepto no activo), ahogo, atragantamiento (hallazgo), atragantamiento
Italian Soffocamento, Strozzamento
Japanese 息詰まり, イキツマリ, イキヅマリ
Portuguese Afogo, SUFOCADO, Sufocação
German Ersticken, ERSTICKEN
English choking, choking (symptom), choke, CHOKING, Choking (finding), Choking (finding) [Ambiguous], Choking
Czech Dušení, dušení se
Hungarian Fuldoklás
Norwegian Kveling
Dutch verstikking, Stikken

Ontology: Foreign body in pharynx (C0161010)

Concepts Injury or Poisoning (T037)
ICD9 933.0
ICD10 T17.2
SnomedCT 157555001, 211627002, 25479004
English Pharyngeal foreign body, foreign body of pharynx (diagnosis), foreign body of pharynx, Foreign body in throat NOS, body foreign pharyngeal, Foreign body (in);pharynx, Foreign body (in);throat, pharyngeal foreign body, foreign body pharyngeal, pharynx foreign body, foreign body throat, foreign body in throat, bodies foreign throat, Pharyngeal foreign body (disorder), Foreign body in throat NOS (disorder), Foreign body in pharynx, Foreign body in throat, Pharyngeal FB - foreign body, Foreign body in pharynx (disorder), foreign body; pharynx, foreign body; throat, Foreign body in throat, NOS, foreign body in pharynx
German Fremdkoerper im Rachen, Fremdkoerper in der Pharynx
Korean 인두의 이물
Spanish Cuerpo extraño en la faringe, cuerpo extraño en garganta, SAI (trastorno), cuerpo extraño en garganta, SAI, cuerpo extraño en la faringe (trastorno), cuerpo extraño en la faringe, cuerpo extraño en la garganta
Portuguese Corpo estranho na faringe
Italian Corpo estraneo nella faringe
French Corps étranger dans le pharynx
Czech Cizí těleso ve faryngu
Dutch vreemd lichaam in keelholte, corpus alienum; farynx, corpus alienum; keel, Corpus alienum in farynx
Japanese イントウナイイブツ, 咽頭内異物
Hungarian Idegentest a garatban

Ontology: Foreign body in larynx (C0161011)

Concepts Injury or Poisoning (T037)
ICD9 933.1
ICD10 T17.3
SnomedCT 157556000, 211628007, 19496008
English Laryngeal foreign body, foreign body of larynx (diagnosis), foreign body of larynx, larynx foreign body (___ cm), laryngeal foreign body, foreign body of larynx (physical finding), Foreign body (in);larynx, Laryngeal foreign body (disorder), Foreign body in larynx, Laryngeal FB - foreign body, Foreign body in larynx (disorder), foreign body; larynx, foreign body in larynx
German Fremdkoerper im Kehlkopf, Fremdkoerper im Larynx
Korean 후두의 이물
Spanish Cuerpo extraño en laringe, cuerpo extraño en la laringe (trastorno), cuerpo extraño en la laringe
Portuguese Corpo estranho na laringe
Italian Corpo estraneo nella laringe
Czech Cizí těleso v laryngu
French Corps étranger dans le larynx
Dutch vreemd lichaam in strottenhoofd, corpus alienum; larynx, Corpus alienum in larynx
Japanese コウトウナイイブツ, 喉頭内異物
Hungarian Idegentest a gégében

Ontology: Foreign body in trachea (C0161013)

Concepts Injury or Poisoning (T037)
ICD9 934.0
ICD10 T17.4
SnomedCT 157557009, 54421009
English Tracheal foreign body, foreign body of trachea (diagnosis), foreign body of trachea, tracheal foreign body, Tracheal foreign body (disorder), Foreign body in trachea, Foreign body in trachea (disorder), foreign body; trachea
German Fremdkoerper in der Trachea, Fremdkoerper in der Luftroehre
Korean 기관의 이물
Spanish Cuerpo extraño en la tráquea, cuerpo extraño en la tráquea (trastorno), cuerpo extraño en la tráquea
Portuguese Corpo estranho na traqueia
Dutch vreemd lichaam in luchtpijp, corpus alienum; trachea, Corpus alienum in trachea
Czech Cizí těleso v trachee
Italian Corpo estraneo nella trachea
French Corps étranger dans la trachée
Japanese 気管内異物, キカンナイイブツ
Hungarian Idegentest a tracheában

Ontology: Foreign body in tracheobronchial tree (C0161016)

Concepts Injury or Poisoning (T037)
ICD9 934.9
SnomedCT 211630009, 157560002, 45865005
English FB in respiratory tree NOS, Foreign body in respiratory tree NOS, FB respiratory tree NOS, Foreign body in respiratory tree, unspecified, Foreign body in respiratory tree NOS (disorder), Foreign body in tracheobronchial tree (disorder), Foreign body in tracheobronchial tree, Foreign body in respiratory tree, Foreign body in respiratory tree, NOS
Spanish Cuerpo extraño en el árbol respiratorio, no especificado, cuerpo extraño en vías respiratorias, SAI (trastorno), cuerpo extraño en vías respiratorias, SAI, Foreign body in respiratory tree NOS, cuerpo extraño en el árbol traqueobronquial (trastorno), cuerpo extraño en el árbol traqueobronquial, presencia de cuerpo extraño en el árbol respiratorio (trastorno), presencia de cuerpo extraño en el árbol respiratorio
Portuguese Corpo estranho NE na árvore respiratória
Italian Corpo estraneo nell'albero respiratorio non specificato
Czech Cizí těleso v bronchiálním stromu, blíže neurčeno
Dutch vreemd lichaam in ademhalingswegen, niet-gespecificeerd
German Fremdkoerper im Respirationstrakt, unspezifisch
French Corps étranger dans l'arbre respiratoire, non précisé
Japanese ショウサイフメイノキドウナイイブツ, 詳細不明の気道内異物
Hungarian Idegentest a bronchus-fában, nem meghatározott

Ontology: Aspiration of foreign body (C0232070)

Concepts Injury or Poisoning (T037)
SnomedCT 62329009
Italian Aspirazione di corpo estraneo
Japanese 異物誤嚥, イブツゴエン
Czech Aspirace cizího tělesa
English Foreign body aspiration, foreign body aspiration, Aspiration of foreign body, Aspiration of foreign body (disorder), foreign body; inhalation, inhalation; foreign body, inspiration; foreign body
Hungarian Idegentest aspiratio
Dutch corpus alienum; inhalatie, inhalatie; corpus alienum, inspiratie; corpus alienum, vreemd lichaam aspiratie
Spanish aspiración de cuerpo extraño (trastorno), aspiración de cuerpo extraño, Aspiración de cuerpo extraño
Portuguese Aspiração de corpo estranho
French Inhalation d'un corps étranger
German Fremdkoerperaspiration

Ontology: Foreign body in bronchus (C0238037)

Concepts Injury or Poisoning (T037)
ICD10 T17.5
SnomedCT 269383006, 282461001
German Fremdkoerper im Bronchus
English foreign body of bronchus (diagnosis), bronchial foreign body(s), foreign body of bronchus, Foreign body (in);bronchus, bodies bronchial foreign, bodies bronchus foreign, foreign body in bronchus, Bronchus - foreign body, Foreign body in bronchus, Foreign body in bronchus (disorder), bronchus; foreign body, foreign body; bronchus
Korean 기관지의 이물
Spanish cuerpo extraño bronquial (trastorno), cuerpo extraño en bronquio (trastorno), cuerpo extraño bronquial, cuerpo extraño en bronquio
Dutch bronchus; corpus alienum, corpus alienum; bronchus, Corpus alienum in bronchus

Ontology: Foreign body in respiratory tract (C0433654)

Concepts Injury or Poisoning (T037)
ICD10 T17 , T17.9
SnomedCT 157554002, 262599003
English Foreign body in respiratory tract, part unspecified, Foreign body-respiratory tract, foreign body in respiratory tract (diagnosis), Foreign body in respiratory tract, Foreign body in respiratory tract (disorder), foreign body; respiratory tract, respiratory tract; foreign body
German Fremdkoerper in den Atemwegen, Teil nicht naeher bezeichnet, Fremdkoerper in den Atemwegen
Korean 상세불명 호흡기로 부분의 이물, 호흡기로의 이물
Dutch corpus alienum; luchtwegen, luchtwegen; corpus alienum, Corpus alienum in luchtwegen, deel niet gespecificeerd, Corpus alienum in luchtwegen
Spanish cuerpo extraño en la vía respiratoria (trastorno), cuerpo extraño en la vía respiratoria

Ontology: Oropharyngeal foreign body (C0433660)

Concepts Injury or Poisoning (T037)
SnomedCT 262604009
English foreign body of oropharynx (diagnosis), foreign body of oropharynx, foreign body in the oropharynx, foreign body of oropharynx (physical finding), Foreign body in oropharynx, Oropharyngeal foreign body, Oropharyngeal foreign body (disorder)
Spanish cuerpo extraño en la orofaringe, cuerpo extraño orofaríngeo (trastorno), cuerpo extraño orofaríngeo