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]

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