Chapter 25 Foreign Body Aspiration
PATHOPHYSIOLOGY
Foreign body aspiration refers to the lodgment of an object or substance in the airway. The foreign body tends to lodge most often in the cricopharyngeal area because of the strong propulsive pharyngeal muscles that move it to this location. Obstruction may be partial or complete. Complete airway obstruction usually occurs in the upper airway and is life threatening. Most objects aspirated by children are small enough to pass through the larynx and trachea and lodge in either of the main bronchi. Examples of items may be poorly chewed hot dog pieces, peanuts, small toys, coins, or disk (button cell) batteries. The right main bronchus is a more common site because it is larger, receives greater airflow, and has a straighter line of entry than the left bronchus. The mechanisms of airway obstruction depend on the site of obstruction and whether the foreign body is partially or completely obstructing an airway. Atelectasis occurs distal to the area where air can no longer enter. Air trapping or hyperinflation occurs when air is inhaled but can be only partially exhaled.
In many cases, foreign bodies are spontaneously expelled from the tracheobronchial tree, and symptoms that persist are from residual irritation and bronchial edema. When foreign body aspiration is diagnosed quickly and the object or substance is removed in a prompt manner, the condition follows a benign course. Aspiration of foreign bodies containing saturated fats, such as peanuts, is more problematic because of the resulting irritation and inflammation of mucosal tissue. The longer a foreign body remains lodged in place, the more complications can develop, related to increasing edema, inflammation, and threat of infection.
INCIDENCE
1. Foreign body aspiration most commonly occurs in children 9 months to 5 years of age.
2. Foreign body aspiration is the leading cause of accidental death in children younger than 1 year of age.
3. Peanuts and other nuts account for about half of all aspirated foreign bodies; vegetable pieces, seeds, and raisins are also common culprits.
4. Large objects such as hot dog pieces, grapes, balloon fragments, and popcorn may obstruct the glottic inlet and lead to respiratory arrest.
CLINICAL MANIFESTATIONS
Clinical manifestations vary according to the site at which the foreign body lodges and the degree of obstruction that occurs.
LABORATORY AND DIAGNOSTIC TESTS
1. Chest radiographic study—anterior, posterior, lateral, and oblique views, to evaluate for opaque foreign body location; for nonopaque foreign body, assess x-ray films for area of atelectasis or, with inspiratory and expiratory x-ray films, assess for air trapping
2. Laryngoscopy and bronchoscopy—performed with general anesthesia in the operating room; provide direct visualization of the upper trachea (a telescope can be used to locate the foreign body, and removal is accomplished by inserting optical forceps)
3. Fluoroscopy—provides a dynamic image of the structures under radiographic study; gives an advantage over radiographic study alone in showing trapped air distal to the foreign body site
4. Xeroradiography (a radiographic technique that uses specially coated x-ray film)—provides higher resolution of images such as of nonmetallic foreign bodies
MEDICAL MANAGEMENT
Emergency management of foreign body aspiration may begin before hospitalization for a life-threatening obstruction when attempts at relief via the Heimlich maneuver or blows to the back cannot be delayed. Initiation of CPR may be required. Provide oxygen via mask or bag-valve mask. Once foreign body aspiration is suspected, immediate attention is warranted, with aggressive diagnostic work-up including bronchoscopy for identification and removal to prevent complications.
NURSING INTERVENTIONS
Emergency Measures
In cases of total airway obstruction or ineffective airway clearance, an airway must be established.
Preoperative Care
1. Provide continuous respiratory monitoring; be prepared to assist with emergency airway management if partial obstruction becomes complete.
2. Monitor vital signs and oxygen saturation.
3. Provide position (of comfort) to ensure adequate airway.
4. Provide nothing by mouth before surgery.
5. Prepare child for bronchoscopy and/or thoracotomy.
6. Provide consistent nursing care to promote trust and to alleviate anxiety.
Discharge Planning and Home Care
1. Instruct parents to observe for, and report immediately, signs of respiratory distress.
2. Provide list of resources for parents in case of emergency.
3. Instruct parents in foreign body airway obstruction removal and cardiopulmonary resuscitation.
4. Instruct in prevention of foreign body aspiration.
Behrman R, Kiegman R, Jenson HB. Nelson textbook of pediatrics, ed 17, Philadelphia: WB Saunders, 2004. editors
Hockenberry M, et al. Wong’s nursing care of infants and children, ed 7. St. Louis: Mosby, 2004.
Rotta A, Wiryawan B. Respiratory emergencies in children. Respir Care. 2003;48(3):248.
Vazquez D, Philotas R. Peds respiratory emergencies. Adv for Nurses. 2004;5(20):17. (Florida Edition)
