Inhaled foreign body

Published on 23/06/2015 by admin

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Last modified 23/06/2015

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6.2 Inhaled foreign body

Peter L.J. Barnett

Essentials

1 The presentation to an emergency department of a child with airway obstruction due to an inhaled foreign body can be life-threatening and requires rapid assessment.
2 One needs to have a prepared approach, which differentiates the situation of total from partial obstruction.
3 One needs to be cautious to avoid the potential to convert partial upper airway obstruction to complete obstruction by unnecessary interventions.
4 Many children who were initially symptomatic may be asymptomatic by the time they are seen in the emergency department and have minimal clinical findings.
5 The majority of objects are radiolucent and the radiological findings are those secondary to the physical presence in the airway.
6 Indication for bronchoscopy should be based on history, examination and radiological investigations. When in doubt, consult a paediatric respiratory physician.

Introduction

Foreign body (FB) aspiration usually occurs in children less than 3 years of age. Exceptions to this can exist, particularly in older children with developmental or neurological issues. Foreign bodies may lodge at any place along the airway from the hypopharynx to the segmental bronchus. Upper airway obstruction due to foreign bodies causes several deaths in Australia each year. The reason toddlers are more prone to aspiration is due to their general inquisitive nature, the presence of small food or non-food objects in the general home environment and their inability to efficiently grind food objects (due to lack of molar teeth).

The most common inhaled foreign bodies are food materials (e.g. peanuts, carrot or apple pieces) and small pieces of toys. Inhaled foreign bodies are rarely radio-opaque, therefore, often not visible on a plain X-ray. Foreign bodies in the upper airway account for only 5–10% of all inhaled objects, but have a higher mortality and morbidity due to their potential to cause high-grade obstruction of the airway proximal to the carina.

Upper airway foreign bodies

History

The presentation of a child with upper airway obstruction due to an inhaled foreign body can be life threatening and require a rapid careful assessment and management. These children present with acute onset of upper airway obstruction – which may be partial, total or fluctuating in severity. Oesophageal foreign bodies can cause upper airways obstruction due to adjacent airway compression, usually characterised by partial obstruction and significant drooling and saliva intolerance. There is generally no preceding history suggesting an infective cause such as croup or epiglottitis or allergic phenomena. Occasionally, the aspiration incident is witnessed as a choking episode, but often not, and a child is only discovered with breathing difficulty following an unwitnessed event.

Examination

A foreign body in the upper airway presents with acute signs of obstruction and respiratory distress. The signs reflect the degree of airway obstruction. In life-threatening cases there may be respiratory arrest with apnoea and cyanosis. Less urgent cases may have stridor, wheeze, cough and abnormal voice or cry. The child may be drooling.

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