Inhaled foreign body

Published on 23/06/2015 by admin

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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.

Investigations

In a stable child with partial obstruction, a soft tissue X-ray may be useful to localise the foreign body, if radio-opaque. This is best performed portably in the emergency department (ED) so that the airway is clinically monitored, with ability to intervene if necessary.

Treatment

Total obstruction

Untreated, total airway obstruction will rapidly lead to hypoxia, loss of consciousness and subsequently cardiorespiratory arrest. In the child presenting with complete obstruction, basic life support should be commenced (see Chapter 2.4 on Resuscitation). The performance of back blows and chest thrusts to dislodge the foreign body should be followed by attempted ventilation with bag and mask. If these methods are unable to remove the foreign body and allow ventilation, then direct visualisation of the larynx and Magill forceps extraction of the foreign body should occur if possible. In the unlikely event of a foreign body visualised below the cords, suctioning may expedite its removal or, if not possible, advancing the object past the carina with an endotracheal tube or bougie may allow life-saving ventilation as a temporising measure.

Partial obstruction

The approach to the child with partial airway obstruction, but who is able to ventilate themselves to maintain adequate oxygenation, needs to be cautious. One needs to avoid the potential to convert the situation to one of complete obstruction by unnecessary interventions. It is best to leave the child undisturbed and as comfortable as possible. Small children are best kept in a parent’s arms. Oxygen should be administered if required and tolerated. Causing distress and crying will usually worsen the degree of airway obstruction. The child needs to be carefully transferred from the ED to an appropriate environment where the object can be safely removed with anaesthetic, endoscopic and surgical facilities available. DO NOT attempt to remove the object by the methods mentioned above as this may convert the partial obstruction to complete obstruction.

Lower airway foreign body

History

The majority (70%) of patients presenting with an inhaled foreign body have a clear history to suggest an inhalation. However, up to 30% have a delayed presentation and/or no history of foreign body aspiration.

Patients generally present with sudden onset of coughing and choking, occasionally associated with a brief period of cyanosis. After the initial coughing episode, the child may have an audible wheeze and/or a persistent dry cough. However, many children who were initially symptomatic may be asymptomatic by the time they are seen in the ED. Depending on the size of the foreign body the symptoms may be mild. Foreign bodies tend to lodge in the right main stem bronchus more than the left, due to its less acute deviation from the lumen of the trachea. A patient may also suddenly deteriorate as the foreign body is coughed from one bronchus to the other causing increasing degree of lower airway obstruction. There may be a history of persistent cough or ‘chestiness’ after a remote choking event.

Examination

Examination usually reveals a well child with mild to moderate respiratory distress. The patient may have a cough. Auscultation may reveal diminished air entry on one side compared to the other ± unilateral wheeze. There may be a fever and signs of collapse or consolidation if a foreign body has resulted in a segmental infection in delayed presentations. However, in some cases the inhaled object will be occult and the chest examination may be completely normal. A high index of suspicion is required, particularly if the history is suggestive.

Investigations

The initial investigation of the child with suspected inhaled foreign body should include a plain chest X-ray. The majority of objects are radiolucent and the radiological findings are those secondary to the physical presence in the airway. This may be normal or may show signs of unilateral hyperinflation.

Good quality inspiratory and expiratory X-rays are helpful. If there is air trapping, then the affected lung or part of the lung remains inflated in expiration. There may be segmental or lobar collapse distal to the foreign body particularly with delayed presentation. Fluoroscopy, if available, shows decreased movement of the diaphragm on the affected side.

Persistent changes on X-ray or recurrent pneumonia in the same place may signal an occult foreign body.

Treatment

Initially, the patient’s airway and breathing should be assessed and oxygen given if required. Referral for bronchoscopy is the definitive treatment for confirmed or suspicious cases. Indications for bronchoscopy should be based on history, examination and radiological investigations ‘2 of 3 rule’ (Table 6.2.1).

Table 6.2.1 Indications for bronchoscopy

Two of the following History • Coughing and choking episode and cyanosis or persistent cough after choking episode Examination • Unilateral wheeze or unilateral decreased air entry Investigations • Hyperinflation on expiration chest X-ray or subsegmental atelectasis or positive fluoroscopy

Patients should then be referred to an appropriate service, which can perform a rigid bronchoscopy to remove the foreign body. When in doubt, consult with a paediatric respiratory consultant.

Children who have had a minor choking episode but no ongoing symptoms or signs and a normal X-ray can be discharged. Parents need to be instructed to return should any relevant symptoms evolve (wheeze, persistent dry cough, etc.).

If a child re-presents with ongoing symptoms after previous referral to a tertiary centre, clarify that an adequate assessment was made to rule out a foreign body at that review.

Prevention

Children under 3 years should be protected from access to toys with small parts or foods requiring molar function, as they are potential inhalation risks (e.g. peanuts).

Further reading

Digoy G.P. Diagnosis and management of upper aerodigestive tract foreign bodies. Otolaryngol Clin N Am. 2008;41:485-496.

Heyer C.M., Bollmeier M.E., Rossler L., et al. Evaluation of clinical, radiologic, and laboratory prebronchoscopy findings in children with suspected foreign body aspiration. J Ped Surg. 2006;41:1882-1888.

Midulla F., Guidi R., Barbato A., et al. Foreign body aspiration in children. Pediatr Int. 2005;47:663-668.

Malick M.S., Khan A.R., Al-Bassam A. Late presentation of tracheobronchial foreign body aspiration in children. J Trop Pediatr. 2005;51(3):145-147.

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