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Foreign Body Aspiration

Foreign Body Aspiration

Foreign body aspiration can lead to choking and death by obstructing airflow at the larynx Larynx The larynx, also commonly called the voice box, is a cylindrical space located in the neck at the level of the C3-C6 vertebrae. The major structures forming the framework of the larynx are the thyroid cartilage, cricoid cartilage, and epiglottis. The larynx serves to produce sound (phonation), conducts air to the trachea, and prevents large molecules from reaching the lungs. Larynx: Anatomy or trachea Trachea The trachea is a tubular structure that forms part of the lower respiratory tract. The trachea is continuous superiorly with the larynx and inferiorly becomes the bronchial tree within the lungs. The trachea consists of a support frame of semicircular, or C-shaped, rings made out of hyaline cartilage and reinforced by collagenous connective tissue. Trachea: Anatomy. Foreign bodies may also become lodged deeper in the bronchi Bronchi The larger air passages of the lungs arising from the terminal bifurcation of the trachea. They include the largest two primary bronchi which branch out into secondary bronchi, and tertiary bronchi which extend into bronchioles and pulmonary alveoli. Bronchial Tree: Anatomy; this may not affect Affect The feeling-tone accompaniment of an idea or mental representation. It is the most direct psychic derivative of instinct and the psychic representative of the various bodily changes by means of which instincts manifest themselves. Psychiatric Assessment breathing but can cause infection or erosion Erosion Partial-thickness loss of the epidermis Generalized and Localized Rashes of bronchial walls. Foreign bodies (FBs) are more frequently aspirated by children, who may present with coughing or wheezing Wheezing Wheezing is an abnormal breath sound characterized by a whistling noise that can be relatively high-pitched and shrill (more common) or coarse. Wheezing is produced by the movement of air through narrowed or compressed small (intrathoracic) airways. Wheezing. As FBs are rarely visible on X-ray X-ray Penetrating electromagnetic radiation emitted when the inner orbital electrons of an atom are excited and release radiant energy. X-ray wavelengths range from 1 pm to 10 nm. Hard x-rays are the higher energy, shorter wavelength x-rays. Soft x-rays or grenz rays are less energetic and longer in wavelength. The short wavelength end of the x-ray spectrum overlaps the gamma rays wavelength range. The distinction between gamma rays and x-rays is based on their radiation source. Pulmonary Function Tests, other modalities of imaging, such as computed tomography or flexible bronchoscopy Bronchoscopy Endoscopic examination, therapy or surgery of the bronchi. Laryngomalacia and Tracheomalacia, must be employed when prompted by symptoms and clinical suspicion. The relative frequency Relative frequency Basics of Probability with which various objects are aspirated varies based on patient demographics. Prompt removal of the FB is the definitive treatment.

Last updated: 10 Sep, 2021

Editorial responsibility: Stanley Oiseth, Lindsay Jones, Evelin Maza

Contents

Overview

Epidemiology

  • 80% of cases occur in patients Patients Individuals participating in the health care system for the purpose of receiving therapeutic, diagnostic, or preventive procedures. Clinician–Patient Relationship < 15 years of age
  • 80% of pediatric cases < 3 years of age
  • Common cause of death: mortality Mortality All deaths reported in a given population. Measures of Health Status highest in patients Patients Individuals participating in the health care system for the purpose of receiving therapeutic, diagnostic, or preventive procedures. Clinician–Patient Relationship < 1 year of age and > 75 years of age

Etiology

Foreign bodies (FBs) aspirated vary based on age.

  • Food is the most common substance in infants:
    • Nuts (35%–50% of all FBs)
    • Seeds
    • Popcorn
    • Raw vegetables (carrots, celery, etc ETC The electron transport chain (ETC) sends electrons through a series of proteins, which generate an electrochemical proton gradient that produces energy in the form of adenosine triphosphate (ATP). Electron Transport Chain (ETC).)
    • Hot dogs 
  • Small objects are more common in older children:
    • Jewelry (30%)
    • Coins (10%)
    • Toys
    • Button batteries
    • Beads
  • Adults:
    • Inorganic:
      • Nails or pins held in the mouth that are accidentally swallowed
      • Dental debris dislodged during dental procedure
      • Tracheostomy Tracheostomy Surgical formation of an opening into the trachea through the neck, or the opening so created. Laryngomalacia and Tracheomalacia tools 
    • Organic: miscellaneous food items

Pathophysiology

  • Upper airway Airway ABCDE Assessment obstruction:
    • More common in children given relative anatomical narrowing of tracheobronchial tree
    • In most pediatric cases, large food or objects are visible in the oropharynx Oropharynx The middle portion of the pharynx that lies posterior to the mouth, inferior to the soft palate, and superior to the base of the tongue and epiglottis. It has a digestive function as food passes from the mouth into the oropharynx before entering esophagus. Pharynx: Anatomy.
  • Lower airway Airway ABCDE Assessment obstruction:

Signs and symptoms

  • Sudden-onset coughing, cyanosis Cyanosis A bluish or purplish discoloration of the skin and mucous membranes due to an increase in the amount of deoxygenated hemoglobin in the blood or a structural defect in the hemoglobin molecule. Pulmonary Examination, respiratory distress
  • Initial choking spell followed by:
    • Cough
    • Stridor Stridor Laryngomalacia and Tracheomalacia (if lodged in trachea Trachea The trachea is a tubular structure that forms part of the lower respiratory tract. The trachea is continuous superiorly with the larynx and inferiorly becomes the bronchial tree within the lungs. The trachea consists of a support frame of semicircular, or C-shaped, rings made out of hyaline cartilage and reinforced by collagenous connective tissue. Trachea: Anatomy)
    • Wheezing Wheezing Wheezing is an abnormal breath sound characterized by a whistling noise that can be relatively high-pitched and shrill (more common) or coarse. Wheezing is produced by the movement of air through narrowed or compressed small (intrathoracic) airways. Wheezing (if lodged in bronchus)
    • Respiratory distress
  • Fever Fever Fever is defined as a measured body temperature of at least 38°C (100.4°F). Fever is caused by circulating endogenous and/or exogenous pyrogens that increase levels of prostaglandin E2 in the hypothalamus. Fever is commonly associated with chills, rigors, sweating, and flushing of the skin. Fever: late finding related to abscess Abscess Accumulation of purulent material in tissues, organs, or circumscribed spaces, usually associated with signs of infection. Chronic Granulomatous Disease or pneumonia Pneumonia Pneumonia or pulmonary inflammation is an acute or chronic inflammation of lung tissue. Causes include infection with bacteria, viruses, or fungi. In more rare cases, pneumonia can also be caused through toxic triggers through inhalation of toxic substances, immunological processes, or in the course of radiotherapy. Pneumonia
  • Hypoxia Hypoxia Sub-optimal oxygen levels in the ambient air of living organisms. Ischemic Cell Damage: Saturation does not improve on providing supplemental oxygen Supplemental Oxygen Respiratory Failure.
  • In 50% of cases, aspiration episode is not noticed; complications due to delayed presentations include the following:
    • Patient may have cough and fever.
    • Retained batteries can cause erosion Erosion Partial-thickness loss of the epidermis Generalized and Localized Rashes of mucosal surfaces.
    • Lung abscesses can form around undetected foreign bodies.

Diagnosis

Most cases involve materials not visible on radiographs (e.g., food, wood, and plastic). In these cases, characteristics of the lung appearance may suggest a foreign body. Computed tomography (CT) or bronchoscopy Bronchoscopy Endoscopic examination, therapy or surgery of the bronchi. Laryngomalacia and Tracheomalacia can confirm suspicion.

  • X-rays X-rays X-rays are high-energy particles of electromagnetic radiation used in the medical field for the generation of anatomical images. X-rays are projected through the body of a patient and onto a film, and this technique is called conventional or projectional radiography. X-rays: lateral neck Neck The part of a human or animal body connecting the head to the rest of the body. Peritonsillar Abscess and chest radiographs
    • Only radiopaque Radiopaque An object of high density that blocks X-rays (looks white) X-rays objects (metal, bone Bone Bone is a compact type of hardened connective tissue composed of bone cells, membranes, an extracellular mineralized matrix, and central bone marrow. The 2 primary types of bone are compact and spongy. Bones: Structure and Types, etc ETC The electron transport chain (ETC) sends electrons through a series of proteins, which generate an electrochemical proton gradient that produces energy in the form of adenosine triphosphate (ATP). Electron Transport Chain (ETC).) are visible.
    • Normal X-ray X-ray Penetrating electromagnetic radiation emitted when the inner orbital electrons of an atom are excited and release radiant energy. X-ray wavelengths range from 1 pm to 10 nm. Hard x-rays are the higher energy, shorter wavelength x-rays. Soft x-rays or grenz rays are less energetic and longer in wavelength. The short wavelength end of the x-ray spectrum overlaps the gamma rays wavelength range. The distinction between gamma rays and x-rays is based on their radiation source. Pulmonary Function Tests does not rule out FB aspiration.
    • Signs of FB invisible on X-ray X-ray Penetrating electromagnetic radiation emitted when the inner orbital electrons of an atom are excited and release radiant energy. X-ray wavelengths range from 1 pm to 10 nm. Hard x-rays are the higher energy, shorter wavelength x-rays. Soft x-rays or grenz rays are less energetic and longer in wavelength. The short wavelength end of the x-ray spectrum overlaps the gamma rays wavelength range. The distinction between gamma rays and x-rays is based on their radiation source. Pulmonary Function Tests: 
      • Mediastinal shift away from side of FB
      • Collapse ( atelectasis Atelectasis Atelectasis is the partial or complete collapse of a part of the lung. Atelectasis is almost always a secondary phenomenon from conditions causing bronchial obstruction, external compression, surfactant deficiency, or scarring. Atelectasis) of single lobe
      • Hyperinflation of segment of lung
      • Focal pneumonia Pneumonia Pneumonia or pulmonary inflammation is an acute or chronic inflammation of lung tissue. Causes include infection with bacteria, viruses, or fungi. In more rare cases, pneumonia can also be caused through toxic triggers through inhalation of toxic substances, immunological processes, or in the course of radiotherapy. Pneumonia
  • Bronchoscopy: Rigid bronchoscopy Bronchoscopy Endoscopic examination, therapy or surgery of the bronchi. Laryngomalacia and Tracheomalacia allows for retrieval of FB (flexible is only diagnostic). 
  • CT: 
    • Used if X-ray X-ray Penetrating electromagnetic radiation emitted when the inner orbital electrons of an atom are excited and release radiant energy. X-ray wavelengths range from 1 pm to 10 nm. Hard x-rays are the higher energy, shorter wavelength x-rays. Soft x-rays or grenz rays are less energetic and longer in wavelength. The short wavelength end of the x-ray spectrum overlaps the gamma rays wavelength range. The distinction between gamma rays and x-rays is based on their radiation source. Pulmonary Function Tests is negative but patient is symptomatic
    • Used in cases with very low clinical suspicion as bronchoscopy Bronchoscopy Endoscopic examination, therapy or surgery of the bronchi. Laryngomalacia and Tracheomalacia achieves same diagnostic results and gives opportunity for treatment
  • Foreign body aspiration x-ray

    X-ray X-ray Penetrating electromagnetic radiation emitted when the inner orbital electrons of an atom are excited and release radiant energy. X-ray wavelengths range from 1 pm to 10 nm. Hard x-rays are the higher energy, shorter wavelength x-rays. Soft x-rays or grenz rays are less energetic and longer in wavelength. The short wavelength end of the x-ray spectrum overlaps the gamma rays wavelength range. The distinction between gamma rays and x-rays is based on their radiation source. Pulmonary Function Tests of coin on chest radiograph

    Image: “Foreign body aspiration X-ray X-ray Penetrating electromagnetic radiation emitted when the inner orbital electrons of an atom are excited and release radiant energy. X-ray wavelengths range from 1 pm to 10 nm. Hard x-rays are the higher energy, shorter wavelength x-rays. Soft x-rays or grenz rays are less energetic and longer in wavelength. The short wavelength end of the x-ray spectrum overlaps the gamma rays wavelength range. The distinction between gamma rays and x-rays is based on their radiation source. Pulmonary Function Tests” by Samir. License: CC BY 3.0
  • X-ray showing dental prosthesis in bronchus

    Chest radiograph shows a dental prosthesis lodged in the left mainstem bronchus.

    Image: “Chest radiograph shows a dental prosthesis lodged in the left mainstem bronchus” by Department of Internal Medicine, Meharry Medical College, Nashville, TN 37208, USA. License: CC BY 3.0
  • Dental floss pick in left main bronchus

    Flexible fiberoptic bronchoscopy Bronchoscopy Endoscopic examination, therapy or surgery of the bronchi. Laryngomalacia and Tracheomalacia reveals a dental floss pick in the left main bronchus (a) and granulation tissue Granulation tissue A vascular connective tissue formed on the surface of a healing wound, ulcer, or inflamed tissue. It consists of new capillaries and an infiltrate containing lymphoid cells, macrophages, and plasma cells. Wound Healing formation after removal of the object with biopsy Biopsy Removal and pathologic examination of specimens from the living body. Ewing Sarcoma forceps Forceps Surgical Instruments and Sutures (b).

    Image: “Flexible fiberoptic bronchoscopy Bronchoscopy Endoscopic examination, therapy or surgery of the bronchi. Laryngomalacia and Tracheomalacia” by Division of Pulmonary Medicine, Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan, Chung-Shan South Rd, Taipei, Taiwan. License: CC BY 2.0

Management

Airway obstruction Airway obstruction Airway obstruction is a partial or complete blockage of the airways that impedes airflow. An airway obstruction can be classified as upper, central, or lower depending on location. Lower airway obstruction (LAO) is usually a manifestation of chronic disease, such as asthma or chronic obstructive pulmonary disease (COPD). Airway Obstruction requires immediate action given the high risk for asphyxia Asphyxia A pathological condition caused by lack of oxygen, manifested in impending or actual cessation of life. Drowning.

  • Life-threatening cases with complete blockage of airway Airway ABCDE Assessment:
    • Look in oropharynx Oropharynx The middle portion of the pharynx that lies posterior to the mouth, inferior to the soft palate, and superior to the base of the tongue and epiglottis. It has a digestive function as food passes from the mouth into the oropharynx before entering esophagus. Pharynx: Anatomy and attempt to remove visible FB with finger sweep (blind finger sweep is not recommended).
    • Back blows Back Blows Cardiopulmonary Resuscitation (CPR) for children < 1 year of age
    • Heimlich maneuver for older children or adults
    • Emergent cricothyroidotomy Cricothyroidotomy Basic Procedures may be required if FB is lodged above larynx Larynx The larynx, also commonly called the voice box, is a cylindrical space located in the neck at the level of the C3-C6 vertebrae. The major structures forming the framework of the larynx are the thyroid cartilage, cricoid cartilage, and epiglottis. The larynx serves to produce sound (phonation), conducts air to the trachea, and prevents large molecules from reaching the lungs. Larynx: Anatomy and patient is in respiratory arrest.
    • During intubation Intubation Peritonsillar Abscess, aspirated FB can be pushed further down into bronchi Bronchi The larger air passages of the lungs arising from the terminal bifurcation of the trachea. They include the largest two primary bronchi which branch out into secondary bronchi, and tertiary bronchi which extend into bronchioles and pulmonary alveoli. Bronchial Tree: Anatomy to prevent complete airway Airway ABCDE Assessment occlusion.
  • Stable cases:
    • Objects that block airway Airway ABCDE Assessment or can lead to mucosal damage need prompt removal.
    • Bronchoscopy (rigid preferred to flexible) is the method of choice when FB is past the oropharynx Oropharynx The middle portion of the pharynx that lies posterior to the mouth, inferior to the soft palate, and superior to the base of the tongue and epiglottis. It has a digestive function as food passes from the mouth into the oropharynx before entering esophagus. Pharynx: Anatomy.
Abdominal thrusts airway aspiration

Abdominal thrusts

Image: “Heimlich maneuver” by Amanda M. Woodhead. License: Public Domain

Clinical Relevance

  • Airway obstruction Airway obstruction Airway obstruction is a partial or complete blockage of the airways that impedes airflow. An airway obstruction can be classified as upper, central, or lower depending on location. Lower airway obstruction (LAO) is usually a manifestation of chronic disease, such as asthma or chronic obstructive pulmonary disease (COPD). Airway Obstruction: partial or complete blockage of airways. Classified into upper or lower airway Airway ABCDE Assessment obstructions. Can be caused by FBs, masses, or infection. Management is based on the causes of obstruction.
  • Pneumonia in children Pneumonia in Children Pneumonia is a disease of the lower airways characterized by inflammation of the alveolar and/or interstitial tissue of the lungs. Pneumonia has numerous potential etiologies, the most common of which is infectious, and is classified according to several factors. Pneumonia in Children: infection of pulmonary parenchyma, diagnosed clinically with signs and symptoms of respiratory distress and inflammation Inflammation Inflammation is a complex set of responses to infection and injury involving leukocytes as the principal cellular mediators in the body’s defense against pathogenic organisms. Inflammation is also seen as a response to tissue injury in the process of wound healing. The 5 cardinal signs of inflammation are pain, heat, redness, swelling, and loss of function. Inflammation. Chest X-ray X-ray Penetrating electromagnetic radiation emitted when the inner orbital electrons of an atom are excited and release radiant energy. X-ray wavelengths range from 1 pm to 10 nm. Hard x-rays are the higher energy, shorter wavelength x-rays. Soft x-rays or grenz rays are less energetic and longer in wavelength. The short wavelength end of the x-ray spectrum overlaps the gamma rays wavelength range. The distinction between gamma rays and x-rays is based on their radiation source. Pulmonary Function Tests may be supportive. Treatment involves antimicrobial therapy based on suspected pathogen. Typically, the patient has a good prognosis Prognosis A prediction of the probable outcome of a disease based on a individual’s condition and the usual course of the disease as seen in similar situations. Non-Hodgkin Lymphomas.
  • Respiratory failure Respiratory failure Respiratory failure is a syndrome that develops when the respiratory system is unable to maintain oxygenation and/or ventilation. Respiratory failure may be acute or chronic and is classified as hypoxemic, hypercapnic, or a combination of the two. Respiratory Failure: inadequate oxygenation of blood or inadequate ventilation Ventilation The total volume of gas inspired or expired per unit of time, usually measured in liters per minute. Ventilation: Mechanics of Breathing ( elimination Elimination The initial damage and destruction of tumor cells by innate and adaptive immunity. Completion of the phase means no cancer growth. Cancer Immunotherapy of CO2) or both. Management involves treating the underlying cause, oxygen administration, and, if necessary, mechanical ventilation Ventilation The total volume of gas inspired or expired per unit of time, usually measured in liters per minute. Ventilation: Mechanics of Breathing.
  • Chronic bronchitis Chronic bronchitis A subcategory of chronic obstructive pulmonary disease. The disease is characterized by hypersecretion of mucus accompanied by a chronic (more than 3 months in 2 consecutive years) productive cough. Infectious agents are a major cause of chronic bronchitis. Rhinovirus: characterized by cough for > 3 months in > 2 consecutive years. Central and peripheral airways are involved in pathophysiology of the disease.

References

  1. Committee on Injury, Violence, and Poison Prevention. Prevention of choking among children. Pediatrics. 2010 Mar;125(3):601-7. doi: 10.1542/peds.2009-2862. Epub 2010 Feb 22. PMID: 20176668.
  2. Boyd M, Chatterjee A, Chiles C, Chin R Jr. Tracheobronchial foreign body aspiration in adults. South Med J. 2009 Feb;102(2):171-4. doi: 10.1097/SMJ.0b013e318193c9c8. PMID: 19139679.
  3. Lund ME. Foreign body removal. In: Principles and Practice of Interventional Pulmonology, 2013. pp. 477-488.
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