eMedicine Specialties > Pediatrics: General Medicine > Pulmonology
Airway Foreign Body
Updated: May 21, 2009
Introduction
Background
The human body has numerous defense mechanisms to keep the airway free and clear of extraneous matter. These include the physical actions of the epiglottis and arytenoid cartilages in blocking the airway, the intense spasm of the true and false vocal cords any time objects come near the vocal cords, and a highly sensitive cough reflex with afferent impulses generated throughout the larynx, trachea, and all branch points in the proximal tracheobronchial tree. However, none of these mechanisms is perfect, and foreign bodies frequently lodge in the airways of children.1
Pathophysiology
Children are more prone to aspirate foreign material for several reasons. The lack of molar teeth in children decreases their ability to sufficiently chew food, leaving larger chunks to swallow. The propensity of children to talk, laugh, and run while chewing also increases the chance that a sudden or large inspiration may occur with food in the mouth. Children often examine even nonfood substances with their mouth.
More foreign body aspirations occur in children younger than 3 years than in other age groups, with a peak between the first and second birthdays. However, foreign bodies have been found in the airways of individuals of all ages and sizes. Even relatively immobile infants may aspirate foreign bodies, despite not having the ability to crawl and find things or the ability to pick up objects and put them in the mouth. They have less chewing capacity and higher respiratory rates, so any objects placed in their mouths are more likely to be aspirated than in older children. They also have well-meaning siblings, who may put the wrong foods in the baby's mouth in an attempt to help feed them.
The most common entities aspirated are small food items such as nuts, raisins, sunflower seeds, improperly chewed pieces of meat and small, smooth items such as grapes, hot dogs, and sausages. All of these should be avoided until the child is able to adequately chew them while sitting. Generally, this occurs around age 5 years, with most foreign body aspirations occurring in children younger than 3 years. Small items that are round, smooth, or both (eg, grapes, hot dogs, sausages, balloons) are more likely to cause tracheal obstruction and asphyxiation. Dried foods may cause progressive obstruction as they absorb water.
In a review of 1068 foreign body aspirations in children, the authors found 3% in the larynx, 13% in the trachea, 52% in the right main bronchus, 6% in the right lower lobe bronchus, fewer than 1% in the right middle lobe bronchus, 18% in the left main bronchus, and 5% in the left lower lobe bronchus; 2% were bilateral.2 In a child in an upright position, the right-sided airways are direct entries from the trachea. The left main bronchus is smaller than the right main bronchus and is slightly angled. In a child in a supine position, material is more likely to enter the right main bronchus.
Frequency
United States
In the year 2000, foreign body aspiration accounted for more than 17,000 emergency department visits and 160 deaths in children aged 14 years or younger.3 Airway foreign bodies are the 5th most common cause of death in children younger than 1 year.4
Mortality/Morbidity
Unfortunately, mortality occurs due to acute aspiration, and morbidity can occur due to acute hypoxia during the acute episode or due to chronic lung and airway damage from a long-standing aspirated foreign body. The National Safety Council estimates that 2900 deaths occur annually in the United States because of foreign body aspiration.5
Race
No racial predilections are noted.
Sex
Most reviews of foreign body aspiration in children show a slight male predominance.
Age
The peak ages during which aspiration of foreign body occurs are the toddler through preschool ages, although foreign bodies have been found in the airways of people of all ages and sizes.
Clinical
History
- Often, the child presents after a sudden episode of coughing or choking while eating with subsequent wheezing, coughing, or stridor. However, in numerous cases, the choking episode is not witnessed, and, in some remote cases, the choking episode is not recalled at the time the history is taken.
- The most tragic cases occur when acute aspiration causes total or near-total occlusion of the airway, resulting in death or hypoxic brain damage.
- The more difficult cases are those in which aspiration is not witnessed or is unrecognized and, therefore, is unsuspected.
- In these situations, the child may present with persistent or recurrent cough, wheezing, persistent or recurrent pneumonia, lung abscess, focal bronchiectasis, or hemoptysis.
- If the material is in the subglottic space, symptoms may include stridor, recurrent or persistent croup, and voice changes.
- In one series, as many as one third of parents were unaware of the aspiration or remembered an event that occurred more than a week before the presentation.4 In as many as 25% of cases, aspiration occurred more than one month before presentation. Consequently, a high index of suspicion in addition to the history may be necessary to reach the diagnosis. In another series of 280 foreign body aspirations, 47% were detected more than 24 hours after the aspiration.4 However, 99% had signs or symptoms or abnormal plain radiographs before the bronchoscopy.
- One of the author's cases involved a 9-year-old boy with persistent pneumonia and lung abscess. Upon bronchoscopy, a plastic toy was visualized in his left lower lobe bronchus. Neither he nor his family could recognize the toy and had no idea how long it had been since it might have been aspirated.
Physical
- Major findings include new abnormal airway sounds, such as wheezing, stridor, or decreased breath sounds. These sounds are often, but not always, unilateral.
- Sounds are inspiratory if the material is in the extrathoracic trachea. If the lesion is in the intrathoracic trachea, noises are symmetric but sound more prominent in the central airways. These sounds are a coarse wheeze (sometimes referred to as expiratory stridor) heard with the same intensity all over the chest.
- Once the foreign body passes the carina, the breath sounds are usually asymmetric. However, remember that the young chest transmits sounds very well, and the stethoscope head is often bigger than the lobes. A lack of asymmetry should not dissuade the observer from considering the diagnosis.
- Similarly, a lack of findings upon physical examination does not preclude the possibility of an airway foreign body.
More on Airway Foreign Body |
 Overview: Airway Foreign Body |
| Differential Diagnoses & Workup: Airway Foreign Body |
| Treatment & Medication: Airway Foreign Body |
| Follow-up: Airway Foreign Body |
| Multimedia: Airway Foreign Body |
| References |
| Next Page » |
References
Pak MW, van Hasselt CA. Foreign bodies in children's airways: a challenge to clinicians and regulators. Hong Kong Med J. Feb 2009;15(1):4-5. [Medline].
Eren S, Balci AE, Dikici B, et al. Foreign body aspiration in children: experience of 1160 cases. Ann Trop Paediatr. Mar 2003;23(1):31-7. [Medline].
CDC. Nonfatal choking-related episodes among children--United States, 2001. MMWR Morb Mortal Wkly Rep. Oct 25 2002;51(42):945-8. [Medline].
Bittencourt PF, Camargos PA, Scheinmann P, de Blic J. Foreign body aspiration: clinical, radiological findings and factors associated with its late removal. Int J Pediatr Otorhinolaryngol. May 2006;70(5):879-84. [Medline].
National Safety Council. Accident Facts. 1992:32.
[Guideline] American Association for Respiratory Care (AARC). Bronchoscopy assisting--2007 revision & update. Respir Care. Jan 2007;52(1):74-80.
Ramirez-Figueroa JL, Gochicoa-Rangel LG, Ramirez-San Juan DH, Vargas MH. Foreign body removal by flexible fiberoptic bronchoscopy in infants and children. Pediatr Pulmonol. Nov 2005;40(5):392-7. [Medline].
Zaupa P, Saxena AK, Barounig A, Hollwarth ME. Management strategies in foreign-body aspiration. Indian J Pediatr. Feb 2009;76(2):157-61. [Medline].
Chung MK, Jeong HS, Ahn KM, et al. Pulmonary recovery after rigid bronchoscopic retrieval of airway foreign body. Laryngoscope. Feb 2007;117(2):303-7. [Medline].
Bloom DC, Christenson TE, Manning SC, et al. Plastic laryngeal foreign bodies in children: a diagnostic challenge. Int J Pediatr Otorhinolaryngol. May 2005;69(5):657-62. [Medline].
Kim IG, Brummitt WM, Humphry A. Foreign body in the airway: a review of 202 cases. Laryngoscope. Mar 1973;83(3):347-54. [Medline].
Mu L, He P, Sun D. Inhalation of foreign bodies in Chinese children: a review of 400 cases. Laryngoscope. Jun 1991;101(6 Pt 1):657-60. [Medline].
Svedstrom E, Puhakka H, Kero P. How accurate is chest radiography in the diagnosis of tracheobronchial foreign bodies in children?. Pediatr Radiol. 1989;19(8):520-2. [Medline].
Tang FL, Chen MZ, Du ZL, Zou CC, Zhao YZ. Fibrobronchoscopic treatment of foreign body aspiration in children: an experience of 5 years in Hangzhou City, China. J Pediatr Surg. Jan 2006;41(1):e1-5. [Medline].
Further Reading
Keywords
foreign body aspiration, choking, foreign body esophagus, aspiration of foreign bodies, airway foreign body, tracheal obstruction, asphyxiation, occlusion of the airway, hypoxic brain damage, lung abscess, focal bronchiectasis, hemoptysis, croup, lung abscess, pneumonia, focal bronchiectasis, diagnosis, treatment
