eMedicine Specialties > Pulmonology > Aspiration and Atelectasis

Foreign Body Aspiration: Differential Diagnoses & Workup

Author: Martin E Warshawsky, MD, FACP, FCCP, Director of Respiratory Intensive Care Unit, Elmhurst Hospital Center; Clinical Assistant Professor, Department of Internal Medicine, Division of Pulmonary and Critical Care, Mount Sinai School of Medicine
Contributor Information and Disclosures

Updated: Jun 3, 2008

Differential Diagnoses

Alcoholism
Pneumonia, Aspiration
Atelectasis
Pneumonia, Bacterial
Chronic Obstructive Pulmonary Disease
Pneumothorax
Delirium
Pulmonary Embolism
Emphysema
Pulmonary Function Testing
Initial Evaluation and Management of Maxillofacial Injuries
Respiratory Failure
Lung Abscess

Other Problems to Be Considered

Intoxication

Workup

Laboratory Studies

  • Arterial blood gas analysis is useful for judging the adequacy of ventilation and identifying the evolution of acute ventilatory failure. Administer the test in conjunction with an assessment of appearance, voice, speech, vital signs, physical examination, and pulse oximetry.

Imaging Studies

  • Perform standard posteroanterior inspiratory chest radiography to look for unilateral hyperinflation, lobar or segmental atelectasis, mediastinal shift, or pneumomediastinum.  
    • Most foreign bodies are radiolucent. Less than 20% of aspirated foreign bodies are radiopaque.
    • The sensitivity for detecting signs of foreign body aspiration improves over time.
    • On chest radiographs, children have air trapping more often, while adults have atelectasis more often. The proportion of patients with foreign body aspiration who have normal findings on chest radiographs varies widely in the literature, and atelectasis or consolidation is often not appreciated for at least 24 hours. If foreign body aspiration is suspected, a normal finding on chest radiographs does not exclude the diagnosis.
  • Expiratory chest radiographs are more sensitive for air trapping than inspiratory chest radiographs. Signs are enhanced lucency and relatively low diaphragm position. If the patient cannot cooperate, lateral decubitus views may demonstrate air trapping in the dependent lung.6
  • CT scanning of the chest may show the object or may identify localized air trapping.7
    • The presence of a foreign body and its condition, anatomic location (ie, larynx, trachea, main, lobar or segmental bronchus), shape, composition, position, size (ie, number of fragments), and extent of entrapment by edema or granulation tissue must be identified prior to attempts at extraction.
    • The foreign body may be missed if it is of a color that would camouflage it from the surrounding mucosa (eg, carrot, rubber pencil eraser) or if it is completely engulfed by granulation tissue.
    • The object also may not be visualized if it is too distal. Straight pins can migrate into deep segmental bronchi beyond the visual range of even a flexible bronchoscope.
    • CT scanning supplemented with virtual bronchoscopic imaging8,9,10 may further provide such useful information prior to an attempt at bronchoscopy, especially when attempting to pass a flexible bronchoscope beyond the first object encountered is not an advisable course of action. Whether virtual bronchoscopy can adequately replace early bronchoscopic inspection when other evidence to support a suspicion of foreign body aspiration is not yet manifest remains undetermined. Virtual bronchoscopy is not yet widely available.
  • Fluoroscopy of the chest can be performed to observe diaphragmatic and mediastinal shifting of air trapping while the patient is breathing if the diagnosis is in doubt or if the patient cannot cooperate.
  • Radioisotope lung perfusion scanning may demonstrate perfusion defects due to hypoxic vasoconstriction in poorly ventilated regions, even when physical examination and radiography findings are minimal.

Other Tests

  • Bronchoscopy (both rigid and flexible) can be both diagnostic and therapeutic.

Procedures

Histologic Findings

Organic foreign bodies such as oily nuts (commonly peanuts) induce inflammation and edema. Local inflammation, edema, cellular infiltration, ulceration, and granulation tissue formation may contribute to airway obstruction while making bronchoscopic identification and removal of the object more difficult. Mediastinitis or tracheoesophageal fistulas might result. Distal to the obstruction, air trapping might lead to local emphysema, atelectasis, hypoxic vasoconstriction, suppurative pneumonia, or bronchiectasis. Bronchoscopically, the object may appear as a tumor, and scar carcinoma may develop over time. Even if the object is removed, the inflammatory changes may not be completely reversible.

More on Foreign Body Aspiration

Overview: Foreign Body Aspiration
Differential Diagnoses & Workup: Foreign Body Aspiration
Treatment & Medication: Foreign Body Aspiration
Follow-up: Foreign Body Aspiration
References
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References

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  2. Debeljak A, Sorli J, Music E, Kecelj P. Bronchoscopic removal of foreign bodies in adults: experience with 62 patients from 1974-1998. Eur Respir J. Oct 1999;14(4):792-5. [Medline].

  3. Mittleman RE, Wetli CV. The fatal cafe coronary. Foreign-body airway obstruction. JAMA. Mar 5 1982;247(9):1285-8. [Medline].

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  8. Adaletli I, Kurugoglu S, Ulus S, Ozer H, Elicevik M, Kantarci F, et al. Utilization of low-dose multidetector CT and virtual bronchoscopy in children with suspected foreign body aspiration. Pediatr Radiol. Jan 2007;37(1):33-40. [Medline].

  9. Haliloglu M, Ciftci AO, Oto A, Gumus B, Tanyel FC, Senocak ME, et al. CT virtual bronchoscopy in the evaluation of children with suspected foreign body aspiration. Eur J Radiol. Nov 2003;48(2):188-92. [Medline].

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  16. Martinot A, Closset M, Marquette CH, Hue V, Deschildre A, Ramon P, et al. Indications for flexible versus rigid bronchoscopy in children with suspected foreign-body aspiration. Am J Respir Crit Care Med. May 1997;155(5):1676-9. [Medline].

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Further Reading

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Keywords

foreign body aspiration, aspirated objects, asphyxia, upper airway obstruction, café coronary, acute ventilatory failure, mediastinitis, tracheoesophageal fistula, bronchial obstruction, bronchiectasis, rigid bronchoscopy, flexible bronchoscopy, virtual bronchoscopy, bronchotomy, segmental resection

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Contributor Information and Disclosures

Author

Martin E Warshawsky, MD, FACP, FCCP, Director of Respiratory Intensive Care Unit, Elmhurst Hospital Center; Clinical Assistant Professor, Department of Internal Medicine, Division of Pulmonary and Critical Care, Mount Sinai School of Medicine
Martin E Warshawsky, MD, FACP, FCCP is a member of the following medical societies: Alpha Omega Alpha, American College of Chest Physicians, American College of Physicians, and American Thoracic Society
Disclosure: Nothing to disclose.

Medical Editor

Stephen P Peters, MD, PhD, Professor, Department of Medicine, Wake Forest University
Stephen P Peters, MD, PhD is a member of the following medical societies: American Academy of Allergy Asthma and Immunology, American Association of Immunologists, American College of Chest Physicians, American College of Physicians, American Federation for Medical Research, American Thoracic Society, and Sigma Xi
Disclosure: See below for list of all activities None None

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

Managing Editor

Robert S Crausman, MD, MMS, Chief Administrative Officer, Rhode Island Board of Medical Licensure and Discipline, Rhode Island Department of Health; Associate Professor, Department of Medicine, Brown University School of Medicine
Robert S Crausman, MD, MMS is a member of the following medical societies: American College of Chest Physicians and American College of Physicians
Disclosure: Nothing to disclose.

CME Editor

Timothy D Rice, MD, Associate Professor, Departments of Internal Medicine and Pediatrics and Adolescent Medicine, Saint Louis University School of Medicine
Timothy D Rice, MD is a member of the following medical societies: American Academy of Pediatrics and American College of Physicians
Disclosure: Nothing to disclose.

Chief Editor

Zab Mosenifar, MD, Director, Division of Pulmonary and Critical Care Medicine, Director, Women's Guild Pulmonary Disease Institute, Executive Vice Chair, Department of Medicine, Cedars Sinai Medical Center; Professor of Medicine, David Geffen School of Medicine at UCLA
Zab Mosenifar, MD is a member of the following medical societies: American College of Chest Physicians, American College of Physicians, American Federation for Medical Research, and American Thoracic Society
Disclosure: Nothing to disclose.

 
 
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