eMedicine Specialties > Pulmonology > Aspiration and Atelectasis
Foreign Body Aspiration
Updated: Jun 3, 2008
Introduction
Background
Foreign body aspiration can be a life-threatening emergency. An aspirated solid or semisolid object may lodge in the larynx or trachea. If the object is large enough to cause nearly complete obstruction of the airway, asphyxia may rapidly cause death. Lesser degrees of obstruction or passage of the obstructive object beyond the carina can result in less severe signs and symptoms.
Chronic debilitating symptoms with recurrent infections might occur with delayed extraction, or the patient may remain asymptomatic. The actual aspiration event can usually be identified, although it is often not immediately appreciated. The aspirated object might even escape detection. Most often, the aspirated object is food, but a broad spectrum of aspirated items has been documented over the years. Commonly retrieved objects include seeds, nuts, bone fragments, nails, small toys, coins, pins, medical instrument fragments, and dental appliances.
Geographic differences in the spectrum of objects commonly found in a particular environment and variations in dietary and eating habits affect the relative frequency with which various objects are aspirated.
The following Medscape CME courses may be of interest:
- Diagnosis of Wheezing in Infants and Children Reviewed
- Examining the Ears, Nose, and Oral Cavity in the Older Patient
Additionally, the eMedicine article Airway Foreign Body may be helpful.
Pathophysiology
Near-total obstruction of the larynx or trachea can cause immediate asphyxia and death. Should the object pass beyond the carina, its location would depend on the patient's age and physical position at the time of the aspiration. Because the angles made by the mainstem bronchi with the trachea are identical until age 15 years, foreign bodies are found on either side with equal frequency in persons in this age group.1 With normal growth and development, the adult right and left mainstem bronchi diverge from the trachea with very different angles, with the right mainstem bronchus being more acute and therefore making a relatively straight path from larynx to bronchus. Objects that descend beyond the trachea are more often found in the right endobronchial tree than in the left.
In the series reported by Debeljak et al,2 42 foreign bodies were in the right endobronchial tree, 20 were in the left, and 1 was in the trachea. Once aspirated, objects may subsequently change position or migrate distally, particularly after unsuccessful attempts to remove the object or if the object fragments. The object itself might cause obstruction. Vegetable material may swell over hours or days, worsening the obstruction. Cough, wheeze, stridor, dyspnea, cyanosis, and even asphyxia might ensue. 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. The airway becomes more likely to bleed with manipulation; the object is more likely to be obscured and becomes more difficult to dislodge. Mediastinitis or tracheoesophageal fistulas may result. Distal to the obstruction, air trapping may occur, leading to local emphysema, atelectasis, hypoxic vasoconstriction, postobstructive pneumonia, and the possibility of volume loss, necrotizing pneumonia or abscess, suppurative pneumonia, or bronchiectasis.
Bronchoscopically, the object may appear as a tumor. Even if the object is removed, the inflammatory changes may not be completely reversible. Some investigators believe scar carcinoma may develop over time. The likelihood of complications increases after 24-48 hours, making expeditious removal of the foreign body imperative.
Frequency
International
Most of the literature relates to statistics, diagnosis, and treatment in children younger than 16 years. Literature on foreign body aspiration in adults is limited. Local environments have an important influence on the types of objects aspirated, location in the tracheobronchial tree, and prognosis.
Geographic differences in the spectrum of objects commonly found in a particular environment and variations in dietary and eating habits affect the relative frequency with which various objects are aspirated. The heterogeneity of the populations studied, materials in the environment, and the availability of medical technology influence the reported incidence and prognosis.
Many aspirated foreign bodies are unexpectedly discovered, go undetected, or are misdiagnosed. The often-fatal syndrome of acute asphyxiation from upper airway obstruction associated with eating, known as the café coronary,3 and aspiration of gastric contents are usually not considered with other foreign body aspiration syndromes. For these reasons, the true incidence and prevalence of foreign body aspiration is unknown.
Mortality/Morbidity
According to the National Safety Council, choking remained the fourth leading cause of unintentional injury death in the United States as of 2004. In 2006, a total of 4,100 deaths (1.4 deaths per 100,000 population) from unintentional ingestion or inhalation of food or other objects resulting in airway obstruction was reported.4 The incidence rate was 0.5 deaths per 100,000 population aged 0-4 years. It was lower for adolescents and young adults. The incidence rate then increased steadily with age beginning in the sixth decade (2.6 deaths per 100,000 population aged 65-75 y) and rose rapidly after age 70 years (13.6 deaths per 100,000 population older than 75 y).
The overall risk of death from the café coronary is estimated to be 0.66 deaths per 100,000 people. Even if the patient does not die, symptoms often develop immediately. Morbidity increases if extraction of the object is delayed beyond 24 hours.
Sex
The male-to-female ratio is 2:1, depending on the study.
Age
Children, especially those aged 1-3 years, are at risk for foreign body aspiration because of their tendency to put everything in their mouths and because of the way they chew. Young children chew their food incompletely with incisors before their molars erupt. Objects or fragments may be propelled posteriorly, triggering a reflex inhalation.
Adults who (1) undergo oropharyngeal procedures, (2) have various oral appliances, (3) become intoxicated, (4) receive sedatives, or (5) may have neurological or psychiatric disorders are at increased risk of aspirating foreign bodies.
Because young children and older persons with neurological, cognitive, or psychiatric disorders might not be able to provide their history, diagnosis may be delayed. In Limper and Prakash's 1990 study,5 the median age for adults (ie, patients >16 y) with foreign body aspirations was 60 years, with an age range of 18-88 years. Numerous studies concur that children younger than 16 years account for most cases of foreign body aspiration.
Clinical
History
In the café coronary syndrome, a large object (often poorly chewed meat) lodges in the larynx or trachea, causing nearly complete airway obstruction. Respiratory distress, aphonia, cyanosis, loss of consciousness, and death occur in quick succession unless the object is dislodged. When the degree of obstruction is less severe or when the aspirated object descends beyond the carina, the presentation is less dramatic. Sudden onset of the classic triad (ie, coughing, wheezing, decreased breathing sounds) is frequently not observed.
Presenting symptoms (other than cough) include fever, hemoptysis, dyspnea, and chest pain. A history of a choking episode is not always obtained or may have initially been ignored or misdiagnosed. Most patients or parents can identify a specific episode of choking; however, presentation is often delayed by more than a week. The latency period prior to the onset of symptoms may last months or years if the foreign body is inert bone or inorganic material.
Patients may have been empirically treated for other conditions, even when a choking episode was witnessed. Patients with chronic symptoms may have been erroneously diagnosed as having asthma or chronic bronchitis. Young children and patients with neurologic or psychiatric disorders are at increased risk for aspiration but might not be able to describe symptoms or to report choking episodes.
Other risk factors include institutionalization, old age, poor dentition, and alcohol or sedative use. A presentation of cyanosis, cough, wheeze, incompletely resolved pneumonia, or localized bronchiectasis should raise suspicion of foreign body aspiration, particularly in individuals at risk for foreign body aspiration. Seek information about a history of impaired swallowing, impaired coughing, traumatic loss of consciousness, intoxication, or oropharyngeal surgery.
Physical
A small number of foreign body aspirations are incidentally found after chest radiography or bronchoscopic inspection. Patients may be asymptomatic or may be undergoing testing for other diagnoses. If present, physical findings may include stridor, fixed wheeze, localized wheeze, or diminished breath sounds. If obstruction is severe, cyanosis may occur. Signs of consolidation can accompany postobstructive pneumonia.
Causes
Children are at risk for putting small toys, candies, or nuts into their mouths. Children aged 1-3 years chew incompletely with incisors before their molars erupt, and objects or fragments may be propelled posteriorly, triggering a reflex inhalation.
Among adults, the following conditions, actions, and procedures facilitate foreign body aspiration:
- Impaired swallow reflex
- Impaired cough reflex
- Mental retardation
- Alcohol or sedative use
- General anesthesia
- Poor dentition
- Dental, pharyngeal, or airway procedures
- Altered sensorium
- Loss of consciousness
- Convulsions
- Maxillofacial trauma
Frequently aspirated objects include food (especially nuts and seeds), teeth, dental appliances, and medical instruments. The original event might have been forgotten. Choking with severe dyspnea, leading to respiratory or cardiac arrest while eating, might be initially misdiagnosed as myocardial ischemia.
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Further Reading
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
