Foreign Body Aspiration Treatment & Management
- Author: Martin E Warshawsky, MD, FACP, FCCP; Chief Editor: Zab Mosenifar, MD, FACP, FCCP more...
Acute choking, with respiratory failure associated with tracheal or laryngeal foreign body obstruction, may be successfully treated at the scene with the Heimlich maneuver, back blows, and abdominal thrusts. Even in nonemergency situations, expeditious removal of tracheobronchial foreign bodies is recommended.
Bronchoscopy can be used diagnostically and therapeutically. Most aspirated foreign bodies are radiolucent. Radiologic procedures do not have extreme diagnostic accuracy, and aspiration events are not always detected. Other medical conditions are possible. The presentation may be delayed, and the patient may have been unsuccessfully treated for other conditions.
The presence of a foreign body and its condition, anatomic location (eg, larynx; trachea; main, lobar, or segmental bronchus), shape, composition, position, and extent of entrapment by edema or granulation tissue must be identified prior to extraction attempts. If the foreign body is of a color that might camouflage it within the surrounding mucosa (eg, carrot, rubber pencil eraser) or if the object is completely engulfed by granulation tissue, it may be missed. If it is too distal, the object may not be visualized.
Straight pins (typically aspirated by tailors and seamstresses) can migrate into deep segmental bronchi beyond the visual range of even a flexible bronchoscope.
Rigid bronchoscopy usually requires heavy intravenous sedation or general anesthesia. The rigid bronchoscope has important advantages over the flexible bronchoscope. The larger diameter of the rigid bronchoscope facilitates the passage of various grasping devices, including a flexible bronchoscope. A better chance of quick, successful extraction and better capabilities of suctioning clotted blood and thick secretions are offered by the rigid bronchoscope. The pediatric flexible bronchoscope lacks a hollow working channel through which instruments may be inserted or blood and secretions may be aspirated.
Unlike the flexible bronchoscope, the patient can be ventilated through the rigid scope; therefore, ventilation of the patient can be maintained. Rigid bronchoscopy is the procedure of choice for removing foreign bodies in children and in most adults. Success rates for extracting foreign bodies are reportedly more than 98%. Large solid and semisolid objects are best managed emergently in the operating room with a rigid bronchoscope and appropriate grasping instruments.
Whichever type of bronchoscope is used, practice grasping and manipulating a similar object outside of the body to help reduce the likelihood of shattering the object or of impacting the object to an even less favorable position.
The flexible fiberoptic bronchoscope can be directly inserted into the trachea transnasally or transorally. It can also be inserted into the trachea through a rigid bronchoscope or through a large endotracheal tube. Sedatives can be administered if needed. Small forceps, baskets, and Fogarty balloon catheters can be inserted through the narrow working channel. The instrument offers a limited capability to visualize, grasp, and remove certain foreign bodies of appropriate size, shape, and position. As with rigid bronchoscopy, it is imperative to practice grasping an identical object outside of the body before attempting to manipulate the aspirated object.
While passing the flexible bronchoscope through the larynx via the transnasal route is easier than the transoral route, the latter is preferable if removal of the foreign body is anticipated. Aspirated foreign bodies are too large or rigid to be withdrawn through the flexible bronchoscope and often also cannot be withdrawn through an endotracheal tube. Withdrawal of an exposed foreign body poses the risks of trauma and impaction in the trachea, larynx, or pharynx. Any attempt to withdraw the bronchoscope from the nose with an exposed foreign body tenuously grasped at its tip poses the additional risk of trauma and impaction in the nasal passage.
Despite its limitations, use of the flexible fiberoptic bronchoscope may be necessary in patients with maxillofacial or cervical trauma in whom rigid bronchoscopy is not feasible.
Flexible bronchoscopy can be performed to confirm, localize, and visualize the foreign body in the tracheobronchial tree. The flexible bronchoscope can provide access to subsegmental bronchi beyond that provided by the rigid bronchoscope. If gas exchange is already compromised or if insertion of the flexible bronchoscope would result in significant impairment of gas exchange, flexible bronchoscopy is contraindicated. Diagnostic flexible bronchoscopy prior to rigid bronchoscopy has even been advocated for nonasphyxiating children in whom the diagnosis of foreign body aspiration cannot be confirmed.
Limit use of the flexible bronchoscope for extracting foreign bodies to adult patients who aspirated objects too small to cause total airway obstruction but that can be grasped securely without shattering. Practicing grasping and manipulating a similar object is necessary to avoid shattering or impacting the object in an even less favorable location. The limited ability to achieve and maintain adequate grasp of the intact foreign body makes extraction via flexible bronchoscopy more time consuming and less reliable than via rigid bronchoscopy.
For the same reasons, flexible bronchoscopy also exposes the patient to a greater risk of bleeding, perforation, shattering of the object, and losing the object in the subglottic area or more distal bronchus. With flexible bronchoscopy, the potential exists for a more difficult subsequent extraction, worse airway obstruction, or even asphyxiation.
Whichever technique is used, it is essential to determine that all of the foreign body has been extracted. Objects not successfully removed may fragment and become impacted in bronchi that are more distal. Carefully examine the extracted object for integrity. Inspect the tracheobronchial tree for fragments or other unsuspected foreign bodies.
Inhalation of a bronchodilator followed by postural drainage with chest therapy may be useful in a minority of asymptomatic adult patients and may obviate the need for bronchoscopy. To avoid increasing morbidity, this conservative measure should not delay bronchoscopic extraction by more than 24 hours. If the object is not intact, if multiple foreign body aspiration is suspected, or if concern exists about airway injury, bronchoscopic inspection may still be necessary.
Almost all aspirated foreign bodies can be extracted bronchoscopically. If rigid bronchoscopy is unsuccessful, surgical bronchotomy or segmental resection may be necessary. Chronic bronchial obstruction with bronchiectasis and destruction of lung parenchyma may require segmental or lobar resection.
A pulmonologist or thoracic surgeon with experience in foreign body extraction should immediately perform bronchoscopic inspection and extraction of the object.
An anesthesiologist may be needed to maintain adequate ventilation and control of the upper airway during diagnostic and therapeutic procedures. Rigid bronchoscopy is performed with the patient under general anesthesia or heavy sedation.
An otolaryngologist can evaluate the pharynx and larynx for the presence of a retained foreign body or signs of injury from either aspiration or extraction of the foreign body. If necessary, the otolaryngologist can perform tracheostomy to maintain airway patency.
A speech pathologist can perform a formal swallowing evaluation and prescribe prophylactic measures for patients at risk for foreign body aspiration (eg, patients with potential for impaired swallow reflex).
In order to prevent food aspiration, the diet should be appropriate for the patient's ability to chew and swallow. The size and shape of food bits should be appropriate for the patient's age and the size of the larynx and tracheobronchial tree.
Speaking while eating increases the likelihood of food aspiration. Impaired consciousness also increases the likelihood of aspiration while eating.
Cleveland RH. Symmetry of bronchial angles in children. Radiology. 1979 Oct. 133(1):89-93. [Medline].
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. 1999 Oct. 14(4):792-5. [Medline].
Oke V, Vadde R, Munigikar P, Bhattarai B, Agu C, Basunia R, et al. Use of flexible bronchoscopy in an adult for removal of an aspirated foreign body at a community hospital. J Community Hosp Intern Med Perspect. 2015. 5 (5):28589. [Medline].
Saki N, Nikakhlagh S, Heshmati SM. 25-Year Review of the Abundance and Diversity of Radiopaque Airway Foreign Bodies in Children. Indian J Otolaryngol Head Neck Surg. 2015 Sep. 67 (3):261-6. [Medline].
Mittleman RE, Wetli CV. The fatal cafe coronary. Foreign-body airway obstruction. JAMA. 1982 Mar 5. 247(9):1285-8. [Medline].
National Safety Council, Research and Statistics Department. Injury Facts 2008 Edition. Itasca, Ill: National Safety Council; 2008. 8, 14-15.
Limper AH, Prakash UB. Tracheobronchial foreign bodies in adults. Ann Intern Med. 1990 Apr 15. 112(8):604-9. [Medline].
Tseng HJ, Hanna TN, Shuaib W, Aized M, Khosa F, Linnau KF. Imaging Foreign Bodies: Ingested, Aspirated, and Inserted. Ann Emerg Med. 2015 Aug 27. [Medline].
Capitanio MA, Kirkpatrick JA. The lateral decubitus film. An aid in determining air-trapping in children. Radiology. 1972 May. 103(2):460-2. [Medline].
Berger PE, Kuhn JP, Kuhns LR. Computed tomography and the occult tracheobronchial foreign body. Radiology. 1980 Jan. 134(1):133-5. [Medline].
Adaletli I, Kurugoglu S, Ulus S, et al. Utilization of low-dose multidetector CT and virtual bronchoscopy in children with suspected foreign body aspiration. Pediatr Radiol. 2007 Jan. 37(1):33-40. [Medline].
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. 2003 Nov. 48(2):188-92. [Medline].
Joshi AR, Agrawal NV, Zambre GY, Khandelwal AR. Role of MSCT chest and virtual bronochoscopy in suspected foreign body inhalation. Bombay Hosp J. [Full Text].
Mercier FJ, Bonnet MP. Tattooing and various piercing: anaesthetic considerations. Curr Opin Anaesthesiol. 2009 Jun. 22(3):436-441. [Medline].
Cakir E, Torun E, Uyan ZS, Akca O, Soysal O. An unusual case of foreign body aspiration mimicking cavitary tuberculosis in adolescent patient: Thread aspiration. Ital J Pediatr. 2012 May 11. 38(1):17. [Medline].
Fraser RG, Pare JA, Pare PD. Pulmonary disease caused by aspiration of solid foreign material and liquids. Diagnosis of Diseases of the Chest. 3rd ed. Philadelphia, Pa: WB Saunders; 1990. 2382-416.
Prakash UB, Cortese DA. Tracheobronchial foreign bodies. Bronchoscopy: A Text Atlas. Philadelphia, Pa: Lippincott-Raven; 1997. 253-77.
Warshawsky ME, Shanies HM, Dharawat M, Grochowski S. Endotracheal intubation-induced upper airway obstruction. Heart Lung. 1996 Jan-Feb. 25(1):69-71. [Medline].