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Foreign Body Aspiration Treatment & Management

  • Author: Martin E Warshawsky, MD, FACP, FCCP; Chief Editor: Zab Mosenifar, MD, FACP, FCCP  more...
 
Updated: Dec 31, 2015
 

Medical Care

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

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.

Flexible bronchoscopy

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.

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Surgical Care

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.

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Consultations

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).

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Diet

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.

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Activity

Speaking while eating increases the likelihood of food aspiration. Impaired consciousness also increases the likelihood of aspiration while eating.

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Contributor Information and Disclosures
Author

Martin E Warshawsky, MD, FACP, FCCP Director of Respiratory Intensive Care Unit, Associate Chief, Division of Pulmonary and Critical Care Medicine, Elmhurst Hospital Center; Clinical Assistant Professor, Department of Internal Medicine, Division of Pulmonary, Critical Care, and Sleep Medicine, Icahn School of Medicine at Mount Sinai

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, American Thoracic Society

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Chief Editor

Zab Mosenifar, MD, FACP, FCCP Geri and Richard Brawerman Chair in Pulmonary and Critical Care Medicine, Professor and Executive Vice Chairman, Department of Medicine, Medical Director, Women's Guild Lung Institute, Cedars Sinai Medical Center, University of California, Los Angeles, David Geffen School of Medicine

Zab Mosenifar, MD, FACP, FCCP is a member of the following medical societies: American College of Chest Physicians, American College of Physicians, American Federation for Medical Research, American Thoracic Society

Disclosure: Nothing to disclose.

Additional Contributors

Stephen P Peters, MD, PhD, FACP, FAAAAI, FCCP, FCPP Thomas H Davis Chair in Pulmonary Medicine, Chief, Section on Pulmonary, Critical Care, Allergy and Immunologic Diseases, Professor of Internal Medicine, Pediatrics, and Translational Science, Associate Director, Center for Genomics and Personalized Medicine Research, Wake Forest University School of Medicine; Executive Director of the Respiratory Service Line, Wake Forest Baptist Medical Center

Stephen P Peters, MD, PhD, FACP, FAAAAI, FCCP, FCPP 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, Sigma Xi

Disclosure: Serve(d) as a speaker or a member of a speakers bureau for: Integrity CE, Merck<br/>Received income in an amount equal to or greater than $250 from: – Array Biopharma, AstraZeneca, Aerocrine, Airsonett AB, Boehringer-Ingelheim, Experts in Asthma, Gilead, GlaxoSmithKline, Merck, Novartis, Ono Pharmaceuticals, Pfizer, PPD Development, Quintiles, Sunovion, Saatchi & Saatichi, Targacept, TEVA, Theron.

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