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Airway Foreign Body

Henrique M Lederman, MD, PhD, Consulting Staff, Department of Radiology, LeBonheur Children's Medical Center and St Jude Children's Research Hospital; Professor of Radiology and Pediatric Radiology, Chief, Division of Diagnostic Imaging in Pediatrics, Federal University of Sao Paulo, Brazil

Updated: Feb 25, 2009

Introduction

Background

Historically, airway foreign bodies have been a major cause of morbidity and mortality in the United States. Although foreign body aspiration most frequently occurs in children, it happens in adults as well. Foreign body aspiration is commonly referred to as a "café coronary" (elderly adults).1,2,3

Inspiratory chest radiograph in a 12-month-old bo...

Inspiratory chest radiograph in a 12-month-old boy with a 2-month history of wheezing demonstrates moderate hyperlucency and hyperexpansion of the right hemithorax. A mild deviation of the mediastinum toward the left chest is noted. Courtesy of Brit B. Gay, Jr, MD, Radiology Department, Egleston Children's Hospital, Atlanta, Ga.



In the United States, approximately 500-2000 deaths occur each year from foreign body aspiration.4 Despite advances in radiologic techniques, the diagnosis of foreign body aspiration can be difficult, and endoscopy may be required.5,6

For excellent patient education resources, visit eMedicine's Esophagus, Stomach, and Intestine Center and Procedures Center. Also, see eMedicine's patient education articles Choking, Swallowed Object, and Bronchoscopy.

Pathophysiology

Food items are the most commonly aspirated foreign bodies; peanuts are the most frequently aspirated food. Other aspirated foods include carrots, popcorn, and fruit. Commonly aspirated nonfood items include rubber balloons, plastic toys, teeth, and dental appliances.7

The severity of foreign body aspiration depends on whether the airway obstruction is complete or partial. Complete airway obstruction occurs in the airway at levels above the carina; it causes acute onset of respiratory distress in which the patient is unable to speak or cough. Unfortunately, complete airway obstruction may rapidly proceed to death if the foreign body is not immediately dislodged or removed.7

Partial airway obstruction occurs when the airway is partially occluded or if the obstruction occurs distal to the carina. Patients with partial airway obstructions may present weeks to months after the foreign body aspiration, and the condition may be diagnosed because of sequelae, such as recurrent pneumonia, persistent cough, hemoptysis, wheezing, or atelectasis.

Most foreign bodies lodge in the peripheral airways. However, foreign bodies that are large or sharp or that have irregular borders have a greater tendency to become lodged in the larynx or trachea.7

Mortality/Morbidity

  • Estimates indicate that in the United States, foreign body aspiration is fatal in 2000 children each year.8
  • Complications from foreign body aspiration include respiratory distress, asphyxia, cardiac arrest, fever, laryngeal edema, pneumothorax, hemoptysis, pneumonia, bronchiectasis, and bronchial stricture.4

Race

No racial predilection has been reported in the United States.

Sex

For unknown reasons, foreign body aspiration occurs more frequently in boys than in girls, with a male-to-female ratio of 2:1.9

Age

  • Foreign body aspiration is most common in children aged 6 months to 4 years, a time when they are exploring their surroundings and placing objects into their mouth.7
  • Persons with decreased airway protective mechanisms, such as with mental retardation, neurologic disorders, psychoses or alcoholism, also are at risk of aspiration.10

Anatomy

Most foreign bodies become lodged in the right mainstem bronchus. Reasons for this include the following7 :

  • The diameter of the right main bronchus is larger than the left.
  • The angle of divergence from the tracheal axis is smaller on the right.
  • Airflow through the right lung is greater than it is through the left.
  • Upright position at the moment of aspiration will locate the foreign body in the right middle or lower lobe.

Presentation

Foreign body aspiration may appear as an acute onset of respiratory distress, or patients may have a silent presentation manifested by secondary complications. Most patients with foreign body aspiration present with an acute onset of choking, respiratory distress, cyanosis, severe coughing, and wheezing.11 A history of aspiration often is lacking, and patients may present days to weeks after the event. On examination, patients may have stridor, crackles, wheezing, decreased breath sounds in the affected lung, or normal results on pulmonary physical examination.

Typical symptoms of complete airway obstruction that occurs while a person is eating a meal include severe respiratory distress and the inability to speak or cough. Individuals typically place their thumbs and index fingers around their neck.7

Patients with partial airway obstruction may present with a sudden onset of coughing, difficulty in breathing, wheezing, or stridor while eating a meal. Unfortunately, a history consistent with foreign body aspiration is usually available in only 70% of patients. After the acute episode of airway distress, patients may continue to experience episodes of persistent coughing and wheezing, or they may become asymptomatic. Moreover, some patients experience recurrent episodes of pneumonia in the same topographic area. Other patients develop complications, such as hemoptysis, bronchiectasis, and bronchial stricture.4

Preferred Examination

When foreign body aspiration is suspected in a patient, screening radiographic studies employed include anteroposterior (AP) and lateral imaging of the soft tissues of the neck, inspiratory and expiratory posteroanterior (PA) chest radiographs (CXRs), and lateral CXRs. Lateral decubitus chest radiography, fluoroscopy, or both may help in diagnosing foreign body aspiration in patients who are unable to cooperate with inspiratory and expiratory CXRs, such as young pediatric patients. If findings are negative for foreign bodies in all radiographic studies and if the clinical suspicion still remains high, bronchoscopy should be performed in the operating room by an airway endoscopist for definitive diagnosis and treatment.

Limitations of Techniques

Radiopaque foreign bodies are easy to diagnose by using radiographs. With radiolucent foreign bodies, secondary radiographic signs, such as obstructive emphysema, atelectasis, pneumonia, and a mediastinal shift, help in diagnosing foreign body aspiration.12

Differential Diagnoses

Atelectasis, Lobar
Bronchiectasis
Foreign Body Aspiration
Pneumonia, Aspiration

Other Problems to Be Considered

Atelectasis
Bacterial tracheitis
Carcinoma
Croup (laryngotracheobronchitis)
Epiglottitis
Esophageal foreign body
Granuloma
Papilloma
Retropharyngeal abscess
Tracheal mucus

Radiography


Inspiratory chest radiograph in a 12-month-old bo...

Inspiratory chest radiograph in a 12-month-old boy with a 2-month history of wheezing demonstrates moderate hyperlucency and hyperexpansion of the right hemithorax. A mild deviation of the mediastinum toward the left chest is noted. Courtesy of Brit B. Gay, Jr, MD, Radiology Department, Egleston Children's Hospital, Atlanta, Ga.



Expiratory chest radiograph in a 12-month-old boy...

Expiratory chest radiograph in a 12-month-old boy with a 2-month history of wheezing demonstrates continued hyperlucency and hyperexpansion of the right hemithorax. A greater mediastinal shift is noted toward the left lung field. A corn kernel was removed from the patient's right mainstem bronchus during bronchoscopy. Courtesy of Brit B. Gay, Jr, MD, Radiology Department, Egleston Children's Hospital, Atlanta, Ga.



Left lateral decubitus chest radiograph demonstra...

Left lateral decubitus chest radiograph demonstrates failure of collapse in an 11-month-old girl with a 2-week history of persistent coughing. A corn kernel was found in the patient's left mainstem bronchus during bronchoscopy. Courtesy of Brit B. Gay, Jr, MD, Radiology Department, Egleston Children's Hospital, Atlanta, Ga.



Chest radiograph in a 6-year-old boy who complain...

Chest radiograph in a 6-year-old boy who complained of chest pain and dysphagia. Complete atelectasis of the left lung is noted, with a mediastinal shift towards the left lung. Courtesy of Brit B. Gay, Jr, MD, Radiology Department, Egleston Children's Hospital, Atlanta, Ga.



Chest radiograph obtained 2 days after a piece of...

Chest radiograph obtained 2 days after a piece of popcorn was removed from the patient's left mainstem bronchus. Resolution of the atelectasis is complete, and the mediastinum is in its normal position. Courtesy of Brit B. Gay, Jr, MD, Radiology Department, Egleston Children's Hospital, Atlanta, Ga.



Findings

Initial radiographic studies should include AP and lateral views of the soft tissues of the neck, PA CXRs obtained during inspiration and expiration, and lateral CXRs. The depiction of radiopaque foreign bodies is straightforward. Obtaining 2 views of the foreign body helps in determining its location and excludes the presence of superimposed multiple foreign bodies. Most foreign bodies are radiolucent; therefore, indirect radiologic findings must often be obtained.13

  • Radiolucent tracheal foreign bodies may show signs of an infraglottic opacity or of swelling from airway inflammation on PA and lateral neck radiographs.14
  • Patients with bronchial foreign bodies may have normal findings on CXRs; however, the affected lung may show hyperaeration (obstructive emphysema) and shifting of the mediastinum away from the affected lung on expiratory CXRs because of the ball-valve effect of the tracheal foreign body (see Images 1-2). In such cases, the patients can inspire air past the foreign body but have difficulty exhaling.
  • In patients who are unable to cooperate for expiratory imaging (eg, young children), decubitus CXR or fluoroscopy may show hyperaeration and mediastinal shifting. Decubitus CXRs reveal failure of the affected lung to collapse, even if the patient is in the decubitus position (see Image 3).
  • Images in patients with chronic bronchial foreign bodies may show atelectasis, with a mediastinal shift toward the foreign body and/or recurrent pneumonias in the affected lung segment (see Images 4-5).

Degree of Confidence

Plain radiographic results cannot exclude foreign body aspiration. If the clinical suspicion is high for foreign body aspiration, endoscopy should be performed for definitive diagnosis and treatment.

False Positives/Negatives

Svedstr ö m and colleagues studied the accuracy of CXRs in the diagnosis of tracheobronchial foreign bodies.15 Of the 34 patients from whom a foreign body was removed, preoperative CXRs showed airtrapping in 50%, atelectasis in 12%, and signs of infection in 18%. Normal CXR findings were obtained in 24% of patients who had endoscopically verified airway foreign bodies. The authors concluded that the diagnostic accuracy, sensitivity, and specificity of CXRs were 67%, 68%, and 67%, respectively. These results show that CXRs alone are neither sensitive nor specific enough to exclude tracheobronchial foreign bodies.

In their study of patients with laryngotracheal foreign bodies, Esclamado and colleagues reported that 92% of neck radiographs showed an infraglottic density or swelling.14 In contrast, 58% of the patients in their study who had laryngotracheal foreign bodies had normal CXR findings. These results suggest that PA and lateral neck radiographs should be part of the radiographic workup when foreign body aspiration is a concern.

Computed Tomography

Findings

As a result of its greater contrast resolution, computed tomography (CT) scanning has been used to demonstrate airway foreign bodies that are radiolucent on plain radiographs.16 Many authors recommend using narrow windows when imaging the thorax, to decrease the likelihood of missing a foreign body.17,18

In addition to providing plain radiographic findings, such as hyperlucency, atelectasis, and lobar consolidation, CT scans can depict the foreign body within the lumen of the tracheobronchial tree and the 3-dimensional position of the foreign body within the thorax.16,19

Current state-of-the-art helical multidetector-row CT scanners may improve the sensitivity of radiologic evaluation in patients who are unable to cooperate for inspiration and expiration radiography.The use of low-dose mutidetector CT and virtual bronchoscopy may help to detect the foreign body. These scanners may be useful with young children and with adults suffering from an altered level of consciousness.20

Degree of Confidence

If CT scans demonstrate signs of foreign body aspiration, the patient should undergo endoscopy for definitive diagnosis and treatment. No further radiologic study is indicated.

False Positives/Negatives

Any process that causes obstruction or narrowing of the airway lumen can produce signs similar to those of foreign body aspiration. Examples include neoplastic disease, granulomatous disease, bronchial stenosis, and a mucus plug.

Magnetic Resonance Imaging

Findings

Many authors have reported on the use of magnetic resonance imaging (MRI) in identifying aspirated peanuts.12,20,21,22 Using T1-weighted images, these authors demonstrated the presence of peanuts via the direct depiction of the high signal intensity emitted by their fat content surrounded by low-intensity lung tissue. Imaizumi and colleagues reported that peanuts can be clearly distinguished from the surrounding areas of granulation and atelectasis because of their hyperintensity on T1-weighted images.23

The advantages of MRI include its noninvasive nature and the lack of radiation exposure from this modality. MRI also offers high-resolution multiplanar images of soft tissue.12

The disadvantages of MRI include its cost, the long data-acquisition time, the need for sedation in some patients, and the necessity to remove all metallic devices from patients.12

Degree of Confidence

As with all imaging modalities, if clinical suspicion of an airway foreign body remains high, endoscopy should be performed for definitive diagnosis and treatment.

Nuclear Imaging

Findings

Leonidas and colleagues used perfusion lung scans to demonstrate areas of decreased ventilation that resulted from tracheobronchial foreign bodies.24 (Decreased ventilation causes reflex vasoconstriction.)

Degree of Confidence

Perfusion defects, or ventilation-perfusion (V/Q) mismatches, are not specific for the presence of airway foreign bodies. Asthma, tuberculosis, emphysema, pneumonitis, and neoplasms may cause perfusion defects.25 If clinical suspicion for foreign body aspiration is high, further evaluation with endoscopy is warranted.

Intervention

Once an aspirated foreign body is diagnosed by using radiographic findings, or if the clinical suspicion is high, the patient should undergo endoscopy for foreign body removal. Endoscopy should be performed in the controlled setting of an operating room by personnel trained in airway foreign body removal.26,27,28,29

Medicolegal Pitfalls

  • The potential is great for morbidity and mortality resulting from an aspirated foreign body; hence, if foreign body aspiration is suspected, the appropriate radiographic studies should be performed.
  • As a result of the limitations of radiographic studies in the diagnosis of aspirated foreign bodies, all patients in whom the clinical suspicion for aspirated foreign bodies is high should undergo endoscopy for definitive diagnosis and treatment.

Multimedia

Inspiratory chest radiograph in a 12-month-old bo...

Media file 1: Inspiratory chest radiograph in a 12-month-old boy with a 2-month history of wheezing demonstrates moderate hyperlucency and hyperexpansion of the right hemithorax. A mild deviation of the mediastinum toward the left chest is noted. Courtesy of Brit B. Gay, Jr, MD, Radiology Department, Egleston Children's Hospital, Atlanta, Ga.

Expiratory chest radiograph in a 12-month-old boy...

Media file 2: Expiratory chest radiograph in a 12-month-old boy with a 2-month history of wheezing demonstrates continued hyperlucency and hyperexpansion of the right hemithorax. A greater mediastinal shift is noted toward the left lung field. A corn kernel was removed from the patient's right mainstem bronchus during bronchoscopy. Courtesy of Brit B. Gay, Jr, MD, Radiology Department, Egleston Children's Hospital, Atlanta, Ga.

Left lateral decubitus chest radiograph demonstra...

Media file 3: Left lateral decubitus chest radiograph demonstrates failure of collapse in an 11-month-old girl with a 2-week history of persistent coughing. A corn kernel was found in the patient's left mainstem bronchus during bronchoscopy. Courtesy of Brit B. Gay, Jr, MD, Radiology Department, Egleston Children's Hospital, Atlanta, Ga.

Chest radiograph in a 6-year-old boy who complain...

Media file 4: Chest radiograph in a 6-year-old boy who complained of chest pain and dysphagia. Complete atelectasis of the left lung is noted, with a mediastinal shift towards the left lung. Courtesy of Brit B. Gay, Jr, MD, Radiology Department, Egleston Children's Hospital, Atlanta, Ga.

Chest radiograph obtained 2 days after a piece of...

Media file 5: Chest radiograph obtained 2 days after a piece of popcorn was removed from the patient's left mainstem bronchus. Resolution of the atelectasis is complete, and the mediastinum is in its normal position. Courtesy of Brit B. Gay, Jr, MD, Radiology Department, Egleston Children's Hospital, Atlanta, Ga.

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Keywords

airway foreign body, foreign body aspiration, aspiration, airway obstruction, choking, café coronary, airway obstruction

Contributor Information and Disclosures

Author

Henrique M Lederman, MD, PhD, Consulting Staff, Department of Radiology, LeBonheur Children's Medical Center and St Jude Children's Research Hospital; Professor of Radiology and Pediatric Radiology, Chief, Division of Diagnostic Imaging in Pediatrics, Federal University of Sao Paulo, Brazil
Henrique M Lederman, MD, PhD is a member of the following medical societies: Society for Pediatric Radiology
Disclosure: Nothing to disclose.

Medical Editor

Lori Lee Barr, MD, FACR, FAIUM, Clinical Associate Professor of Radiology, University of Texas Health Science Center in San Antonio; Clinical Assistant Professor of Radiology, University of Texas Medical Branch at Galveston; Member, Board of Directors, Austin Radiological Association; Consulting Staff, Seton Health Network, Columbia/St David's Healthcare System, Healthsouth Rehabilitation Hospital of Austin, Georgetown Hospital, St Mark's Medical Center, Cedar Park Regional Medical Center
Lori Lee Barr, MD, FACR, FAIUM is a member of the following medical societies: American Association for Women Radiologists, American College of Radiology, American Institute of Ultrasound in Medicine, American Roentgen Ray Society, American Society of Pediatric Neuroradiology, Association of University Radiologists, Radiological Society of North America, Society for Pediatric Radiology, Society of Radiologists in Ultrasound, Southern Medical Association, Texas Radiological Society, and Undersea and Hyperbaric Medical Society
Disclosure: Nothing to disclose.

Pharmacy Editor

Bernard D Coombs, MB, ChB, PhD, Consulting Staff, Department of Specialist Rehabilitation Services, Hutt Valley District Health Board, New Zealand
Disclosure: Nothing to disclose.

CME Editor

Robert M Krasny, MD, Consulting Staff, Department of Radiology, The Angeles Clinic and Research Institute
Robert M Krasny, MD is a member of the following medical societies: American Roentgen Ray Society and Radiological Society of North America
Disclosure: Nothing to disclose.

Chief Editor

John Karani, MBBS, FRCR, Consulting Staff, Department of Radiology, King's College Hospital, London
Disclosure: Nothing to disclose.

Acknowledgments

Ramone Toliver, MD, and Soheil Hanna, MBBCh, are gratefully acknowledged for contributions made to this article.

Further Reading

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Airway Foreign Body (from Pediatrics: General Medicine)

Foreign Body Aspiration

Foreign Bodies, Trachea

Foreign Bodies, Nose

Guidelines

 Modifications in Endoscopic Practice for Pediatric Patients 
 

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