Foreign Bodies of the Airway Treatment & Management
- Author: Alan D Murray, MD; Chief Editor: Arlen D Meyers, MD, MBA more...
Patients with complete airway obstruction require immediate medical attention and typically are aphonic and unable to breathe. Patients who are coughing, gagging, and vocalizing have partial obstruction.
Use of the Heimlich maneuver has improved the mortality rate of patients with complete airway obstruction, but use of it in patients with partial obstruction may produce complete obstruction.
Most patients who arrive at the hospital are beyond the acute stage and are not in respiratory distress.
After a complete history and physical examination are completed and radiographic studies are performed, a decision is made in regard to the need for surgical intervention.
In most cases, antibiotics and steroids are not administered initially.
An operating room well equipped with proper endoscopic equipment of various sizes, personnel familiar with the use of the instrumentation, and anesthesiologists experienced in foreign body removal are critical for safe removal of airway foreign bodies.
Select and organize age-appropriate endoscopic equipment before the patient enters the operating room. Various foreign body forceps should be available for use, and a similar object should be available for comparison. Communication between the endoscopist and anesthesiologist before the procedure to outline a plan of action is critical. Prior to surgical intervention in patients who are not in respiratory distress, the patient should remain on nothing by mouth (NPO) status for an adequate period to prevent aspiration.
Use inhalational anesthetics to anesthetize patients. Apply 1-2% lidocaine to the larynx to reduce reflexes and prevent laryngospasm. Keep patients spontaneously breathing throughout the procedure for control of the airway.
With laryngeal foreign bodies, use an insufflation catheter through the nose with the tip in the hypopharynx to maintain anesthesia and oxygenation. The laryngoscope tip is placed in the vallecula for exposure, and the foreign body is visualized in the larynx and removed with appropriate foreign body forceps. After removal, reassess the larynx for other foreign bodies. Perform rigid bronchoscopy afterward to assess for other foreign bodies in the lower airway.
In tracheobronchial foreign body removal, the bronchoscope is inserted into the airway after exposure to the larynx, and continuous ventilation of the patient is provided through the bronchoscope. In a patient with a bronchial foreign body, the unaffected side is examined first. The bronchoscope then is placed immediately above the foreign body. Secretions are gently suctioned around the object. The patient is oxygenated with 100% oxygen before any attempt at removal. The forceps are placed through the bronchoscope, and the object is grasped after complete visualization of the foreign body. The bronchoscope is advanced to the foreign body while the surgeon continues to grasp the object. The foreign body, foreign body forceps, and bronchoscope are removed as a unit, and the bronchoscope immediately is returned to the airway for ventilation and reassessment for other foreign bodies.
Occasionally, easy retrieval of the foreign body is not possible. Larger objects unable to pass through the larynx can be broken into pieces and removed. If the object cannot pass through the larynx, a tracheotomy can be performed to remove the object through the tracheostoma. At times, the object becomes embedded into the surrounding mucosa because of edema caused by the object or because of multiple failed attempts at removal. In this situation, stop and to wait 48-72 hours to allow the edema to subside for a repeat attempt at removal. Thoracotomy may be necessary when the object stays embedded after failed endoscopic attempts.
Foreign bodies in the distal bronchial segments may be removed with the use of a Fogarty endovascular catheter through the suction port of a rigid bronchoscope. Flexible bronchoscopy as an adjunct may be beneficial in the removal of distal objects.
Sharp objects are extremely challenging for endoscopic removal. The pointed end tends to engage in the mucosa, causing the object to tumble with the point trailing. Pointed objects tend to be bendable or breakable. The bronchoscope is placed into the airway, and, using foreign body forceps, the pointed end of the object is disengaged from the mucosa, moved distally, and then removed. Pin-bending forceps may be used in certain situations. Safety pin removal is uniquely challenging; removal is performed endoscopically by sheathing the pointed end into the endoscope and locking the keeper outside the endoscope. Open removal by thoracotomy may be necessary when the sharp object is severely embedded into the mucosa.
The use of steroids or racemic epinephrine is not necessary when age-appropriate endoscopes are used. Antibiotics typically are not prescribed because the source of infection has been removed. Chest physiotherapy is performed after foreign body removal to help remove secretions. Patients are discharged when fully awake and breathing comfortably without the need for supplemental oxygen. Chest radiographs are performed postoperatively if the patient's signs and symptoms persist or worsen.
Follow-up care is necessary if the patient's signs and symptoms return after discharge. For excellent patient education resources, see eMedicineHealth's patient education article Bronchoscopy.
Most complications are the result of a delay in diagnosis.
Of patients with laryngotracheal foreign bodies, 67% experience associated complications when the removal delay is more than 24 hours.
Pneumonia and atelectasis are the most common complications secondary to and after removal of bronchial foreign bodies.
Bleeding can occur from granulation tissue surrounding the foreign body or erosion into a major vessel.
Pneumothorax and pneumomediastinum can result from an airway tear.
A study by Kinoshita et al found that patients who, in the presence of a bystander, choked on a foreign body during a meal and became unresponsive or unconscious had a better neurologic outcome if the bystander performed chest compressions. The study, which included 138 patients who became unresponsive or unconscious due to foreign body airway obstruction, also found better outcomes among patients who did not suffer cardiopulmonary arrest during this episode. However, attempts to remove the foreign object from the patient before emergency medical technicians arrived were reported not to improve outcome.
Future and Controversies
Literature describes other means of foreign body removal. Chest physiotherapy and bronchodilators have been suggested in the past but are not currently recommended as treatment. Some have advocated flexible bronchoscopic removal of all foreign bodies in children, but poor airway control and the need for the immediate availability of rigid endoscopic equipment limit its use as an exclusive intervention.
Predictive models using computerized scoring systems may help in more specifically identifying those children with and without foreign body aspiration. Simulation training may aid in preparation of future otolaryngologists involved with foreign body removal in children.
Bloom DC, Christenson TE, Manning SC, et al. Plastic laryngeal foreign bodies in chidren: A diagnostic challenge. Int J Pediatr Otorhinolaryngol. 2005. 69:657-662.
Brown JC, Chapman T, Klein EJ, Chisholm SL, Phillips GS, Osincup D, et al. The utility of adding expiratory or decubitus chest radiographs to the radiographic evaluation of suspected pediatric airway foreign bodies. Ann Emerg Med. 2013 Jan. 61(1):19-26. [Medline].
Behera G, Tripathy N, Maru YK, et al. Role of virtual bronchoscopy in children with a vegetable foreign body in the tracheobronchial tree. J Laryngol Otol. 2014 Dec. 128(12):1078-83. [Medline].
Holinger LD. Management of sharp and penetrating foreign bodies of the upper aerodigestive tract. Ann Otol Rhinol Laryngol. 1990 Sep. 99(9 Pt 1):684-8. [Medline].
Kinoshita K, Azuhata T, Kawano D, et al. Relationships between pre-hospital characteristics and outcome in victims of foreign body airway obstruction during meals. Resuscitation. 2015 Mar. 88:63-7. [Medline].
Kadmon G, Stern Y, Bron-Harlev E, Nahum E, Battat E, Schonfeld T. Computerized scoring system for the diagnosis of foreign body aspiration in children. Ann Otol Rhinol Laryngol. 2008 Nov. 117(11):839-43. [Medline].
Black RE, Johnson DG, Matlak ME. Bronchoscopic removal of aspirated foreign bodies in children. J Pediatr Surg. 1994 May. 29(5):682-4. [Medline].
Chatterji S, Chatterji P. The management of foreign bodies in air passages. Anaesthesia. 1972 Oct. 27(4):390-5. [Medline].
Cohen S, Avital A, Godfrey S, Gross M, Kerem E, Springer C. Suspected foreign body inhalation in children: what are the indications for bronchoscopy?. J Pediatr. 2009 Aug. 155(2):276-80. [Medline].
Deutsch ES, Dixit D, Curry J, et al. Management of aerodigestive tract foreign bodies: innovative teaching concepts. Ann Otol Rhinol Laryngol. 2007 May. 116(5):319-23. [Medline].
Esclamado RM, Richardson MA. Laryngotracheal foreign bodies in children. A comparison with bronchial foreign bodies. Am J Dis Child. 1987 Mar. 141(3):259-62. [Medline].
Holinger PH. Foreign bodies of the air and food passages. Trans Am Acad Ophthalmol Otolaryngol. 1966.
Inglis AF Jr, Wagner DV. Lower complication rates associated with bronchial foreign bodies over the last 20 years. Ann Otol Rhinol Laryngol. 1992 Jan. 101(1):61-6. [Medline].
McGuirt WF, Holmes KD, Feehs R, Browne JD. Tracheobronchial foreign bodies. Laryngoscope. 1988 Jun. 98(6 Pt 1):615-8. [Medline].
Mu L, He P, Sun D. Inhalation of foreign bodies in Chinese children: a review of 400 cases. Laryngoscope. 1991 Jun. 101(6 Pt 1):657-60. [Medline].
Murray AD, Mahoney EM, Holinger LD. Foreign bodies of the airway and esophagus. Cummings, et al. (eds). Otolaryngology-Head and Neck Surgery. (ed 3). St. Louis, MO: 1998. Vol 5: p 377.
Murray AD, Walner DL. Methods in instrumentation for removal of airway foreign bodies. Operative Techniques in Otolaryngology-Head and Neck Surgery. 2002 March. 0(1):2-5.
Ritter F. Questionable methods of foreign body treatment. Ann Otol Rhinol Laryngol. 1974;83:729.
Shah RK, Patel A, Lander L, Choi SS. Management of foreign bodies obstructing the airway in children. Arch Otolaryngol Head Neck Surg. 2010 Apr. 136(4):373-9. [Medline].
Svedstrom E, Puhakka H, Kero P. How accurate is chest radiography in the diagnosis of tracheobronchial foreign bodies in children?. Pediatr Radiol. 1989. 19(8):520-2. [Medline].
Swanson KL, Prakash UB, Midthun DE, et al. Flexible bronchoscopic management of airway foreign bodies in children. Chest. 2002 May. 121(5):1695-700. [Medline].