Foreign Bodies of the Airway Treatment & Management

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.^[2]

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, visit eMedicine's Procedures Center. Also, see eMedicine'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.

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.^[3] Simulation training may aid in preparation of future otolaryngologists involved with foreign body removal in children.