Foreign Body Aspiration Treatment & Management

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.

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.

Rigid bronchoscopy

Rigid bronchoscopy is the procedure of choice for removing foreign bodies in children and in most adults. 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. 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.

If the foreign body is quickly and easily removed before mucosal alterations, atelectasis, emphysema, or suppurative complications set in and if the patient is asymptomatic, no further inpatient care should be necessary. Observing patients for 1-2 days postextraction may be appropriate, in case complications from impaction or extraction arise. Noncardiogenic reexpansion pulmonary edema, airway inflammation, hemoptysis, pneumothorax, tracheoesophageal fistula, pneumonia, atelectasis, fever, or ventilatory failure may require continued hospitalization, including ICU monitoring, intubation, mechanical ventilation, repeated bronchoscopic procedures (eg, directed suctioning of inspissated pus, laser therapy of bleeding, obstructing granulation tissue or polyps), antibiotics, corticosteroids, bronchodilators, or chest physical therapy.

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.

D’Souza et al conducted a retrospective chart review of children 18 years of age and younger who underwent a rigid bronchoscopy with retrieval of airway foreign bodies. Of 64 cases, 69% involved aspiration of nuts. Most of the cases involved children younger than 3years. The authors concluded that nuts should be slowly introduced to the diets of children after they reach 3 years of age. ^[1]

Pay attention to the size and texture of foods and objects available to children and adults with impaired mentation or ability to protect the airway (eg, impaired chewing, swallowing, coughing). Removal of appliances prior to manipulation of the teeth or airway is essential. Note the condition of medical equipment at the beginning and end of procedures involving the pharynx, larynx, respiratory tract, or digestive tract. Sedatives and topical anesthetics increase the risk for aspiration; therefore, use them sparingly. Oral pierced jewelry should be removed prior to general anesthesia, emergency airway management, or other such manipulation of the oral pharynx because of the risk of dislodgement and aspiration. ^[19]