A mother brings her 14 month old son into the urgent care clinic with complaints of choking and gagging after eating potato chips 15-20 minutes ago at his grandmother's house. His mother is unsure if he had eaten anything else with the potato chips and does not think the child turned blue during the choking and gagging episode. He returned to his normal activity shortly after the episode occurred, but since then, he has had a few intermittent coughing spells. The patient has two older siblings who are still at the grandmother's house.
Exam: VS T 37.2, P 103, R 28, BP 98/55, O2 saturation 96% in RA, height/weight/head circumference are all 25-50%ile. He is walking around the exam room in no acute distress. He has a normal physical exam except for an occasional low-pitched, monophonic expiratory wheeze heard best over the sternal notch.
A CXR is obtained which appears normal. Since end exhalation films were unable to be obtained, decubitus films were performed. The right lateral decubitus film (right side down) shows air trapping on the right as evidenced by failure of the mediastinum to shift toward the dependent side. A pediatric surgery consult is obtained and they take the child to the OR for rigid bronchoscopy. They find a whole sunflower seed in the right main stem bronchus and remove it. The child is then hospitalized overnight for observation and chest physiotherapy (CPT) that is ordered for atelectasis seen on a post-op film. Upon arrival of the patient's grandmother to the hospital, further history elicited from her is significant for the older siblings eating sunflower seeds. The patient is discharged the next morning with follow up scheduled with his pediatrician in the next few days.
Foreign body aspiration is a very serious, often life-threatening, condition. According to the 1998 National Safety Council statistics for the United States, 3% of all unintentional deaths among children (<15 years old) were secondary to the inhalation/ingestion of food or objects (IOFO) (1). In fact, 5% of all IOFO deaths occur in this age group. IOFO is the 5th leading cause of death in the United States and Hawaii for all age groups (1). Of children younger than 15 years, toddlers seem to be the most vulnerable for foreign body aspiration (77% of deaths) (1). Some reasons for this are related to their developmental age such as: 1) exploration of their environment by putting objects into their mouths; 2) learning to walk and run; 3) inadequate dentition; 4) immature swallowing coordination; and 5) supervision by an older sibling. Baharloo, et al, found that 91% of foreign bodies aspirated by children (<8 years old) were organic in nature with peanuts accounting for 54% of that number (2). Meat (especially hot dogs) and other types of nuts are also frequently found on bronchoscopy. They also found that children, unlike adults, did not have a significant difference between the foreign body being found in the right or left bronchial tree (2). This may be explained by the fact that children have symmetric bronchial angles until about 15 years of age. At that time, the aortic knob has developed fully, causing the left mainstem bronchus to be displaced, which creates a more obtuse angle at the carina favoring the right mainstem for a foreign body (3).
There are three distinct clinical phases that occur after a foreign body is aspirated (4). The first phase occurs immediately following the incident. The patient will usually experience choking, gagging, coughing, wheezing, and/or stridor. There may also be an associated temporary cyanotic episode, usually perioral. The occurrence of death is very high during this first phase of aspiration. The second phase is the asymptomatic period that can last from minutes to months following the incident. The duration of this period depends on the location of the foreign body, the degree of airway obstruction, and the type of material aspirated. The ease with which the foreign body can change its location is also a factor in the duration of this period. The third clinical phase is the renewed symptomatic period. Airway inflammation or infection from the foreign body will cause symptoms of cough, wheezing, fever, sputum production, and occasionally, hemoptysis.
There are several conditions that could mimic an aspirated foreign body. Some of these illnesses are: asthma, croup, pneumonia, bronchitis, tracheomalacia, bronchomalacia, vocal cord dysfunction, or psychogenic cough (4).
The diagnosis and treatment of an aspirated foreign body depends on which clinical phase the patient has on presentation. History, as always, is the best determinant of how suspicious one should be of a potential aspiration. However, this is often complicated by the fact that the event may be unwitnessed, witnessed by a person not present for history taking, or witnessed by an older sibling who may have had a role in the aspiration and chooses not to say anything. On physical exam, the classic findings consist of cough, unilateral decreased breath sounds, and unilateral monophonic wheezing. Although 75% of patients have one or more of these findings, only 40% have all three (5). If stridor (inspiratory and/or expiratory), aphonia, or hoarseness is present, the foreign body is most likely in the larynx or cervical trachea. The usefulness of diagnostic imaging is variable. Since most foreign bodies are not radiopaque, one must rely on indirect findings suggestive of the presence of a foreign body such as: mediastinal shift, atelectasis, and hyperinflation. It has been reported that imaging studies have a sensitivity of 73% and a specificity of 45%, however, up to 20% of patients will have both negative history and radiographic evaluation (6).
For patients who present early, radiographic studies must look for evidence of air trapping. Some clinicians have been taught to look for asymmetry on an expiratory view. However, many foreign body aspirations involve both main stem bronchi or the foreign body is in the trachea. Thus, asymmetry is not seen in these instances. Identification of air trapping is the key. If the expiratory view looks the same as the inspiratory view, this implies bilateral air trapping. Asymmetry suggests unilateral air trapping. Expiratory views rely on timing, so these are sometimes deceiving (an "expiratory view" could have been really taken during inspiration). Decubitus views may be more reliable in this regard. In a lateral decubitus view, the mediastinum should shift downward toward the dependent side. Failure to see this implies air trapping on the dependent side. Thus, if a decubitus view looks the same as an upright inspiratory view, this suggests air trapping on the dependent side.
If the patient presents in the first clinical phase, the family and/or health care professional should be advised to follow the recommendations of the American Academy of Pediatrics and American Heart Association (7). Unless there is a complete airway obstruction, spontaneous coughing and respiration should be the only treatment encouraged. Blind finger sweeps should never be performed in infants or children since this may push the foreign body further downward into the airway. Infants with complete airway obstruction should have back blows and chest thrusts performed while children with complete airway obstruction should have abdominal thrusts performed in either the supine position or by the Heimlich maneuver. Once the patient is brought to the hospital, the patient will require rigid bronchoscopy for visualization of the airway and removal of the foreign body. Flexible bronchoscopy does not have a role in this situation because it is not the optimal tool for control of the foreign body or the safety of the patient during the removal procedure.
The other situation in which patients commonly seek medical attention is usually the third clinical phase. At this point in time, clinical suspicion based on the history, exam, and ancillary studies must be used to determine the appropriate course of action. Patients may present with signs and symptoms of pneumonia. In many such instances, a foreign body is not suspected and the foreign body remains untreated. Such patients return with "recurrent pneumonia" which is actually a pneumonia or atelectasis which has never resolved because the foreign body is still there.
If foreign body aspiration is suspected in this phase, the patient should undergo direct airway visualization by bronchoscopy (flexible or rigid). Even if the patient has expectorated a foreign body, direct visualization is recommended to ensure there are no additional foreign bodies present and to determine if there is any compromise of the airway from inflammation. Medical management (from expectant management to CPT with bronchodilator therapy) should not be done in this situation because the object could become dislodged causing a complete airway obstruction (4). However, once the foreign body is removed, CPT and bronchodilator therapy could help with complications such as atelectasis. If there is airway edema and/or inflammation present on direct visualization, a short course of oral corticosteroids may be useful. Unless there are signs or symptoms of an infection (tracheitis, pneumonia, etc.), antibiotics need not be used.
Complications arising from foreign body aspiration depend on the location and type of foreign body aspirated (organic vs. non-organic, sharp vs. dull), and the duration of time the foreign body remained in the airways. If the foreign body is successfully removed within 24 hours of the incident, the complication rate is very low. However, the longer the foreign body remains in the airways, the more likely inflammation and thus, complications will occur. Potential complications include: bronchial stenosis, bronchiectasis, lung abscess, tissue erosion/perforation, and pneumomediastinum or pneumothorax.
1. True/False: Foreign body aspiration is sufficiently uncommon that it need not be considered in a patient with a chronic cough.
2. Which radiographic imaging study would be the most helpful if a foreign body aspiration is suspected in a child (<3 y.o.)?
. . . . . a. PA
. . . . . b. Inhalation/Exhalation
. . . . . c. Lateral
. . . . . d. Decubitus
3. Describe the three clinical phases of foreign body aspiration.
4. What would be worse to aspirate: organic or non-organic material? Why?
5. True/False: Aspirated foreign bodies in children are more likely to be in the right main-stem bronchus than the left main-stem bronchus.
6. Why should a blind finger sweep never be done in a child with a foreign body aspiration?
7. What physical exam sign/symptom is most suggestive of foreign body aspiration?
. . . . . a. Fever
. . . . . b. Polyphonic wheezing
. . . . . c. Cough
. . . . . d. Stridor
. . . . . e. Monophonic wheezing
8. What physical exam sign/symptom is most worrisome in terms of degree of airway compromise?
. . . . . a. Fever
. . . . . b. Polyphonic wheezing
. . . . . c. Cough
. . . . . d. Stridor
. . . . . e. Monophonic wheezing
9. True/False: Nuts + Choking = Bronchoscopy
Foreign body aspiration case: Boychuk RB. Foreign Body Aspiration in a Child. In: Yamamoto LG, Inaba AS, DiMauro R (eds). Radiology Cases In Pediatric Emergency Medicine, 1994, volume 1, case 8. Available online at: www.hawaii.edu/medicine/pediatrics/pemxray/v1c08.html
Foreign body aspiration case: Feng AK. Recurrent Pneumonia. In: Yamamoto LG, Inaba AS, DiMauro R (eds). Radiology Cases In Pediatric Emergency Medicine, 1995, volume 2, case 7. Available online at: www.hawaii.edu/medicine/pediatrics/pemxray/v2c07.html
Miscellaneous chest x-rays with foreign body aspiration case: Yamamoto LG. Test Your Skill In Reading Pediatric Chest Radiographs. In: Yamamoto LG, Inaba AS, DiMauro R (eds). Radiology Cases In Pediatric Emergency Medicine, 1995, volume 3, case 20. Available online at: www.hawaii.edu/medicine/pediatrics/pemxray/v3c20.html
1. Itasca, IL. National Safety Council: Injury Facts, 2001 Edition. pp. 8-11, 16-18, 30, 152.
2. Baharloo F, Veyckemans F, Francis C, et al. Tracheobronchial Foreign Bodies: Presentation and Management in Children and Adults. Chest 1999;115(5):1357-1362.
3. Rovin JD, Rodgers BM. Pediatric Foreign Body Aspiration. Pediatr Rev 2000;21(3):86-90.
4. Bressler KL, Green CG, Holinger LD. Chapter 27-Foreign Body Aspiration. In: Taussig LM, Landau LI (eds). Pediatric Respiratory Medicine. 1999, Carlsbad: St. Louis: Mosby, pp. 430-435.
5. Cotton RT. Chapter 34-Foreign Body Aspiration. In: Chernick V, Boat TF (eds). Kendig's Disorders of the Respiratory Tract in Children, sixth edition. 1998, Philadelphia: WB Saunders Company, pp. 601-607.
6. Freidman EM. Update on the Pediatric Airway: Tracheobronchial Foreign Bodies. Otolaryngol Clin North Am 2000;33(1):179-185.
7. Chameides L, Hazinski MF (eds). Pediatric Advanced Life Support. 1997, American Heart Association, pp. 3.11-3.13.
8. Brown MA. Personal communication. 2002.
9. Boychuk RB. Foreign Body Aspiration in a Child. Radiology Cases In Pediatric Emergency Medicine, Volume 1, Case 8 (www.hawaii.edu/medicine/pediatrics/pemxray/pemxray.html)
Answers to questions
3. First phase: Acute symptomatic period that immediately follows the incident. May see choking, gagging, coughing, and/or cyanosis. High risk of death. Second phase: Quiescent asymptomatic period. May last minutes to months depending on location, type, and ease of movement of the foreign body. Third phase: Renewed symptomatic period. May see wheezing, chronic cough, fever, hemoptysis. High risk of complication.
4. Organic material is worse to aspirate because it will cause a more intense inflammatory response, thereby increasing the risk for complications. Additionally, most organic material is non-radiopaque making it more difficult to visualize.
5. False. Right and left foreign bodies occur at roughly the same frequency.
6. A blind finger sweep may reposition the foreign body causing a complete airway obstruction.
9. True. Whenever a choking episode occurs while a young child is eating nuts, the risk of foreign body aspiration is high. Bronchoscopy should be highly considered here (9).