OVERVIEW: What every practitioner needs to know
Are you sure your patient has an airway foreign body? What are the typical findings for this disease?
Airway foreign bodies are a common pediatric emergency, but often the child will recover from the initial event with very few residual physical findings. A thorough history and high index of suspicion is required.
There are three primary aspects of the presentation that are important:
History of a coughing or choking event
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Physical findings of unilateral wheezing or unilateral decreased breath sounds
Chest radiographic findings of air trapping (early) or postobstructive pneumonitis (late)
Of these aspects, the history is the most critical. A story of choking or coughing while eating or of having a suspected foreign body in the oral cavity demands further investigation.
What other disease/condition shares some of these symptoms?
Other disease processes share many of the physical findings seen with aspirated airway foreign bodies. These may include:
Bronchiolitis
Pneumonia
Esophageal foreign body
Pneumonia that is recalcitrant or unresponsive to routine treatment
Mediastinal masses or vascular abnormalities causing extrinsic tracheal compression
What caused this disease to develop at this time?
Patient age is a strong determinant in the occurrence of airway foreign bodies. Although it can occur at any age, children aged 1-3 years are the most likely to experience this condition. Generally, a child who is old enough to self-feed or orally explore the environment is at risk. Food, toys, and coins are the most common responsible foreign bodies. Button batteries are an increasing cause and pose a risk for significant morbidity or even death.
Poor parental supervision may contribute, but an airway foreign body can occur in almost any child regardless of the level of supervision or parental vigilance.
The lack of developed molar teeth, which are used to grind more solid food particles, is another important risk factor.
Exposure to inappropriate food for the child’s age is a common risk. Children younger than 4 years should not be given firm foods that require the grinding motion of the molars.
What laboratory studies should you request to help confirm the diagnosis? How should you interpret the results?
Laboratory studies are largely unnecessary for suspected airway foreign bodies. Oxygen saturation monitoring may be helpful in determining the severity of respiratory compromise related to the event.
Monitoring with continuous pulse oximetry should be maintained to watch for increased respiratory distress.
Would imaging studies be helpful? If so, which ones?
Standard anteroposterior (AP) and lateral views of the chest are helpful, but not always necessary, for evaluation of airway foreign bodies. If the history is strong and reliable, rigid bronchoscopy will be necessary even if the chest roentgenogram is normal. This should be kept in mind before routinely ordering films.
When the history and physical examination are less than convincing, inspiratory and expiratory AP/posteroanterior (PA) views of the chest may help to demonstrate air trapping. Unilateral or lobar air trapping in the absence of other known pulmonary disease should be considered an airway foreign body until proved otherwise.
If you are able to confirm that the patient has an airway foreign body, what treatment should be initiated?
Consultation with a pediatric otolaryngologist or a pediatric surgeon (depending on the practice and consultation patterns at the institution) should be obtained on suspecting the diagnosis of an airway foreign body. In the vast majority of cases, rigid bronchoscopy will be necessary to confirm the diagnosis and remove the foreign body.
In some institutions, the department of pediatric pulmonary medicine may remove airway foreign bodies. Some pediatric pulmonologists also perform rigid bronchsoscopy.
The patient should have nothing by mouth for potential general anesthesia administration.
An intravenous line should be started. This is to hydrate the patient who may now be afraid to eat/drink after the coughing/choking episode; it is also used to administer emergency drugs if more acute obstruction occurs and to ease the administration of general anesthesia.
It is generally believed that if the foreign body has been present for more than 24 hours and respiratory status has been stable, it is unlikely that the foreign body will move and cause increased obstructive symptoms.
If the patient is in severe respiratory distress and immediate consultation is not available, endotracheal intubation may be necessary. Severe distress is usually a sign that the foreign body is in the trachea or that multiple foreign body fragments are obstructing both left and right mainstem bronchi.
Intubation may allow positive-pressure ventilation, may bypass the foreign body, or may force the foreign body into a more distal position so that ventilation can be accomplished. This should be attempted as a life-saving effort only when immediate rigid endoscopy is not available.
What are the adverse effects associated with each treatment option?
Choking is a leading cause of death and injury in pediatric patients, especially those younger than 3 years of age. Food, toys, and coins are the most common responsible foreign bodies. The goal is prompt recognition and treatment. Rigid bronchoscopy with removal of the foreign body is the treatment of choice.
If a foreign body has been present for some time and is particularly apt to produce inflammation (food, especially peanuts), and obstructive infection is present in the distal airway, treatment with broad spectrum intravenous antibiotics is warranted. Intravenous steroids may also be beneficial in reducing airway inflammation and reactivity. This treatment can be instituted before bronschoscopy and may be continued after successful removal.
There are some cases in which complete removal is not possible with the initial procedure because of significant airway edema and inflammation. In these cases, patients may require repeated bronchoscopy until it is ensured that the entire foreign body has been removed. Patients may often remain hospitalized for antibiotic and corticosteroid therapy until repeated bronchoscopy is performed.
Bronchial or tracheal perforation or laceration during removal is a rare but is a potential and possibly catastrophic complication of bronchoscopy and foreign body removal. Mediastinitis, pneumomediastinum, and pneumothorax are possible. Penetration of the trachea can also result in penetration of adjacent vascular structures with catastrophic complications.
Button batteries are an increasing cause of airway and esophageal foreign bodies. This increase is due to increased use of these alkaline cells in small electronic devices and the ubiquitous nature of these devices. These batteries are also increasingly used in small toys and the security of the battery in the toy or device may not be optimal. When lodged anywhere in the upper aerodigestive tract these represent a surgical emergency! The primary damage caused by the battery is most likely to be caused by residual electrical energy, even when the battery is otherwise thought to have lost its charge. Prompt removal is crucial, but monitoring of ongoing injury is necessary even after removal because apparent tissue damage may progress.
What are the possible outcomes of an airway foreign body?
The prognosis after removal of the foreign body is excellent. Complete recovery within a short time frame is generally expected.
Complications of rigid bronchoscopy with foreign body removal include injury to the teeth or gums, sore throat, injury to the glottis or vocal folds, and injury to the trachea or bronchi. Bronchial and tracheal laceration are rare but possible.
Foreign bodies that are sharp or have sharp edges can pose significant difficulty for even the experienced bronchoscopist. Pins, thumbtacks, and screws are not uncommon and require significant skill in removal. These types of foreign bodies are, not surprisingly, the most common associated with tracheal or bronchial injury.
Pneumothorax or pneumomediastinum are possible, and special precautions are warranted. Partially or fully obstructive foreign bodies may cause air trapping in distal airways, which is promoted by positive-pressure ventilation. For this reason, spontaneous breathing during the procedure is ideal. Topical anesthesia of the glottis and trachea makes this easier.
Proper communication with the anesthesia team and appropriate planning before the procedure can improve safety and reduce complications.
In rare cases, the foreign body cannot be removed or cannot be safely removed by rigid bronchoscopy. In these cases, thoracotomy and direct removal may be necessary. Pulmonary lobectomy may be required but is unusual.
What is the evidence?
“Committee on Injury, Violence, and Poison Prevention. Prevention of choking among children”. Pediatrics. vol. 125. 2010. pp. 601-7.
Litovitz, T, Whitaker, N, Clark, L, White, NC, Marsolek, M. “Emerging battery-ingestion hazard: clinical implications”. Pediatrics. vol. 125. 2010. pp. 1168-1177.
Yoshikawa, T, Asai, S, Takekawa, Y, Kida, A, Ishikawa, K. “Experimental investigation of battery-induced esophageal burn injury in rabbits”. Crit Care Med. vol. 25. 1997. pp. 2039-2044.
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