Essential Information
Aspiration of foods or small objects into the airway is a leading cause of death in infants, toddlers, and preschoolers
Common foods include hot dogs, whole grapes, nuts, candies, seeds, popcorn, chewing gum, meat/cheese chunks, peanut butter, and raw vegetables
Common objects include coins, buttons, small toys, balloons, hair accessories, rubber bands, marbles, and pen caps. Of note, button batteries and magnets are especially problematic objects in aspirations/ingestions
Risk factors for aspiration
Children under 3 years of age are at highest risk:
Narrow airways, natural curiosity, underdeveloped swallow, distractible
Children with developmental delay, altered level of consciousness, or dysphagia
Certain foreign body characteristics lead to difficulty with clearance from the airway (e.g., similar to size of the airway, cylindrical, compressible)
Clinical Presentation
Signs and symptoms are highly variable
Usually witnessed aspiration or choking, but not always
Laryngotracheal foreign body: more likely to present with severe respiratory distress, stridor, and hoarseness
Bronchial foreign body: more likely to present with cough, tachypnea, and focal wheeze or decreased air entry. Can also be asymptomatic or have delayed presentation with fever
Foreign body aspirations can mimic other common illnesses: asthma, bronchiolitis, croup, pneumonia
Natural history
Variable courses that depend on location and degree of obstruction. However, without intervention, outcomes carry significant morbidity. Spontaneous clearance with resolution is uncommon
Large laryngotracheal foreign bodies can result in asphyxiation and death
Undiagnosed cases of bronchial foreign bodies can lead to recurrent focal pneumonias, pulmonary abscesses, and bronchiectasis. Similarly, they may present as an “asthmatic with a persistent, focal wheeze”
Diagnosis and Evaluation
History and physical examination are critical for timely diagnosis. Focal pulmonary examination findings should prompt further investigation
Role of testing
Posteroanterior (PA) and lateral chest radiographs
May detect radiopaque objects
Enlarged lung lobe may indicate object with ball valve effect
Atelectatic lung lobe may indicate complete airway obstruction
Findings may be nonspecific
Although historically performed for further evaluation, lateral decubitus chest radiographs may not add significant value
Include neck and abdomen films for foreign body ingestions
Early rigid bronchoscopy for reasonable concern, even if negative radiographs
In cases with low acuity/low suspicion
Flexible bronchoscopy can rule out distal objects
Typically diagnostic, but not therapeutic
Treatment
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In life-threatening cases first, per basic life support guidelines
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Abdominal thrusts (Heimlich maneuver) in older children
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Back blows/chest thrusts in infants
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Supportive therapy: continuous monitoring, supplemental oxygen
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Emergent rigid bronchoscopy with foreign body removal may be necessary if compatible history, examination, or radiographic findings.
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May consider antibiotics if clinical presentation is consistent with concurrent infection
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Preventive policies
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Educate parents: developmentally appropriate toys, safe infant/toddler foods
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Federal legislation: warnings on packages with small parts, size regulations for toys for young children
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AAP recommendations
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<5 years, no gum or hard candy
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Raw vegetables and fruit cut into small pieces
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Supervise children when eating
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Children should sit when eating
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Caregivers should know rescue maneuvers
