Foreign body aspiration (FBA) is a potentially life-threatening emergency that most commonly occurs in children aged 1–3 years. FBA typically manifests with sudden onset of coughing and choking, followed by stridor and dyspnea. Obstruction of the larynx or trachea is a potentially life-threatening situation that causes severe respiratory distress, cyanosis, and suffocation. Most commonly, the foreign body (FB) becomes lodged in the main and intermediate bronchi; approx. 60% of FB are located in the right main bronchus due to the more vertical orientation compared to the left main bronchus. Partially obstructed airways result in the formation of a ball-valve obstruction, in which air trapping occurs in the lung segments distal to the obstruction. This focal hyperinflation of the lung segments are detectable on x-ray as hyperlucency and reduced pulmonary marking. Complete obstruction results in atelectasis distal to the FB. The FB should be removed via bronchoscopy as soon as possible. If an FBA remains undetected, it may result in chronic cough and recurrent pulmonary infections.
- 80% of cases occur in children < 3 years
- Peak incidence: 1–2 years
Epidemiological data refers to the US, unless otherwise specified.
- Aspiration of a FB (e.g., nuts, raisins, coins, pieces of toys)
- Often occurs when children speak, laugh, or play while chewing; toddlers are also prone to examining objects with their mouth, so that a sudden inspiration can result in aspiration.
- Aspiration of a FB → airway obstruction
- Upper airway obstruction: a minority of FB are lodged in the larynx or trachea
Bronchi: the right main bronchus is more often affected than the left main bronchus
- Aspirated particles are most likely to become lodged at the junction of the right inferior and right middle bronchi → right lower and middle lobe aspiration pneumonia
- Upper right lobe affected in bedridden patients, particularly while lying on their right side.
- In children, the two main bronchi are affected with more similar frequency than in adults; however, there still a slight right-sided predominance.
- Less severe than upper airway obstructions
- Immediate symptoms
- Diminished breath sounds on the affected side
- On inspiration: indicates laryngotracheal localization
- On expiration: indicates bronchial localization
- Hyper-resonance on the affected side in partial obstruction
- Late symptoms: days or weeks later if the initial aspiration and choking episode is not witnessed
- Bronchial asthma, acute obstructive bronchitis:
The differential diagnoses listed here are not exhaustive.
|Life-threatening FBA (respiratory distress)|| |
|Stable patients with suspected FBA|
- Chest x-ray
- CT (nearly 100% sensitivity): if x-ray is inconclusive
- Bronchoscopy: if imaging is inconclusive but there is a high clinical suspicion of FBA
- In alert patients, encourage coughing to dislodge FB
- : if the patient is unable to speak or cry
- Intubation: Attempt to mobilize FB via endotracheal tube
- Emergency tracheotomy may be required
Removing the foreign body
- Bronchoscopy (gold standard)
- In rare cases, surgical removal may be necessary
Life-threatening asphyxiation or signs of impending airway compromise
- Administer chest blows and/or abdominal thrusts.
- Emergency anesthesia and/or ENT consult
- Airway management
- Consider advanced imaging to better locate the foreign body.
- Pulmonary consultation for rigid or flexible bronchoscopy
- Postobstructive pneumonia, lung abscess
- In complete obstruction:
We list the most important complications. The selection is not exhaustive.