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Foreign body aspiration

Last updated: May 6, 2021

Summarytoggle arrow icon

Foreign body aspiration (FBA) is a potentially life-threatening emergency that most commonly occurs in children 1–3 years of age. A foreign body (FB) can become lodged in either the upper or lower airway and cause either a partial or complete airway obstruction. Complete obstruction of the larynx or upper trachea is a potentially life-threatening situation that causes severe respiratory distress, cyanosis, and suffocation; it should be managed with first-aid maneuvers (e.g., CPR in unresponsive patients or maneuvers to dislodge an aspirated FB in responsive patients) and, if needed, emergency airway procedures for FBA. Partial obstructions that do not cause significant respiratory distress can be removed via laryngoscopy, nasal endoscopy, or bronchoscopy if coughing fails to dislodge the FB. Lower airway FBA typically manifests with sudden-onset coughing and choking, followed by wheeze and dyspnea. Most commonly, the FB becomes lodged in the main and intermediate bronchi; approx. 60% of foreign bodies become lodged in the right main bronchus because of its more vertical orientation compared to the left main bronchus. If initial maneuvers fail to dislodge the FB and the patient is stable, imaging (e.g., x-ray of the neck or chest, CT chest, bronchoscopy) to localize the FB should be obtained, followed by a planned removal of the aspirated FB. If an FB remains undetected, it may result in chronic cough and recurrent pulmonary infections.

  • Pediatric
    • 80% of all cases occur in children < 3 years. [1]
    • Peak incidence: 1–2 years
  • Adult
    • FBA accounts for 0.16–0.33% of adult bronchoscopies. [2]
    • Incidence: rises with age [3]
    • Mortality rate: highest in patients 80–90 years of age [4]

Epidemiological data refers to the US, unless otherwise specified.

  • Children and infants [5]
    • Aspiration of a FB (e.g., of nuts, raisins, coins, toys) while chewing
    • The risk of aspiration is higher if the infant or child is speaking, laughing, or playing while chewing.
    • Toddlers are prone to examining objects with their mouth, and a sudden inspiration can result in aspiration. [1]
  • Adults
  • Aspiration of an FBairway obstruction
    • Complete airway obstruction → collapse of the respiratory structures distal to the obstruction (e.g., atelectasis)
    • Partial airway obstruction: formation of a ball-valve obstruction with air trappingbuild-up of pressure distal to the obstruction
  • Localization
    • 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 similar frequency (compared to adults); however, there is still a slight right-sided predominance.
      • Less severe than upper airway obstructions

Approximately 60% of foreign bodies become lodged in the right main bronchus because of its more vertical orientation compared to the left main bronchus.

References:[6][7]

Clinical features depend on the degree of airway obstruction and the duration of time since aspiration of the FB. See also “Upper airway FB obstruction” and “Lower airway FB obstruction” for differentiating features. [8]

Clinical features in FBA
Complete airway obstruction [9] Partial airway obstruction Chronic FB airway obstruction
  • Symptom onset may occur days or weeks later
  • Persistent or recurrent cough
  • Purulent or mucopurulent sputum [2]
  • Wheeze
  • Fever

Findings can change as organic foreign bodies absorb water and swell in the lung, converting a partial obstruction into a complete one. [6]

The differential diagnoses listed here are not exhaustive.

In patients with signs of life-threatening airway obstruction, immediately initiate critical interventions such as first aid (e.g., CPR), basic airway maneuvers, and emergency airway procedures for FBA (see “Unresponsive patients” below for details).

Overview of diagnostic and therapeutic approach to FBA
Upper airway FB obstruction [11] Lower airway FB obstruction [2]
Physical findings
  • Cough
  • Absent breath sounds in the affected lung field
  • Wheeze (inspiratory/expiratory)
Initial imaging

Advanced imaging and/or

dual diagnostic/therapeutic procedures

Management: unresponsive patient with suspected FBA
Management: responsive patient with suspected FBA

Commence CPR

Emergency airway procedures in FBA

  • Indication: failed first-aid attempts to dislodge the FB
  • Anesthesia

Laryngoscopy [14]

Laryngoscopy risks converting a partial obstruction into a total obstruction by displacing the object or causing laryngeal trauma and/or hemorrhage [15]

Emergency surgical airway [16]

Suspected complete airway obstruction (patient unable to speak, cry, or cough) [13]

If the patient can speak, cry, or cough, do not attempt back blows or abdominal thrusts, as these maneuvers risk dislodging the FB and converting a partial obstruction into a complete obstruction.

Approach

Technique

Maneuvers to dislodge an aspirated foreign body
Infants Adults and children ≥ 1 year old
Initial maneuver: Back blows
  • Place the infant prone along the provider's forearm with the head lower than the chest.
  • Support the infant's head by holding the jaw (avoid compressing soft tissues of the neck).
  • Using the heel of the hand, deliver a back blow between the shoulder blades.
  • Repeat up to 5 times.
  • Check if FB has dislodged.
  • If ineffective, proceed to give chest thrusts (see below)
  • Stand or kneel posterolateral to the patient.
  • Place one hand on their chest to support their body weight while they lean forward.
  • Using the heel of the hand, deliver a back blow between the shoulder blades, repeat as needed. [20]
  • Check if FB has dislodged.
  • If ineffective, proceed to abdominal thrusts. (see below)
Next step: chest thrusts Next step: abdominal thrusts [21][22]
  • Place the child in a supine position.
  • Tilt the head back.
  • Apply pressure swiftly and firmly to the lower third of the sternum (similar location as CPR).
  • Repeat up to 5 times at the rate of 1 compression per second.
  • Check if FB has dislodged.
  • If chest thrusts are ineffective, give another 5 back blows.
  • Alternate cycles of chest thrusts and back blows as needed.
  • Stand or kneel behind the person.
  • Place one fist slightly above the navel (but below the xiphoid process).
  • Grasp the fist with the other hand.
  • Perform a quick inward and upward thrust.
  • Check if FB has dislodged.
  • Repeat up to 5 times or until the FB is expelled.

Suspected partial upper airway FBA

Suspected partial lower airway FBA

If at any time the patient becomes unresponsive despite treatment, start CPR, and, if trained, proceed to emergency airway procedures in FBA.

Prioritize airway management and respiratory stabilization over diagnostics if there are any signs of respiratory distress or respiratory failure (see the “Initial management” sections above).

Imaging in suspected upper airway FBA

Neck x-ray (lateral view)

An x-ray may not detect a FB due to radiolucency or if the aspirated object is further down than suspected.

Laryngoscopy [25]

  • Indications: next management step after failed first-aid attempts to dislodge an upper airway FB
  • Findings
    • Direct visualization of the FB
    • Potentially surrounding mucosal edema, abrasions, or blood
  • Additional considerations: Nasal endoscopy can be used to remove a nasal FB or ensure there is no FB remnant in the upper airway that can be re-aspirated.

Imaging in suspected lower airway FBA

Chest x-ray [2]

  • Indications
  • Views
    • PA, lateral, and expiratory
    • Left and right lateral decubitus views in patients unable to cooperate with inspiratory/expiratory views [11]
  • Findings
    • FB may be visualized if radiopaque (∼ 25%).
    • Lung parenchyma changes suggestive of FBA are described in the table below.
  • Disadvantages
    • False reassurance if chest x-ray is normal
    • Insufficient detail for planning removal of FB; further imaging usually necessary
Chest x-ray findings suggestive of FBA [2]
Early findings Late findings
Partial airway obstruction
  • Evidence of focal hyperinflation
    • Focal hyperlucency
    • Reduced pulmonary markings in the affected lung
    • Severe causes: flattening of the ipsilateral hemidiaphragm and mediastinal shift to the unaffected side
Complete airway obstruction

Chest x-ray may be normal in patients with FB aspiration.

If there is a high suspicion of FBA, CT chest or bronchoscopy should be performed even if the chest x-ray is inconclusive.

CT chest without contrast (∼ 100% sensitivity) [2]

Bronchoscopy [2]

Bronchoscopy is the gold standard diagnostic and therapeutic modality for a suspected lower airway FBA.

Investigation of the underlying causes

Emergency management of suspected FBA is covered in the “Initial management” sections above.
This section describes procedures to remove a FB in stable/stabilized patients if CPR or initial maneuvers to dislodge the aspirated FB have failed.

Planned removal of an upper airway FB

Avoid positive pressure ventilation (e.g., bag-mask ventilation) during anesthesia induction in patients with suspected upper airway FBA as it can dislodge the FB more distally. [31]

Planned removal of a lower airway FB

Bronchoscopy (gold standard) [2]

Bronchoscopy choice in FBA [2][34]
Indications Advantages Disadvantages
Flexible bronchoscopy
  • Stable adults
  • Gold standard if the diagnosis is unclear or the location of the FB is unknown [2]
  • More widely available
  • Can be performed through an ETT/rigid bronchoscope
  • Possible in facial trauma or with limited neck movement
  • More comprehensive investigation of the airways
  • Ability to access smaller airways
  • Does not allow ventilation
  • No airway protection as objects pass the glottis
Rigid bronchoscopy
  • All children [2]
  • Patients with acute respiratory distress
  • Flexible bronchoscopy has failed to remove the FB.
  • Allows ventilation
  • Tools such as suction and cautery can be passed through the bronchoscope.
  • Shielding of sharp objects within the tube during extraction
  • Prevents complete airway obstruction if the FB is dislodged during removal
  • Usually requires a general anesthesia
  • Not all operators are trained to use rigid bronchoscopes.

Surgical management [2][33]

  • Indications
  • Procedure: thoracotomy with bronchotomy or segmental resection

All patients

Suspected complete airway obstruction

Unresponsive patient

Responsive patient

Suspected partial upper airway FB obstruction or suspected lower airway FBA

References:[37]

We list the most important complications. The selection is not exhaustive.

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