Foreign Body Inhalation Summary

High-Risk Groups

  • Children: Age <4 years (peak 1-3)
  • Adults: Altered mental status, neurological disorders
  • 70-90% are organic (seeds, nuts)

Clinical Presentation

  • Sudden choking/coughing episode
  • Witnessed aspiration (~50% cases)
  • Unilateral decreased breath sounds
  • Localized wheezing/stridor

Imaging Findings

  • CXR: Air trapping, atelectasis, pneumonia
  • Normal in ~35% of cases
  • Only ~10% radio-opaque
  • CT more sensitive for radiolucent FBs

Management - Conscious

  • Encourage effective coughing
  • Infants <1yr: Back blows + chest thrusts
  • Children/Adults: Abdominal thrusts
  • Bronchoscopy if persistent

Management - Unconscious

  • Immediate airway management
  • Endotracheal intubation
  • Cricothyroidotomy if complete obstruction
  • Bronchoscopy for removal

Bronchoscopy

  • Flexible: First-line in stable patients (>90% success)
  • Rigid: Complete obstruction, pediatric cases
  • Surgical removal if bronchoscopy fails

Complications

  • Acute: Asphyxia, pneumomediastinum
  • Chronic: Recurrent pneumonia, bronchiectasis
  • Bronchial stricture, lung abscess

Foreign Body Inhalation

Overview

Foreign body aspiration occurs when an object is inhaled into the larynx and respiratory tract. Children are at particularly high risk due to poor chewing ability, tendency to mouth objects, and vigorous inspirations when laughing or crying.

Most common foreign bodies: 70-90% are organic (seeds, nuts). Inorganic objects include coins, pins, teeth, and small toys.

Risk Factors

Children

  • Age <4 years (peak 1-3 years)
  • Male sex
  • Poor chewing ability
  • Exploratory behavior

Adults

  • Altered mental status (alcohol/sedatives)
  • Seizures
  • Neurological disorders
  • Trauma with decreased LOC
  • Dental procedures
  • Advanced age (>70 years)
  • Dysphagia
  • Impaired cough reflex

Clinical Features

Classic Presentation

  • Choking crisis: Sudden onset choking/coughing
  • Intractable cough
  • Witnessed aspiration event (in ~50% of cases)

Physical Findings

  • Unilateral decreased breath sounds
  • Localized wheezing
  • Stridor (if laryngeal/tracheal)
  • Fever (if delayed presentation)
  • Dyspnea

Signs of Complete Airway Obstruction

  • Inability to speak/cough
  • Cyanosis
  • Altered consciousness
  • Respiratory arrest

Imaging

Chest X-ray (Initial Choice)

  • Findings:
    • Air trapping (hyperinflation on expiratory films)
    • Atelectasis
    • Pneumonia
    • Mediastinal shift
    • Radio-opaque FB (only ~10% of cases)
  • Note: Normal in ~35% of cases

CT Chest

  • More sensitive than X-ray
  • Can detect radiolucent FBs
  • Low-dose MDCT with virtual bronchoscopy useful in children

Management

Conscious Patient

  1. Encourage coughing (if effective)
  2. If ineffective:
    • Infants <1yr: 5 back blows + chest thrusts
    • Children/Adults: Abdominal thrusts (Heimlich)
  3. If still present: Bronchoscopy for removal

Unconscious Patient

  1. Immediate airway management:
    • Endotracheal intubation if possible
    • Consider cricothyroidotomy if complete obstruction
  2. Bronchoscopy for FB removal

Bronchoscopy

  • Flexible: First-line in stable patients (>90% success)
  • Rigid: Preferred for:
    • Complete obstruction/asphyxia
    • Large/irregular objects
    • Pediatric cases
  • Surgical removal if bronchoscopy fails

Complications

Acute

  • Asphyxia/death
  • Pneumomediastinum
  • Bronchospasm (procedure-related)
  • Subglottic edema

Chronic

  • Recurrent pneumonia
  • Bronchiectasis
  • Bronchial stricture
  • Granulation tissue formation
  • Lung abscess

Key Points

  • Suspect in any child with sudden choking/coughing episode
  • Normal CXR doesn't exclude diagnosis (35% normal)
  • Airway management takes priority over imaging
  • Flexible bronchoscopy first-line for stable patients
  • Rigid bronchoscopy preferred for complete obstruction/pediatric cases
  • Consider CT if high suspicion but negative X-ray