Lecture
7-month-old male with dry heaves, crying, and agitation shortly after a meal
Patient will present as → a 2-year-old male child who is brought to the emergency department by his mother with a sudden onset of choking, gagging, coughing, and wheezing. Vital signs are temperature 37.0°C (98.6°F), pulse 120/min, and respirations 28/min. The physical examination reveals decreased breath sounds over the right lower lobe with inspiratory rhonchi and localized expiratory wheezing. The chest X-ray reveals normal inspiratory views, but expiratory views show localized hyperinflation with a mediastinal shift to the left.
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Aspirated solid or semi-solid object, usually lodged in a mainstem or lobar bronchus; laryngeal and tracheal foreign bodies are less common but the most dangerous
- About 80% lodge in a mainstem or lobar bronchus and 20% in the upper airway; right more often than left - most commonly the right mainstem bronchus (wider and more vertical)
- Most often food (nuts, seeds, popcorn, grapes, hot dogs), but can also include small toys, coins, pens, etc.
Who gets it (risk factors)
- Peak age 1 to 3 years (about 80% of pediatric cases occur before age 3); boys more than girls
- Second peak in older adults: advanced age, dysphagia or neurologic disease (stroke, dementia, Parkinson disease), institutionalization, poor dentition, alcohol, and sedative use
Presentation depends on the location of the obstruction
- Inspiratory stridor if high in the airway (larynx or trachea)
- Wheezing and decreased breath sounds if low in the airway (bronchus)
- The classic triad (cough + one-sided wheeze + decreased breath sounds) is present in only about half of children, so its absence does not rule out aspiration
- High-yield clue: normal child with abrupt respiratory symptoms and no fever → think aspiration, not infection
- Adults often do not recall choking and present with chronic cough, one-sided wheeze, or recurrent pneumonia in the same lung segment
The sound of inspiratory stridor:
Complications
- It may be life-threatening if large enough to completely obstruct the airway
- Delayed removal → recurrent or postobstructive pneumonia, atelectasis, bronchiectasis, airway stricture; acute respiratory distress syndrome and asphyxia in severe cases
All pharyngeal and airway foreign bodies are medical emergencies
Inspiratory and expiratory CXR (first test; decubitus views if the child cannot cooperate) - the expiratory radiograph may reveal regional hyperinflation (air trapping) of the affected side, with mediastinal shift away from the affected side
- Most aspirated objects (especially food) are radiolucent - in children 1 to 3 years old, more than 75% do not show on x-ray
- X-rays are normal in more than 50% of tracheal and more than 25% of bronchial foreign bodies
- A normal chest x-ray does not rule out aspiration - if suspicion is high, proceed to bronchoscopy
- Moderate suspicion with an inconclusive x-ray → low-dose CT chest
- Bronchoscopy confirms the diagnosis and removes the object
ABG - necessary for appropriately evaluating ventilation, may be useful for following the progression of respiratory failure when it is of concern
Aspiration of a dental crown. This projects onto the right lower lobe bronchus.
Complete obstruction (cannot cough, speak, or breathe) → immediate first aid
- Infant under 1 year → 5 back blows alternating with 5 chest thrusts
- Child 1 year or older and adults → 5 back blows alternating with 5 abdominal thrusts
- Never do a blind finger sweep; do not intervene while the patient can still cough or speak; if the patient becomes unresponsive, start CPR
Bronchoscopy (flexible or rigid) may help to establish the diagnosis and can also be the treatment of choice for the removal of the object
- Rigid bronchoscopy is preferred in children due to the wider instrument lumen (as compared to its flexible counterpart), which allows for ventilation and easier removal of objects
- Flexible bronchoscopy is both diagnostic and therapeutic and is preferred for most stable adults
- Surgical removal - indicated when endoscopy is impossible or unsuccessful
- Antibiotics only for postobstructive pneumonia (obtain cultures first); steroids are not routine
Prevention - no nuts, whole grapes, hot dogs, popcorn, or hard candy for children under 4; keep small toys and parts away from children under 3
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Question 1 |
A 2-year-old boy is brought to the emergency department 1 hour after he choked while eating peanuts. He now has a persistent cough. Breath sounds are decreased on one side. In children, which of the following is the most common location of an aspirated foreign body?
Carina Hint: Objects can straddle the carina, but most pass into a mainstem bronchus. | |
Larynx Hint: Laryngeal foreign bodies are uncommon but are the most dangerous because they can completely block the airway. | |
Left mainstem bronchus Hint: Left-sided foreign bodies are common in young children, but the right side is still involved more often. | |
Right mainstem bronchus | |
Trachea Hint: Tracheal foreign bodies are less common than bronchial ones and usually cause stridor rather than one-sided findings. |
Question 1 Explanation:
Most aspirated foreign bodies pass through the larynx and trachea and lodge in a bronchus, most often the right mainstem bronchus (wider and more vertical than the left). The right-sided predominance is less marked in young children than in adults. Aspiration peaks at 1 to 3 years of age (about 80% of pediatric cases occur before age 3), and food such as nuts, seeds, and popcorn is the most common culprit. Laryngeal and tracheal foreign bodies are less common but the most dangerous.
Question 2 |
A 3-year-old girl began coughing and wheezing while eating popcorn 2 hours ago. She is alert and speaking. Temperature is 37.0°C (98.6°F), respirations are 32/min, and SpO2 is 97% on room air. There is a focal wheeze and decreased breath sounds over the right lung. Which of the following is the most appropriate initial imaging study?
CT angiography of the chest Hint: CT angiography evaluates pulmonary embolism; a low-dose noncontrast airway CT is sometimes used when suspicion is moderate and x-rays are inconclusive, but it is not the first study. | |
Inspiratory and expiratory chest radiographs | |
Lateral soft-tissue neck radiograph Hint: A lateral neck film looks for upper-airway problems such as epiglottitis or retropharyngeal abscess; her findings are below the larynx. | |
MRI of the chest Hint: MRI is slow, often needs sedation, and has no role in the initial evaluation of a suspected airway foreign body. | |
Ventilation-perfusion scan Hint: A V/Q scan evaluates pulmonary embolism, not an airway foreign body. |
Question 2 Explanation:
For a stable child with suspected foreign-body aspiration, start with inspiratory and expiratory chest radiographs (or bilateral decubitus views if the child cannot cooperate). Most objects are radiolucent, so look for indirect signs: unilateral air trapping/hyperinflation on expiration from a ball-valve effect, with the mediastinum shifting away from the affected side, or atelectasis and pneumonia. Remember that a normal film does not rule out aspiration.
Question 3 |
A 2-year-old boy has coughing and wheezing after choking on a peanut. He is alert with SpO2 96% on room air. An expiratory chest radiograph shows hyperinflation of the right lung with the mediastinum shifted to the left. Which of the following is the most appropriate management?
Albuterol nebulization and observation Hint: Bronchodilators may ease wheeze but do nothing to remove the object; delay raises the risk of pneumonia and airway damage. | |
Chest physiotherapy with postural drainage Hint: Chest physiotherapy can move the object into the central airway and cause complete obstruction. | |
Intravenous dexamethasone Hint: Steroids are not routine and do not remove the object. | |
Oral amoxicillin-clavulanate Hint: Antibiotics are used only for a documented infection; this child needs the object removed. | |
Rigid bronchoscopy |
Question 3 Explanation:
Air trapping with mediastinal shift away from the affected side in a toddler who choked on a peanut confirms a bronchial foreign body. Rigid bronchoscopy under general anesthesia is the procedure of choice in children: it secures the airway, allows ventilation, and lets the operator remove the object. Prompt removal prevents postobstructive pneumonia, atelectasis, granulation tissue, and later bronchiectasis. Flexible bronchoscopy is preferred for most stable adults.
Question 4 |
An 18-month-old girl had a witnessed choking episode while eating raw carrot 2 days ago. She now has an intermittent cough and a focal, monophonic wheeze over the left lung base. She is afebrile with normal oxygen saturation. Inspiratory and expiratory chest radiographs are normal. Which of the following is the most appropriate next step?
Barium swallow Hint: A barium swallow evaluates the esophagus, not an airway foreign body. | |
Bronchoscopy | |
Discharge with reassurance Hint: Most aspirated foods are radiolucent, so a normal film does not rule out aspiration; sending her home risks a retained foreign body. | |
Repeat chest radiograph in 6 weeks Hint: Waiting 6 weeks allows complications such as pneumonia, granulation tissue, and bronchiectasis to develop. | |
Trial of inhaled albuterol Hint: A wheeze that started with a choking episode should not be treated as asthma; the object must be found and removed. |
Question 4 Explanation:
A witnessed choking episode followed by cough and a focal, monophonic wheeze is a high-suspicion history. Because most aspirated objects (especially food) are radiolucent, chest radiographs are normal in roughly a third of children with a confirmed foreign body, so a normal x-ray does not rule out aspiration. With high suspicion, proceed to bronchoscopy, which is both diagnostic and therapeutic (rigid bronchoscopy in children). With moderate suspicion and an inconclusive film, a low-dose noncontrast airway CT is an option.
Question 5 |
An 8-month-old infant suddenly stops crying while eating at a restaurant. She is awake, cannot cough or make any sound, and is becoming cyanotic. Which of the following is the most appropriate immediate intervention?
Abdominal thrusts Hint: Abdominal thrusts are not used in infants under 1 year because of the risk of injury to the liver and other abdominal organs. | |
Back blows alternating with chest thrusts | |
Blind finger sweep of the mouth Hint: A blind finger sweep can push the object deeper; remove an object only if you can see it. | |
Encourage coughing and observe Hint: She cannot cough or make sound, which means complete obstruction; waiting is not appropriate. | |
Rescue breaths Hint: Rescue breaths will not move air past a complete obstruction in a responsive infant; relieve the obstruction first and start CPR only if she becomes unresponsive. |
Question 5 Explanation:
An infant who cannot cry, cough, or breathe has a complete airway obstruction. For an infant under 1 year, give 5 back blows (head-down, supported on the forearm) alternating with 5 chest thrusts until the object comes out or the infant becomes unresponsive. For a child 1 year or older or an adult, give 5 back blows alternating with 5 abdominal thrusts. If the patient becomes unresponsive, start CPR and remove an object only if it is visible. Never do a blind finger sweep, and do not intervene while the patient can still cough or speak.
Question 6 |
A 78-year-old man with Parkinson disease has had a chronic cough and 3 episodes of right lower lobe pneumonia in 6 months. He does not recall choking. CT of the chest shows an endobronchial density in the right lower lobe bronchus with distal postobstructive changes. Which of the following is the most appropriate next step?
Flexible bronchoscopy | |
Long-term azithromycin Hint: Preventive antibiotics do not address a retained foreign body or obstructing lesion. | |
Repeat chest CT in 3 months Hint: Waiting delays diagnosis of a foreign body or tumor and allows more pneumonias. | |
Sputum culture and a 14-day antibiotic course Hint: Antibiotics may treat the infection but will not fix the obstruction causing it. | |
Thoracotomy with lobectomy Hint: Surgery is reserved for objects that cannot be removed endoscopically. |
Question 6 Explanation:
In adults, foreign-body aspiration is often unwitnessed and presents as chronic cough, unilateral wheeze, or recurrent pneumonia in the same segment, usually the right lower lobe. Risk factors include advanced age, dysphagia and neurologic disease, dementia, sedatives, and alcohol. Diagnosis requires direct visualization: flexible bronchoscopy is the preferred first procedure for stable adults (it can also remove the object or biopsy a tumor). Rigid bronchoscopy is reserved for large central objects, life-threatening obstruction, or failed flexible extraction.
There are 6 questions to complete.
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