Inhaled Foreign Bodies In Pediatric Patients: Proven Management Techniques In The Emergency Department

Table of Contents

 

1. Abstract
2. Case Presentations
3. Introduction
4. Critical Appraisal of the Literature
5. Etiology And Pathophysiology
6. Differential Diagnosis
7. Prehospital Care
8. Emergency Department Evaluation
   1. Initial Evaluation
9. Diagnostic Studies
   1. Radiographic Studies To Assess For Signs Of An Aspirated Foreign Body
10. Specialty Consultation
11. Treatment
12. Special Populations
13. Controversies And Cutting Edge
14. Disposition
15. Summary
16. Risk Management Pitfalls For Management Of Inhaled Foreign Bodies
17. Time- And Cost-Effective Strategies
18. Case Conclusions
19. Clinical Pathway For Management Of Inhaled Foreign Bodies
20. Tables and Figures
    1. Table 1. Physical Examination Findings Based On Anatomical Location
    2. Table 2. Differential Diagnosis Based On Signs And Symptoms
    3. Figure 1 Airway Foreign Body With Atelectasis Of The Left Lung
    4. Figure 2. Screw In The Left Mainstem Bronchus
    5. Figure 3. Sunflower Seed Lodged In The Subglottis
    6. Figure 4. Subcutaneous Emphysema And Pneumomediastinum
    7. Figure 5. Right-Sided Hyperexpansion And Mediastinal Shift
    8. Figure 6. Foreign Body In The Lower Trachea, Shown By Coronal Reconstruction
21. References

Abstract

Foreign body inhalation affects thousands of children every year, and it remains a significant cause of morbidity and mortality in children. Inhaled organic or inorganic foreign bodies can become lodged in the posterior nasopharynx, larynx, trachea, or bronchi. Presentation of foreign body inhalation can range from nonspecific respiratory symptoms to respiratory failure associated with a choking episode. In this issue, an in-depth review of the etiology, pathophysiology, diagnosis, and treatment of inhaled foreign bodies is presented. Risk factors for foreign body inhalation and clinical clues to diagnosis, as well as emergent management of inhaled foreign bodies are reviewed. A systematic approach, as described in this issue, will aid in timely and accurate diagnosis and treatment of inhaled foreign bodies, thereby limiting future complications and morbidity.

Case Presentations

A mother runs past triage screaming, “My daughter is choking!” You run over to assess the child, who is coughing but has good air entry bilaterally, no retractions, and appears generally well in between coughs. The mother reports that her 3-year-old was eating trail mix and started coughing and gasping for air. You debate the need for imaging and wonder how long you should observe this child.

A resident approaches you to present a 6-year-old boy brought in by his father after the child swallowed a small magnetic toy. The father tells you his son coughed and gagged, and now reports that it feels like there is something in his throat. What imaging should you obtain, and what consultants should you call, if any?

You are evaluating a 2-year-old girl who has had 1 week of fever, coughing, and increasing respiratory distress with no known history of foreign body ingestion. You obtain an x-ray that shows significant air trapping in the right lung field, as well as right middle lobe pneumonia. What should you do to stabilize this patient? Is there a role for bronchodilators, racemic epinephrine, and/or steroids? Is any other imaging needed to rule out an inhaled foreign body?

Introduction

Inhaled foreign bodies remain a significant cause of morbidity in children, with reported mortality between 0 and 1.8%.^1-3 Prior to the advent of advanced endoscopic techniques, mortality rates were reported to be as high as 24%.⁴

Exploring their surroundings with their mouths is a normal part of development that puts children at higher risk of accidental foreign body inhalation than adults. Children aged < 3 years are at greater risk for inhalation of foreign bodies than older children. These young children have immature oropharyngeal coordination, poorly developed or no molar chewing, higher respiratory rates, are more likely to be active and playing while eating, and more likely to experience reflex inhalation while laughing or crying.^5-7

According to the United States Centers For Disease Control and Prevention (CDC), an estimated 17,000 children aged < 14 years presented to the emergency department (ED) for choking-related episodes in 2001 (29.9 persons/100,000 population). Approximately 10% of these patients were admitted to the hospital. Choking rates were highest for infants aged < 1 year and decreased with age, with a slight peak in the 5-year-old to 9-year-old age group. Overall, 59.5% of these children were treated for choking on a food substance, 31.4% on a nonfood substance, and 9% on an undetermined substance. The incidence of choking on food versus nonfood substances varied with age. Food substances accounted for 75.7% of choking-related episodes in children aged 5 to 14 years, 58.4% in children aged 1 to 4 years, and 52.1% among infants aged < 1 year. When considering inhaled or aspirated foreign bodies, organic food substances are the most common. Hard candy was the most commonly inhaled food substance (64%), and coins were the most frequently inhaled nonfood substance (18%). Coins accounted for 18.2% of choking-related episodes among children aged 1 to 4 years.⁸ However, these data do not distinguish between choking episodes resulting in coins lodged in the esophagus versus the airway.

Foreign body inhalation can present variably, ranging from nonspecific respiratory symptoms to respiratory failure associated with a choking episode. Delayed diagnosis of > 24 hours is common and is associated with increased complications and mortality.⁹ In a 2012 meta-analysis of 1063 papers published over a 30-year period, delayed diagnosis of > 24 hours occurred in an estimated 40% of patients, and complications occurred in approximately 15% of these patients.⁹ A 2005 retrospective study cited pneumonia, bronchiectasis, and bronchoesophageal fistula as complications of diagnosis delayed > 1 month. Misdiagnosis and parental delay in seeking care were cited as common reasons for delayed diagnosis, although all patients presented with a chief complaint of chronic cough.¹⁰

Critical Appraisal Of The Literature

A literature search was performed in PubMed using a combination of the search terms pediatrics, child, infant, toddler, inhaled, aspirated, tracheobronchial foreign body, and aspiration pneumonia. Over 150 articles published in the English language were reviewed, and 89 were included in this issue.

Many case series and a significant number of retrospective studies were available, but very few prospective studies were found. There is a lack of uniformity of definitions and management recom-mendations from center to center, and between specialties. Additionally, there is a paucity of emergency medicine literature, as most articles originate from otolaryngology and surgical literature.

Risk Management Pitfalls For Management Of Inhaled Foreign Bodies

1. “The x-ray appears normal, so there can’t be a foreign body.”
   Normal x-ray findings do not exclude radiolucent foreign body aspiration. Additionally, radiographic signs may be delayed > 24 hours. Most aspirated foreign bodies are organic, which includes food products, paper, and other mostly radiolucent objects. Radio-opaque objects include glass and metal; however, many plastic objects will not be radio-opaque.
2. “No one saw him choke or cough, so a foreign body is not on my differential.”
   While a witnessed choking episode is helpful in suspecting the diagnosis of foreign body inhalation, it is not present in the majority of cases, and, therefore, its absence does not exclude an inhaled foreign body.
3. “Some kids are just prone to pneumonia; it doesn’t mean it’s a foreign body.”
   Recurrent or nonresolving unilateral pneumonia should raise the emergency clinician’s suspicion for a retained inhaled foreign body, and workup should be done before the assumption is made that the child is simply prone to pneumonia. Infection usually occurs distal to the site of obstruction, as a late complication.
4. “I thought patting the choking toddler, who was coughing and gasping, on the back would help to dislodge the foreign body he was chok-ing on, but instead, his status worsened and he stopped breathing.”
   In infants aged < 12 months, chest compressions or back blows are the preferred method to dislodge a foreign body. In older children, abdominal thrusts are preferred. However, these methods are indicated in cases of complete obstruction and should not be attempted if a patient is coughing or able to speak (partially obstructed), as these methods can cause complete obstruction.
5. “I saw a patient bite off a piece of a ‘glove balloon’ and start coughing right in front of me. What is the harm of trying to get it out with my finger while it still may be in his posterior pharynx?”
   By the time a patient is coughing, the foreign body is probably at least at the level of the larynx. Blind finger sweeps can not only further dislodge any material that is left in the posterior pharynx, but can cause significant trauma to the delicate tissues. In this case, direct visualization with direct laryngoscopy and the use of Magill forceps for removal at the bedside may be indicated.
6. “He has no symptoms, so let's just discharge him.”
   Foreign body inhalation may be asymptomatic for hours to weeks after the event. History and index of suspicion, in addition to the presence of symptoms, should guide the decision to image and/or observe the patient.
7. “He is wheezing and the x-ray shows atelectasis. He isn’t really improving in the ED, but it’s probably just asthma. Let’s admit him for steroids, bronchodilator therapy, and observation.”
   While there may be a role for bronchodilator therapy in the event of an inhaled foreign body, any patient with abnormal x-ray findings who fails to improve with bronchodilator therapy should be assessed for a possible inhaled foreign body. Inspiratory/expiratory films, fluoroscopy or CT, as well as a thorough history and physical examination, may help elucidate the diagnosis.
8. “This child will never cooperate with inspiratory and expiratory films; let’s just do a CT.”
   An x-ray may show signs of air trapping or a radio-opaque foreign body without inspiratory/ expiratory films. Additionally, although the sensitivity of decubitus films is debatable, they may show air trapping that would be an indication for bronchoscopy, thus avoiding a CT. Disadvantages of CT are the cost and time of testing, the possible need for sedation with its inherent risks, and the risks of radiation.
9. “There is no way my child could have inhaled a toy. It just wouldn’t fit!”
   According to the 1994 Child Safety Protection Act, any toy with small parts (defined as < 4.44 cm) is considered a choking hazard to small children.
10. “The child has stridor, but the chest x-ray is negative, so there is no foreign body, right?”
    Stridor is indicative of a tracheal or laryngeal foreign body, both of which may not be seen on chest films. Anterior-posterior and lateral neck films should be obtained in the case of stridor. The index of suspicion should drive the decision to order a bronchoscopy for a foreign body rather than image alone.

Tables And Figures

References

Evidence-based medicine requires a critical appraisal of the literature based upon study methodology and number of subjects. Not all references are equally robust. The findings of a large, prospective, randomized, and blinded trial should carry more weight than a case report.

To help the reader judge the strength of each reference, pertinent information about the study, such as the type of study and the number of patients in the study will be included in bold type following the references, where available. The most informative references cited in this paper, as determined by the author, will be noted by an asterisk (*) next to the number of the reference.

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