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?
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
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.
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.
Money-back GuaranteeMegan Maraynes, MD; Konstantinos Agoritsas, MD
October 2, 2015
November 1, 2018
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