Foreign Body Aspiration in the ED: Down the Wrong Pipe

-Case-
A 3-year-old boy is brought to the ED by his parents after a sudden coughing fit while eating peanuts. He’s now in mild respiratory distress with decreased breath sounds to the right chest. No fever, no vomiting, and his chest X-ray is normal. 

-Evaluation-
Foreign body aspiration (FBA) occurs when an object is inhaled into the airway, most commonly in young children. In adults, it’s often associated with altered mental status or intoxication. Immediate identification is critical, as delay increases the risk of airway obstruction, pneumonia, and even death.

  • Common Presentations:
    • Sudden onset coughing, choking, wheezing
    • Stridor (upper airway) or unilateral wheeze/decreased breath sounds (lower airway), classically affecting the right lung
    • Persistent or recurrent cough, especially if unexplained
  • Red Flags:
    • Known episode of choking
    • Asymmetric breath sounds
    • Refractory wheezing not responding to albuterol

Diagnosis:

  • H&P are key; a witnessed choking event is tantamount to the diagnosis!
  • CXR (AP/lateral):
    • Often normal, especially in radiolucent objects (like in our case above!)
    • May less commonly show hyperinflation, atelectasis, or air trapping
  • Inspiratory/expiratory films or lateral decubitus films in children can help reveal air trapping
  • CT chest can aid in difficult cases, but often do not yield much utility
  • Bronchoscopy is the gold standard for diagnosis and treatment

-Management-

  • Immediate airway assessment: if unstable or in severe distress, initiate BLS maneuvers (back blows, abdominal thrusts) and prepare for intubation or surgical airway
  • Stable patients:
    • Consult ENT or pulmonary for rigid bronchoscopy in children
    • Flexible bronchoscopy may be appropriate in adults
  • Do not delay bronchoscopy if high suspicion remains, even with normal imaging!

-Fast Facts-

  • 80% of FBAs occur in children under 3
  • Right mainstem bronchus is the most common site
  • Normal imaging does not exclude FBA

In the ED, when a child (or even an adult) presents with sudden coughing, unilateral wheeze, or unexplained respiratory symptoms, think foreign body aspiration. Trust the history more than the imaging, and don’t hesitate to involve your airway experts early. Early recognition and bronchoscopy can make the difference between a minor scare and a major disaster!

Want to learn more? Listen to our podcast episode on this topic!

Cheers,

Tamir Zitelny, MD

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-References-

  1. Tan HK, Brown K, McGill T, Kenna MA, Lund DP, Healy GB. Airway foreign bodies (FB): a 10-year review. Int J Pediatr Otorhinolaryngol. 2000;56(2):91-99. doi:10.1016/S0165-5876(00)00417-4
  2. Hegde SV, Rajeev R, Kamath MP. Foreign body aspiration in children: a 5-year experience at a tertiary care hospital. Indian J Otolaryngol Head Neck Surg. 2013;65(Suppl 1):S50–S53. doi:10.1007/s12070-011-0365-5
  3. Baharloo F, Veyckemans F, Francis C, Biettlot MP, Rodenstein DO. Tracheobronchial foreign bodies: presentation and management in children and adults. Chest. 1999;115(5):1357-1362. doi:10.1378/chest.115.5.1357
  4. Zur KB, Litman RS. Pediatric airway foreign body retrieval: surgical and anesthetic perspectives. Pediatr Anesth. 2009;19 Suppl 1:109-117. doi:10.1111/j.1460-9592.2009.03008.x
  5. Foltran F, Ballali S, Passali FM, et al. Foreign bodies in the airways: a meta-analysis of published papers. Int J Pediatr Otorhinolaryngol. 2012;76(Suppl 1):S12-S19. doi:10.1016/j.ijporl.2012.02.004
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