An 18-month-old boy was brought to the pediatric emergency department by his parents. Two hours previously, he had gagged and choked while eating dinner. Since then, he has been agitated and coughing intermittently.
What is foreign body aspiration, and how does it occur?
Foreign body aspiration, the lodging of a substance in the trachea or bronchus, is a very serious condition and can be a life-threatening emergency because there is a potential for complete airway obstruction. Foreign body aspiration occurs most commonly in children 1–3 years old because they often put foreign substances in their mouths, lack molars to chew their food adequately, and often run or play with objects in their mouths. Peanuts, seeds, and other food particles are the most common foreign bodies aspirated ( Figure 66-1 ). Less frequently, other objects such as plastic game pieces and small batteries are aspirated. In addition, certain aspirated objects may cause intense irritation and edema (e.g., peanuts from the oil component) or corrosion and necrosis (e.g., batteries) to the airway mucosa.
Foreign bodies can also be ingested into the hypopharynx, esophagus, and stomach. Although often not as urgent or life-threatening, these cases can still present a significant challenge. These children are typically older (1–6 years old), and the foreign bodies are usually coins, bones, or plastic game pieces.
How does a patient with foreign body aspiration typically present?
There is often a history of choking, gagging, coughing, or wheezing occurring when the child is eating or when playing with small objects. A period of cyanosis may be noted by the parents. A foreign body large enough to obstruct the trachea completely requires immediate treatment with back blows and chest compressions in infants or abdominal thrusts in children. More often, airway obstruction is incomplete, and these patients typically present to the emergency department.
On physical examination, the child may appear agitated. Agitation could be due to hypoxemia. Tachypnea and tachycardia are often present. Coughing, unilateral decreased breath sounds, and wheezing are the classic signs. There should be a high suspicion for foreign body aspiration in any child in this age range who presents to the emergency department with new-onset wheezing, especially if unilateral. If the child shows significant respiratory compromise, rapid transport to the operating room is indicated. In stable children with a questionable diagnosis, chest x-rays may be helpful. Although most foreign bodies are not radiopaque, indirect findings such as hyperinflation of the obstructed lung secondary to air trapping or atelectasis secondary to decreased ventilation may be suggestive of the diagnosis. Hyperinflation is best visualized in an expiratory film but may be difficult to obtain in younger age groups.
The presentation of a patient with foreign body ingestion is slightly different. Coughing and choking can occur initially because of laryngeal irritation, followed by refusal to feed, increased salivation, discomfort with swallowing, and vomiting. In contrast to airway foreign bodies, these foreign bodies are often radiopaque, and a chest x-ray is frequently helpful to confirm the diagnosis, revealing type and location. These cases are typically not as urgent, with the exception of ingestion of potentially toxic objects, such as batteries, or potentially traumatic objects, such as open safety pins ( Figure 66-2 ).