Overview
Definition:
Foreign body aspiration in toddlers refers to the inhalation of an object into the tracheobronchial tree, most commonly occurring between 6 months and 3 years of age
Unilateral wheezing is a classic, though not universally present, sign suggesting a focal obstruction in one lung or bronchus.
Epidemiology:
It is a leading cause of accidental death in young children
Common aspirated objects include food items (nuts, seeds, popcorn, grapes) and small toys
Unilateral wheezing is reported in approximately 50-70% of cases, often persistent and localized.
Clinical Significance:
Prompt diagnosis and management are crucial to prevent serious complications such as pneumonia, atelectasis, lung abscess, and even respiratory failure
Inadequate evaluation or delayed diagnosis can lead to significant morbidity and mortality, making its recognition vital for pediatricians and residents preparing for DNB and NEET SS.
Clinical Presentation
Symptoms:
Sudden onset of choking, gagging, or coughing episode
Subsequent development of persistent, localized wheezing (unilateral)
Decreased breath sounds on one side
Recurrent pneumonia or bronchitis episodes
Dyspnea and tachypnea
Possible hemoptysis
Fever may develop if secondary infection occurs.
Signs:
Unilateral decreased breath sounds
Unilateral wheezing, often inspiratory or expiratory
Increased work of breathing
Localized crackles or rhonchi
Possible cyanosis in severe cases
Fever if infection is present
Inability to vocalize clearly if the object is in the trachea.
Diagnostic Criteria:
No specific diagnostic criteria exist
diagnosis is primarily clinical, supported by imaging and direct visualization
A history of a witnessed or suspected choking event, followed by persistent unilateral wheezing, is highly suggestive.
Diagnostic Approach
History Taking:
Detailed history of the inciting event: onset, timing, nature of the object (if known), and symptoms
Inquire about any preceding respiratory illness or other conditions
Ask about parental observations of choking, gagging, or changes in breathing pattern
Explore risk factors for aspiration (e.g., feeding practices, toys within reach).
Physical Examination:
Thorough assessment of respiratory status: respiratory rate, heart rate, oxygen saturation, work of breathing
Auscultate lung fields systematically, noting the presence, location, and type of wheezing and breath sounds
Palpate chest for symmetry of expansion and tactile fremitus
Assess for any signs of distress or cyanosis
Inspect the oropharynx for any visible foreign body.
Investigations:
Chest X-ray (PA and lateral views): may show hyperinflation of the affected lung, atelectasis, or a visible radiopaque foreign body
However, up to 50% of X-rays can be normal, especially with radiolucent objects
Fluoroscopy can reveal dynamic air trapping or mediastinal shift
CT scan of the chest with expiratory views: superior sensitivity for detecting air trapping and occult foreign bodies, especially radiolucent ones
Bronchoscopy: the gold standard for diagnosis and simultaneous removal of the foreign body
It allows direct visualization of the tracheobronchial tree.
Differential Diagnosis:
Asthma: typically bilateral wheezing, episodic, responds to bronchodilators
Bronchiolitis: diffuse wheezing, usually in younger infants, often viral prodrome
Pneumonia: fever, crackles, lobar consolidation, usually bilateral or diffuse
Viral croup: stridor, barking cough, inspiratory wheeze
Congenital airway anomalies: persistent symptoms from birth
Bronchogenic cyst or other masses: may cause extrinsic compression.
Management
Initial Management:
Immediate assessment of airway patency and respiratory status
Administer supplemental oxygen to maintain saturation >94%
If object is visible in the oropharynx and easily accessible, attempt removal cautiously
If significant respiratory distress, consider positive pressure ventilation
Definitive management is bronchoscopic removal.
Medical Management:
Generally not indicated for acute foreign body aspiration itself, but supportive care is essential
Bronchodilators (e.g., albuterol) may be tried for wheezing but are often ineffective if the obstruction is fixed
Antibiotics are indicated if pneumonia or infection is suspected or develops.
Surgical Management:
Bronchoscopy is the primary intervention for removal
Rigid bronchoscopy is preferred due to its ability to provide ventilation and adequate visualization
If bronchoscopy fails or complications arise, rigid bronchoscopy or even thoracotomy may be considered in rare, refractory cases.
Supportive Care:
Continuous cardiorespiratory monitoring
Maintain adequate hydration and nutrition
Close observation for signs of respiratory compromise
Management of secondary infections (e.g., pneumonia) with appropriate antibiotics and pulmonary toilet.
Complications
Early Complications:
Complete airway obstruction leading to asphyxiation
Laryngospasm and bronchospasm
Pneumothorax due to barotrauma during ventilation
Tracheobronchial perforation.
Late Complications:
Post-obstructive pneumonia
Lung abscess
Atelectasis and bronchiectasis
Granuloma formation around the foreign body
Chronic cough and persistent wheezing
Hemoptysis
Bronchiolitis obliterans.
Prevention Strategies:
Educate parents about choking hazards and safe food preparation for toddlers
Avoid feeding small, round, or hard foods to young children
Ensure toys are age-appropriate and free of small detachable parts
Supervise young children during meals and play.
Prognosis
Factors Affecting Prognosis:
The type and location of the foreign body
The duration of airway obstruction
The promptness of diagnosis and intervention
The presence and severity of complications like infection or lung damage
The skill of the endoscopist.
Outcomes:
With timely diagnosis and bronchoscopic removal, the prognosis is generally excellent, with complete resolution of symptoms
Delayed diagnosis or complications can lead to long-term respiratory sequelae, including chronic lung disease.
Follow Up:
Follow-up chest X-rays may be needed to assess resolution of atelectasis or pneumonia
Patients with residual symptoms or complications may require ongoing pulmonary assessment, including PFTs if age-appropriate, and management for conditions like bronchiectasis or reactive airway disease.
Key Points
Exam Focus:
Remember that a normal chest X-ray does NOT rule out foreign body aspiration
Unilateral wheeze in a toddler with a history of choking is a strong indicator
Bronchoscopy is both diagnostic and therapeutic
Radiopaque foreign bodies are easier to visualize on X-ray.
Clinical Pearls:
Always consider foreign body aspiration in a toddler with unexplained unilateral wheezing or recurrent pneumonia
Even without a witnessed choking episode, it should remain in the differential
Consider expiratory CT scans if initial investigations are negative but suspicion remains high.
Common Mistakes:
Dismissing symptoms as asthma without considering foreign body aspiration
Relying solely on chest X-ray findings
Delaying bronchoscopy in the presence of high clinical suspicion
Failure to counsel parents on prevention strategies.