Overview
Definition:
Foreign body aspiration (FBA) in children occurs when an object is inhaled into the tracheobronchial tree, leading to airway obstruction, inflammation, or infection
Rigid bronchoscopy is the gold standard for diagnosis and therapeutic removal of these foreign bodies.
Epidemiology:
Most common in toddlers (1-3 years old) due to their oral exploration phase and immature airway reflexes
Common aspirated objects include peanuts, small toys, coins, buttons, and seeds
Incidence varies geographically but remains a significant cause of pediatric respiratory emergencies.
Clinical Significance:
FBA can lead to immediate life-threatening airway obstruction, pneumonia, lung abscess, atelectasis, and chronic respiratory symptoms
Prompt diagnosis and intervention, often via rigid bronchoscopy, are crucial to prevent severe morbidity and mortality, making it a critical skill for pediatricians and pulmonologists.
Clinical Presentation
Symptoms:
Sudden onset of choking or gagging
Persistent cough
Wheezing or stridor
Dyspnea
Hemoptysis
Cyanosis in severe cases
Recurrent pneumonia or failure to thrive in chronic cases.
Signs:
Tachypnea
Retractions
Accessory muscle use
Decreased breath sounds on one side
Localized wheezing or rhonchi
Postural changes to facilitate breathing
Fever if secondary infection develops.
Diagnostic Criteria:
Diagnosis is primarily based on a history suggestive of aspiration, characteristic physical examination findings, and confirmed by imaging
Direct visualization and removal during rigid bronchoscopy is the definitive diagnostic and therapeutic step.
Diagnostic Approach
History Taking:
Detailed history of witnessed or suspected choking episode, including the type of object if known
Onset and duration of symptoms
Presence of fever, cough, or dyspnea
History of recurrent respiratory infections or failure to thrive.
Physical Examination:
Assess the general condition, alertness, and respiratory distress
Auscultate lungs for unilateral decreased breath sounds, wheezing, or rhonchi
Check vital signs including oxygen saturation
Palpate for subcutaneous emphysema if tracheal perforation is suspected.
Investigations:
Chest X-ray (anteroposterior and lateral views) may show hyperinflation of one lung, atelectasis, or the foreign body itself (if radiopaque)
However, a normal X-ray does not rule out FBA
Fluoroscopy can help identify air trapping
CT scan of the chest can be useful in difficult cases or to identify complications.
Differential Diagnosis:
Asthma
Bronchiolitis
Pneumonia
Laryngotracheobronchitis (croup)
Esophageal atresia
Tracheoesophageal fistula
Vocal cord paralysis
Allergic reactions.
Rigid Bronchoscopy Indications
Definitive Diagnosis:
When clinical suspicion is high despite negative imaging, or to confirm the presence and location of an aspirated foreign body.
Therapeutic Removal:
For all radiopaque or radiolucent foreign bodies causing significant airway obstruction, recurrent pneumonia, or persistent respiratory symptoms
This includes objects causing partial or complete airway occlusion.
Airway Compromise:
Acute, severe airway obstruction due to a foreign body, posing an immediate threat to life
Bronchoscopy is the definitive treatment to secure the airway.
Biopsy Or Debridement:
In cases of suspected endobronchial tumors or granulation tissue obstructing the airway, or to debride mucus plugs unresponsive to conservative management
In specific pediatric scenarios, it may be used for airway sampling or treatment of stenotic lesions.
Failed Conservative Management:
When medical management for suspected foreign body (e.g., antibiotics for presumed pneumonia) fails to resolve symptoms, and FBA remains a strong possibility.
Management
Initial Management:
Secure airway if compromised
Administer oxygen
Monitor vital signs closely
Immediate transfer to a facility equipped for rigid bronchoscopy.
Bronchoscopic Procedure:
Performed under general anesthesia with spontaneous ventilation or controlled ventilation depending on the location and size of the foreign body
A rigid bronchoscope is inserted, and the foreign body is visualized and removed using appropriate instruments (forceps, snares, aspirators).
Post Bronchoscopy Care:
Monitor vital signs and respiratory status
Administer humidified oxygen
Provide analgesia and antipyretics as needed
Chest physiotherapy may be beneficial
Monitor for complications such as pneumothorax, bleeding, or airway injury.
Medical Management:
Antibiotics for suspected or confirmed post-obstructive pneumonia or lung abscess
Bronchodilators may be used cautiously if bronchospasm is present, but direct removal is paramount
Steroids are generally not indicated unless there is significant associated inflammation or post-operative swelling.
Complications
Early Complications:
Laryngospasm
Bronchospasm
Hypoxia
Bradycardia
Laryngeal edema
Vocal cord injury
Tracheal or bronchial mucosal injury
Pneumothorax
Hemorrhage.
Late Complications:
Persistent atelectasis
Post-obstructive pneumonia or lung abscess
Bronchiectasis
Granulation tissue formation
Airway stenosis
Chronic cough
Recurrent aspiration
Failure to thrive.
Prevention Strategies:
Education of parents and caregivers about choking hazards and safe feeding practices
Appropriate toy selection for young children
Prompt medical evaluation for any suspected choking episode
Timely referral for bronchoscopy when indicated.
Prognosis
Factors Affecting Prognosis:
Time to diagnosis and removal
Nature and location of the foreign body
Presence of complications (e.g., infection, significant airway damage)
Skill of the bronchoscopist.
Outcomes:
With timely and successful removal via rigid bronchoscopy, the prognosis is generally excellent, with complete resolution of symptoms
However, delayed diagnosis or management can lead to long-term respiratory sequelae.
Follow Up:
Routine follow-up with a pediatrician or pulmonologist is recommended, especially if complications were present or if there is concern for residual airway issues
Follow-up chest X-rays may be indicated
Education on prevention should be reinforced.
Key Points
Exam Focus:
Rigid bronchoscopy is the investigation of choice for suspected foreign body aspiration in children
Indications include airway compromise, failure of conservative management, and diagnostic confirmation
Common aspirated objects and their typical locations (e.g., right main bronchus)
Recognize symptoms of acute vs
chronic FBA.
Clinical Pearls:
Never underestimate the history of a choking episode, even if the child is asymptomatic at presentation
A normal chest X-ray does not exclude FBA
Always consider the possibility of FBA in children with unexplained recurrent pneumonia, wheezing, or hemoptysis
The right bronchial tree is the most common site for aspiration due to its wider diameter and more vertical orientation.
Common Mistakes:
Delaying bronchoscopy in a symptomatic child with high suspicion of FBA
Relying solely on chest X-ray to rule out FBA
Mistaking FBA for asthma or pneumonia, leading to delayed or incorrect treatment
Inadequate removal of the foreign body or associated secretions.