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Clinical Features

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Foreign body (FB) aspiration, though uncommon, accounts for 7% of deaths in children under 4 years of age. Most aspirated FBs become lodged in the bronchi because their size allows for passage through the larynx and glottis. Large FBs may become impacted in the larynx or trachea, potentially causing complete obstruction, a true emergency. Nuts and seeds are the most commonly aspirated objects. Beans and seeds absorb water and can swell in the airway over time. Organic FBs can cause a surrounding tissue reaction leading to severe inflammation; nuts and seeds release linolic acid, which can cause unilateral or bilateral wheezing.

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Figure 6.1 ▪ Aspiration/Asphyxiation by Food Products.
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(A) The most commonly aspirated food products by infants and children include peanuts, chunky peanut butter, hot dogs, popcorn, seeds, grapes, raisins, carrots, meat, and hard candies. Children too young to chew and swallow carefully (usually <5 years of age) should not be given these foods. (B) A piece of hot dog is seen lodged in the trachea of a 2.5-year-old child presenting in cardiopulmonary arrest. For children <5 years, hot dogs should be cut longitudinally and not into round pieces. (Photo contributor: Binita R. Shah, MD [A] and Charles Catanese, MD [B].)

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Aspirated FBs can be difficult to diagnose as clinical symptoms may mimic asthma, recurrent pneumonia, or URI. Sudden choking and gagging with dyspnea are the first signs of aspiration. However, in up to 50% of cases, the choking episode is not witnessed. After the initial phase of choking and paroxysms of cough, children often enter into an asymptomatic phase that lasts for hours or even weeks as the FB becomes lodged. In cases of FBs of the larynx or trachea, children may present with hoarseness, stridor, and possibly cyanosis. Children with bronchial FB often present with a triad of cough, wheezing, and decreased breath sounds. However, only about two-thirds of children have all components of this triad. When these symptoms are prolonged or atypical, FB should be suspected. Unilateral decreased air entry on chest auscultation is only present in one-third of cases. Untreated, patients may enter into the third phase of the disease course, resulting in complications from atelectasis to pneumonia.

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Most FBs are not radiopaque and small FBs may cause symptoms but no radiologic changes. Frontal view of chest may show air trapping secondary to obstructive emphysema. Bronchial FB results in obstruction during expiration, where air entry is possible during inspiration due to a partial obstruction (“ball-valve”) or can result in complete obstruction with poor pneumatization and atelectasis. The sensitivity of plain chest radiograph is increased when inspiratory and expiratory films are taken. Mediastinal shift to the opposite side on the expiratory phase is diagnostic. Patients who are not old enough to obtain inspiratory and expiratory films should have right and left lateral decubitus radiographies performed. The lung positioned in the dependent position will deflate under the weight of the heart unless it is obstructed. ...

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