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RESPIRATORY DISORDERS*

*The authors acknowledge the special contributions of Nooruddin R. Tejani, Diana E. Weaver, Ari J. Goldsmith, Haidy Marzouk, and Jessica Stetz to prior edition.

TRACHEOBRONCHIAL FOREIGN BODIES

Clinical Features

Foreign body (FB) aspiration, although 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, but hot dogs, candy, meat, and grapes are the most implicated objects in choking fatalities. Aspiration of manmade objects is less likely to result in death; balloons, small balls, and beads account for most fatalities. 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 linoleic acid, which can cause unilateral or bilateral wheezing.

Aspirated FBs can be difficult to diagnose because clinical symptoms may mimic asthma, recurrent pneumonia, bronchiolitis, or URIs. Aspirated FBs should be considered in any young child with new-onset respiratory distress, choking, stridor, cough, or wheezing. 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. FBs of the lower respiratory tract occur in younger children, with a slight propensity for the right lung. The classic triad of cough, focal wheezing, and decreased breath sounds is observed in <20% of children with aspiration. 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 the third phase of the disease course, resulting in complications ranging from atelectasis to pneumonia.

FIGURE 6.1

Aspiration/Asphyxiation by Food Products. (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 contributors: Binita R. Shah, MD [A], and Charles Catanese, MD [B].)

FIGURE 6.2

Carrot Aspiration. A 4-year-old boy had a choking episode while he was running with a carrot in his hand. He presented to the ED with a new onset of bilateral wheezing. (A, B) Decubitus views of the chest demonstrate hyperinflation of both lungs, (C) Carrot after bronchoscopic removal from ...

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