BACKGROUND
Foreign body aspiration (FBA) is a common cause of morbidity and mortality in children. Thousands of children are seen in emergency departments each year for choking-related episodes, and choking is a leading cause of death in young children. The age group most at risk is 1 to 3 years of age. These children may choke on food substances given their incomplete dentition, immature swallowing coordination, and tendency toward distraction during meals. In addition, infants and toddlers are newly adapted to walking and have a tendency to put everything in their mouths. This increases their risk of unwitnessed choking events. Older children more commonly aspirate things such as pins and pen caps, which they are holding in their mouths.
PRESENTATION
Children who have aspirated foreign material may present acutely following a witnessed or reported event. Families commonly report a choking or gagging episode. Such an event, followed by sudden onset of coughing with unilateral wheezing or decreased aeration, represents the classic diagnostic triad for FBA in the mainstem or lower bronchi. When the foreign body becomes lodged more proximally, partial upper airway obstruction can lead to hoarseness or stridor. Complete obstruction of the trachea or larynx can occur either from mechanical blockage or from induced laryngospasm. The mortality with complete laryngeal obstruction approaches 50%.
Many children have unwitnessed or unreported aspiration events. Infants are preverbal, and young children may not recognize the need to tell their parents. Alternatively, if immediate symptoms resolve, caregivers may not recognize the significance of the event unless a provider directly asks about recent choking episodes. As a result, respiratory symptoms may be incorrectly attributed to illnesses such as asthma or croup. Subsequent recurrent pulmonary infections may lead to the delayed diagnosis of chronic FBA. This can occur weeks to months after the aspiration event.
For the purpose of this chapter, we will focus only on acute airway management in the context of known or suspected FBA.
TECHNIQUE
The approach to the management of FBA will differ depending on whether the obstruction is partial or complete, and the child’s level of consciousness.
Partial Airway Obstruction
Children with FBA who have the ability to cough, cry, or speak are demonstrating adequate air exchange, and by definition have incomplete airway obstruction. Beyond infancy, children will naturally hold themselves in a position that maximizes airway patency. In addition, they possess a reflexive cough, which is the most effective means of clearing the airway. These patients, therefore, should be managed “expectantly.” That is, no attempts at relief maneuvers should be attempted to avoid dislodgement of the foreign body to a location that worsens the degree of obstruction.
Resources should be summoned to facilitate removal in the operating room setting whenever possible. If an operating room or pediatric expert resources are unavailable, an alternative plan must be initiated. Appropriately sized equipment should be gathered for foreign body removal, as well as for more definitive airway management in the event that the child progresses to complete airway obstruction (discussed below).
Attempts at removal of the foreign body for children with partial airway obstruction are rarely performed in the emergency department. Children are unlikely to cooperate with efforts to remove an airway foreign body even with effective topical anesthesia. Furthermore, unintentionally placing a laryngoscope blade too deeply in small children will risk placing direct pressure on the foreign body, which can further obstruct the airway. Therefore, in most cases, the child should be allowed to continue to attempt to clear the foreign body reflexively as long as possible, or until an operating room is available. Only when the patient is showing signs of tiring or progression toward complete obstruction should attempts at removal be made. In such circumstances, sedation with ketamine titrated intravenously (1 to 2 mg per kg IV) to effect if possible (or 4 mg per kg IM if not) reliably produces dissociative sedation while maintaining respiratory drive and airway reflexes. Once sedated, the laryngoscope is inserted methodically, while the provider maintains anatomic visualization attempting to identify any supraglottic foreign body.
If the patient progresses to complete obstruction, either because of unavoidable progression or as a result of attempts at removal, immediate intervention is required.
Complete Airway Obstruction
The loss of the ability to phonate in an awake child with a suspected FBA indicates complete airway obstruction. Chest wall movement will persist with attempted respiratory efforts; however, no sounds will be heard on inspiration or expiration. Conscious children will appear scared, although infants will not reliably place their hands to their neck to signify choking as older children or adults will. Instead, they will often raise clenched fists above their heads with eyes wide open as an expression of distress.
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