You have a new patients!
Patient 1
A 72-year-old male was brought from an inpatient stroke rehabilitation center to the emergency department for a cough lasting the past ten days. Along with the cough, the patient was noted to have blood-tinged sputum, which is sometimes foul-smelling. His vital signs are as follows: temperature of 38.4°C, blood pressure of 138/78 mmHg, heart rate of 103 bpm, respiratory rate of 26 breaths/min, and oxygen saturation of 93% on room air. On physical examination, the patient exhibits tachypnea, dullness on percussion, bronchial breathing, egophony, and increased vocal fremitus upon examining the right side of his lung.
Patient 2
Thirty minutes later, the nurse calls you regarding a 5-year-old boy brought in by his mother, presenting with stridor and an ongoing cough. The mother mentions that she found her child playing with her wallet while she was in the next room and discovered him in this condition. The child is tachypneic, saturating at 90% on room air with subcostal retractions. Examination of the right lung revealed wheezing with decreased air entry.
What do you need to know?
Importance
Tracheobronchial foreign body aspiration (FBA) can be a potentially life-threatening event. FBA in children may be suspected based on a choking episode if such an episode is witnessed by an adult or remembered by the child. In contrast, the clinical presentation of unwitnessed FBA may be subtle, requiring careful review of the history, clinical assessment, and judicious use of radiography and bronchoscopy for diagnosis. Flexible and rigid bronchoscopy have become the cornerstone of both diagnosis and treatment in patients with suspected airway foreign bodies, which are most commonly seen in patients with FBA [1].
Epidemiology
FBA is more common in children than in adults. Data from the National Security Council report that approximately 80 percent of cases occur in patients younger than 15 years of age, with the remaining 20 percent presenting in those older than 15 years. Overall, death from FBA is the fourth leading cause of accidental home and community deaths in the United States, with over 5,000 fatal episodes of FBA reported during 2015. Death from FBA peaks in children under 1 year old and in adults over 75 years [2].
Pathophysiology
In children, nuts, seeds, and other organic material account for the majority of foreign bodies. However, in adults, the nature of inhaled objects is highly variable, ranging from organic to inorganic material. The type of foreign body significantly impacts the degree of tissue reaction in the airway. For example, some inorganic materials, such as metal or glass items, may cause little tissue inflammation but can result in direct airway injury if they are sharp. In contrast, some organic materials, such as nuts and a variety of pills, can cause significant inflammation, granulation tissue formation, and airway stenosis. Aspirated organic material can also expand from airway moisture, worsening obstruction. Aspiration of medications in pill form, such as iron tablets, aspirin, and potassium chloride, can also cause severe airway inflammation and ulceration [2].
Medical History
Clinical presentation can range from chronic nonspecific respiratory complaints to acute airway obstruction. In most cases of aspiration, the presence of a foreign body can be suspected after a thorough history. Patients with airway foreign bodies may present with noisy breathing, inspiratory stridor, rhonchi, vomiting, changes in voice, and hemoptysis [3]. Some patients may report a history known as penetration syndrome, which includes a choking sensation accompanied by wheezing and coughing. Coughing may not completely expel the foreign body but may instead cause its impaction in the subglottic region. Therefore, coughing after suspected aspiration should prompt a search for a foreign body, even if symptoms improve [4].
In pediatric patients with suspected foreign body aspiration, the sudden onset of choking or intractable cough associated with wheezing and respiratory distress occurs in more than 63% of cases [5,6]. In addition to coughing and choking, stridor is a frequent symptom. The absence of early coughing and choking is associated with delayed diagnosis and chronic presentations, such as recurrent pneumonia [4]. The sudden onset of dyspnea and odynophagia may indicate an impacted subglottic object. If the object is sharp and thin, the emergency clinician should suspect embedding between the vocal cords or in the subglottic region, resulting in partial obstruction [7].
Other components of the history can assist in diagnosing and characterizing foreign bodies in patients with aspiration of nonfood objects. Many types of items may be aspirated by children exploring their environment. Another at-risk population includes individuals who habitually store small items in their mouths for quick access; examples include construction workers (nails) and seamstresses (pins). The presentation of patients with a retained airway foreign object may involve only infectious complications. A foreign object can lead to a retropharyngeal abscess. Patients with atypical or recurrent pneumonia may have pulmonary infections caused by the persistence of a foreign object serving as a focus of infection [6].
Physical Examination
Physical findings depend on the degree of airway obstruction and the duration of the object’s presence. Depending on the size and location of the foreign body, the examination may reveal a normal patient, one with cyanosis and respiratory arrest, or any condition between these two extremes. Patients may exhibit stridor or hoarseness with upper airway foreign objects, and intercostal or sternal retractions may be observed in patients with high-grade obstruction caused by tracheal foreign bodies [8]. Hypoxemia may be present; however, normoxia does not rule out the presence of a foreign body. Patients with secondary infections may present with fever.
Oropharyngeal examination may reveal a foreign body posteriorly or donor sites of fractured teeth. The examination should also include a search for fractured or missing dental prostheses. Oropharyngeal examination can often be supplemented by indirect or direct laryngoscopy or nasopharyngoscopy, but these procedures should be performed only if the procedural stress does not pose an undue risk of airway compromise.
Coughing may result from local irritation caused by bronchial foreign bodies. Localized or apparently generalized wheezing is frequently auscultated in patients with lower respiratory tract foreign bodies [9]. Complete obstruction of a mainstem bronchus may result in absent ipsilateral breath sounds; however, breath sounds can sometimes be transmitted across the thorax, and the only physical abnormality may be asymmetric chest rise. Occasionally, a foreign body acts as a one-way valve, allowing air into the lung during inspiration but preventing its exit during expiration. The affected lung becomes hyperexpanded, which may be detected as hyper-resonance on percussion [6].
Alternative Diagnoses
The selected differential diagnoses for airway foreign bodies include anaphylactic reactions, acute pharyngitis, acute epiglottitis, retropharyngeal abscess, neck tumors, pulmonary carcinomas, pneumonia, bronchitis, bronchiolitis, and tuberculosis.
Acing Diagnostic Testing
Imaging should not delay intervention in cases of suspected acute asphyxiation but is indicated for stable patients [10].
Findings on imaging depend on the type and location of the material aspirated and the time elapsed. In practice, plain films of the neck and chest are often performed simultaneously and can be followed by site-specific CT if suspicion remains. The majority of foreign bodies are radiolucent and not easily identified on plain film. If obstruction of the upper airway (oropharynx and upper trachea) is suspected, initial imaging should include anterior-posterior and lateral soft tissue views of the neck [11]. If these tests are negative and suspicion for FBA persists, further imaging with CT may be indicated. When FBA of the lower airways (below the vocal cords) is suspected, a chest radiograph should be the initial radiographic test to look for an obvious radiopaque airway lesion. Negative scans may prompt further evaluation with CT. The reported sensitivity of chest radiography is approximately 60 to 80 percent in children, and clinical experience suggests similarly poor sensitivity in adults [12].
Given its widespread availability, flexible bronchoscopy is often the diagnostic procedure of choice for non-life-threatening FBA in adults, particularly in cases involving smaller foreign bodies in the lower airway. Flexible bronchoscopy allows precise identification and localization of foreign bodies and facilitates the selection of instruments necessary for retrieval [13]. Additionally, flexible bronchoscopy enables removal of the foreign body during the diagnostic procedure if the operator is skilled in these techniques. Standard diagnostic or therapeutic flexible bronchoscopes are usually adequate for the management of FBA in adults [6].
Risk Stratification
Risk factors in adults include loss of consciousness due to trauma, drug or alcohol intoxication, or anesthesia. Additional risk factors in older adults include age-related slowing of the swallowing mechanism, medication use (impairing cough and swallowing), stroke-related dysphagia, and various degenerative neurologic diseases such as Alzheimer’s or Parkinson’s disease [2].
Management
In a conscious adult, data support the efficacy of chest thrusts, back blows or slaps, blind finger sweeps, and abdominal thrusts in relieving complete foreign body airway obstruction [6, 14]. In cases of life-threatening asphyxiation, initial support should focus on treating airway obstruction and respiratory failure. Once the airway is secured, a laryngoscopic evaluation of the oropharynx should be performed immediately to diagnose and retrieve a supraglottic or glottic foreign body. If a foreign body is not seen, rigid bronchoscopy is generally the procedure of choice for suspected asphyxiating foreign bodies located in the trachea or major bronchi. In patients with non-life-threatening FBA, flexible bronchoscopy is typically performed [15].
When large foreign bodies completely or almost completely obstruct major upper airways (glottis, supraglottis, trachea), it is critical to ensure the patient is oxygenated and the airway is secured [16]. Support measures may include bag-valve-mask ventilation and endotracheal intubation. If ventilation is unsuccessful, an emergent cricothyrotomy or tracheotomy may be required if the foreign body is suspected to be above the vocal cords. Once the airway is secured, immediate inspection of the oropharynx (glottis, supraglottis) is indicated, as one-third of FBA cases presenting as acute asphyxiation are located in the supraglottis. Retrieval of the foreign body with Magill forceps can be safely performed using direct laryngoscopy (glottis, supraglottis) or with smooth or alligator forceps during rigid or flexible bronchoscopy (large central foreign body in the trachea or major bronchus) [17].
The choice of procedure for foreign body removal depends on the type of presentation, characteristics of the inhaled foreign body, its location, the duration it has been in the airway (if known), and local expertise. Anti-inflammatories and antibiotics are not routinely administered to patients with suspected or documented FBA. Antibiotics are indicated only in cases of clinically, radiologically, or microbiologically documented respiratory tract infections. However, their use should not delay foreign body extraction, even if pneumonia or sepsis is suspected [2].
Special Patient Groups
In the pediatric age group, moderate or high suspicion of FBA is suggested by any of the following:
- Witnessed FBA, regardless of symptoms.
- History of choking, with any subsequent symptoms or suspicious characteristics on imaging.
- A young child with suggestive symptoms without another explanation, especially if there are suspicious characteristics on imaging. Suspicious symptoms include cyanotic spells, dyspnea, stridor, sudden onset of cough or wheezing (often focal and monophonic), and/or unilaterally diminished breath sounds.
The tracheobronchial tree should be examined in all cases with moderate or high suspicion of FBA, using rigid bronchoscopy (or, in some cases, computed tomography [CT]). On occasion, the adjunctive use of a flexible bronchoscope may be helpful. Normal chest radiographs are not sufficient to rule out FBA [19], primarily because most foreign bodies are radiolucent. Morbidity and mortality may increase if bronchoscopic evaluation is delayed.
When To Admit This Patient
Most patients improve clinically following FBA removal. Those with imaging abnormalities should undergo follow-up imaging six weeks to three months after extraction to confirm resolution. Patients presenting with a delayed presentation and belonging to high-risk groups should be admitted for management of complications and FBA retrieval and removal.
Revisiting Your Patients
The elderly patient, given his history of a recent stroke and being in a rehabilitation center, is at risk of FBA. His presentation with chronic cough and fever raises suspicion of pneumonia; however, the emergency medicine clinician should maintain a broad differential diagnosis based on further history, including foul-smelling sputum and nursing staff observations of difficulty swallowing and previous admissions for pneumonia. Such delayed presentations of FBA can occur in this age group. The patient’s management began with initial stabilization using oxygen support, along with workup for infection. Imaging modalities started with a chest plain film, which showed right lower lobe opacities but no clear foreign body. With suspicion for FBA still high, a chest CT scan was performed and revealed evidence consistent with FBA. The patient was started on broad-spectrum antibiotics, and bronchoscopy was scheduled as the definitive management for FBA. Follow-up bronchoscopy identified distal fragments of nuts impacted in the right lower lobe bronchus.
In the pediatric patient, the presentation is more acute and requires securing the airway. After placing the patient on a non-rebreather mask with 15L of oxygen, his saturation improved to 100%. Given the history of playing with a wallet, suspicion of coin aspiration was considered. A chest radiograph with posteroanterior and lateral views was performed, showing a rounded radiopaque structure in the right main bronchus. Airway support and supplemental oxygen should be provided until bronchoscopy is performed and the coin is retrieved.
Authors
Elhaitham Ahmed
Zayed Military Hospital, AbuDhabi
Khalifa Alqaydi
Zayed Military Hospital, AbuDhabi
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References
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Reviewed and Edited By
Arif Alper Cevik, MD, FEMAT, FIFEM
Prof Cevik is an Emergency Medicine academician at United Arab Emirates University, interested in international emergency medicine, emergency medicine education, medical education, point of care ultrasound and trauma. He is the founder and director of the International Emergency Medicine Education Project – iem-student.org, chair of the International Federation for Emergency Medicine (IFEM) core curriculum and education committee and board member of the Asian Society for Emergency Medicine and Emirati Board of Emergency Medicine.
