We all know kids love to get objects stuck in areas where no foreign body should be. We have discussed this several times (the Nasal Foreign Body, the Ear Foreign Body, and the Ingested Foreign Body), but the Aspirated Foreign Body is the one that gets our attention the quickest. That is, unless, we missed it at first. Unfortunately, a foreign body in the bronchus may be deceptive and present in a delayed fashion… so, we must be vigilant (as always).

Young Kids are at Risk

• It would seem intuitive that younger kids are at greater risk for aspiration… but why?
• Young kids:

1. put random things in their mouths. They like to explore their world… and don’t know what is not edible (hmmm crayons).
2. don’t chew their food well. They do not have molar teeth and are prone to have insufficient mastication.
3. are easily distracted.  It is not a great idea to yell at your sister while stuffing hotdogs in your mouth, but they don’t know that yet.
4. don’t protect themselves well. They have relatively high epiglottis and immature swallowing coordination.

Drama is Easy to See, but Subtle can be Dangerous too.

• The aspirated foreign body that leads to respiratory distress won’t be missed by many.
• Unfortunately, an aspirated foreign body may go undiagnosed and this can lead to significant sequelae.
  • Persistent febrile illness
  • Chronic cough
  • Recurrent pneumonia
  • Recurrent / persistent “croup”
  • Poorly controlled “asthma”
  • Lung abscess
  • Hemoptysis
  • Progressive respiratory distress
  • Death

• Delayed diagnosis of an aspirated foreign body is associated with increased incidence of complications.
• This is particularly true for any vegetable matter (ex, peanuts), which cause more inflammatory response the longer it is in the body.

Factors Related to Delayed Diagnosis

• Younger age

  • Kids 3 years of age and younger are more likely to be diagnosed with foreign body in a delayed fashion.
  • These kids are less able to give a reliable history and more at risk (as mentioned above) for aspiration.

• Negative Chest X-rays

  • Just because the child’s CXR is negative, doesn’t mean that there is not a foreign body!
    • It just means your job is more difficult.
    • ~50% of known cases of aspiration will have normal chest x-rays.
  • Special projection films (decubitus position, exhalation films) can help, but should not be used to completely rule out the condition.
  • Normal X-rays should not preclude bronchoscopy in a patient that you have concern for an aspirated foreign body.
    • That is taken from the ENT literature — in case you need some support when dealing with consultants.

• Care provider negligence

  • When no one is supervising, badness can happen (says Captain Obvious).
  • One study showed that having No history of a witnessed aspiration episode was associated with delayed diagnosis.
  • A lack of a parental report of an aspiration event should not sway you from considering retained foreign body in a child who’s clinical picture suggests it.

• Lack of typical symptoms

  • With a radio-opaque foreign body, the diagnosis will depend on the history (hopefully someone saw something) and the physical exam.
  • Unfortunately, after the initial choking event, the aspirated foreign body may cause little if any symptoms, particularly if it falls to the bronchus.
  • The diagnosis is then delayed until symptoms of complications arise.

• Location matters:
  • Larynx – typically will have symptoms of obstruction, dysphonia, or hoarseness. If blockage is complete, then can have cyanosis and severe distress / arrest.
  • Trachea – similar to larynx in presentation, but can have biphasic stridor, dry cough. Often appear uncomfortable or scared.
  • Bronchus – 80-90% of foreign bodies are found in the bronchus. Only 65% will have triad of cough, wheeze, and decreased breath sounds! Can be asymptomatic!
• The absence of symptoms and signs does not rule out the possibility of foreign body if the child has a concerning history of aspiration.

• We were not vigilant

  • Simply put, we didn’t think about the possibility.
  • The diagnosis can be rather difficult, as it may present similar to other conditions:
    • Recurrent Croup and Croup are commonly diagnosed instead of Foreign Body.
    • Asthma, bronchitis, pneumonia, laryngitis, and URI are other common mis-diagnoses.

Believe the Parents

• Multiple studies have shown that, while a variety of clinical signs may be seen with an aspirated foreign body…
• The most sensitive clinical indicator for an aspiration is there being a “Witnessed Aspiration Episode.”
• Since the physical exam and radiographs may be unenlightening, the parental report of a choking crisis needs to be taken seriously!

References