Summary
Foreign body aspiration (FBA) is a potentially life-threatening emergency that most commonly occurs in children 1–3 years of age. A foreign body (FB) can become lodged in either the upper or lower airway and cause either a partial or complete airway obstruction. Complete obstruction of the larynx or upper trachea is a potentially life-threatening situation that causes severe respiratory distress, cyanosis, and suffocation; it should be managed with first-aid maneuvers (e.g., CPR in unresponsive patients or maneuvers to dislodge an aspirated FB in responsive patients) and, if needed, emergency airway procedures for FBA. Partial obstructions that do not cause significant respiratory distress can be removed via laryngoscopy, nasal endoscopy, or bronchoscopy if coughing fails to dislodge the FB. Lower airway FBA typically manifests with sudden-onset coughing and choking, followed by wheeze and dyspnea. Most commonly, the FB becomes lodged in the main and intermediate bronchi; approx. 60% of foreign bodies become lodged in the right main bronchus because of its more vertical orientation compared to the left main bronchus. If initial maneuvers fail to dislodge the FB and the patient is stable, imaging (e.g., x-ray of the neck or chest, CT chest, bronchoscopy) to localize the FB should be obtained, followed by a planned removal of the aspirated FB. If an FB remains undetected, it may result in chronic cough and recurrent pulmonary infections.
Epidemiology
-
Pediatric
- 80% of all cases occur in children < 3 years. [1]
- Peak incidence: 1–2 years
-
Adult
- FBA accounts for 0.16–0.33% of adult bronchoscopies. [2]
- Incidence: rises with age [3]
- Mortality rate: highest in patients 80–90 years of age [4]
Epidemiological data refers to the US, unless otherwise specified.
Etiology
-
Children and infants [5]
- Aspiration of a FB (e.g., of nuts, raisins, coins, toys) while chewing
- The risk of aspiration is higher if the infant or child is speaking, laughing, or playing while chewing.
- Toddlers are prone to examining objects with their mouth, and a sudden inspiration can result in aspiration. [1]
-
Adults
- Accidental aspiration
- Underlying conditions that increase the risk of aspiration [2]
- Neurological illnesses causing dysphagia
- Intoxication
- Altered mental status
- Neuromuscular disease
Pathophysiology
-
Aspiration of an FB → airway obstruction
- Complete airway obstruction → collapse of the respiratory structures distal to the obstruction (e.g., atelectasis)
- Partial airway obstruction: formation of a ball-valve obstruction with air trapping → build-up of pressure distal to the obstruction
-
Localization
- Upper airway obstruction: a minority of FB are lodged in the larynx or trachea
-
Bronchi: the right main bronchus is more often affected than the left main bronchus
- Aspirated particles are most likely to become lodged at the junction of the right inferior and right middle bronchi → right lower and middle lobe aspiration pneumonia
- Upper right lobe affected in bedridden patients, particularly while lying on their right side.
- In children, the two main bronchi are affected with similar frequency (compared to adults); however, there is still a slight right-sided predominance.
- Less severe than upper airway obstructions
Approximately 60% of foreign bodies become lodged in the right main bronchus because of its more vertical orientation compared to the left main bronchus.
References:[6][7]
Clinical features
Clinical features depend on the degree of airway obstruction and the duration of time since aspiration of the FB. See also “Upper airway FB obstruction” and “Lower airway FB obstruction” for differentiating features. [8]
| Clinical features in FBA | ||
|---|---|---|
| Complete airway obstruction [9] | Partial airway obstruction | Chronic FB airway obstruction |
|
| |
Findings can change as organic foreign bodies absorb water and swell in the lung, converting a partial obstruction into a complete one. [6]
Differential diagnoses
-
Children
- See “Differential diagnoses of pediatric inspiratory stridor”.
- See “Wheezing in children”.
- Acute obstructive bronchitis
- Laryngomalacia [10]
-
All ages [10]
- Tracheal blunt trauma, tumor, or stenosis
- Laryngeal trauma, tumor/papilloma
- Anaphylaxis
- Acute bilateral vocal cord paralysis
- Bronchial asthma (presents with bilateral wheezing, as opposed to the unilateral wheeze seen in FBA)
- Spontaneous pneumothorax
- Pneumonia
- Tracheobronchial tumor
- Extrinsic compression or infiltration of a large airway from an adjacent mass
The differential diagnoses listed here are not exhaustive.
Initial management (overview)
- Prioritize airway management and respiratory stabilization. [8]
- Defer diagnostic imaging if there are signs of respiratory distress or respiratory failure.
In patients with signs of life-threatening airway obstruction, immediately initiate critical interventions such as first aid (e.g., CPR), basic airway maneuvers, and emergency airway procedures for FBA (see “Unresponsive patients” below for details).
| Overview of diagnostic and therapeutic approach to FBA | ||
|---|---|---|
| Upper airway FB obstruction [11] | Lower airway FB obstruction [2] | |
| Physical findings |
| |
| Initial imaging |
| |
| Advanced imaging and/or dual diagnostic/therapeutic procedures |
| |
| Management: unresponsive patient with suspected FBA |
|
|
| Management: responsive patient with suspected FBA |
|
|
Unresponsive patient
Commence CPR
- Chest compressions may dislodge the object by raising intrapulmonary pressure. [12]
- Attempt to remove the FB while CPR is ongoing.
- Head-tilt/chin-lift maneuver to open the airway
- At every 2-minute pulse check, check the airway for a dislodged FB; remove if present.
- Do not perform blind finger sweeps if a FB is not visible. [13]
- Attempt laryngoscopy-guided FB retrieval.
Emergency airway procedures in FBA
- Indication: failed first-aid attempts to dislodge the FB
-
Anesthesia
- Unresponsive patients: none required
- Responsive patients: See “Planned removal of upper airway FB.”
Laryngoscopy [14]
- Laryngoscopy-guided FB retrieval: Under direct laryngoscopy, attempt to remove any visible FB with Magill forceps.
-
Inability to remove FB with forceps: Intubate using an endotracheal tube (ETT) to displace the FB as distally as possible into either main bronchus.
- Successful distal displacement: Withdraw the ETT to the standard tip-to-lip distance and ventilate if possible.
- Unsuccessful distal displacement: emergency surgical airway (see below)
Laryngoscopy risks converting a partial obstruction into a total obstruction by displacing the object or causing laryngeal trauma and/or hemorrhage [15]
Emergency surgical airway [16]
- Indication: failure of the above maneuvers to remove the FB in an unresponsive patient
-
Options
- Adults: scalpel cricothyroidotomy (or emergency tracheotomy if expertise is readily available) [17]
- Infants and children < 12 years old: needle cricothyroidotomy with percutaneous transtracheal ventilation [18]
-
Further management (after establishing an emergency airway)
- Planned removal of the aspirated FB.
- Urgently consult the relevant department (e.g., ENT, anesthesia) for a definitive airway as needed.
Responsive patient
Suspected complete airway obstruction (patient unable to speak, cry, or cough) [13]
If the patient can speak, cry, or cough, do not attempt back blows or abdominal thrusts, as these maneuvers risk dislodging the FB and converting a partial obstruction into a complete obstruction.
Approach
-
Initiate maneuvers to dislodge the aspirated FB (see table below for technique instructions).
- Back blows: preferred initial maneuver in all patients
-
If back blows are ineffective
- Infants: Perform chest thrusts.
- Adults and children ≥ 1 year old: Perform abdominal thrusts (formerly known as the Heimlich maneuver). [19]
- Failure to dislodge the FB with repeated back blows and chest/abdominal thrusts
- If trained: Proceed with emergency airway procedures for FBA.
- Untrained or instruments not on hand: Continue maneuvers to dislodge the aspirated FB until help arrives.
-
Patient becomes unresponsive
- If trained, proceed to emergency airway procedures in FBA.
- If not trained, start CPR (see “Unresponsive patient”).
Technique
| Maneuvers to dislodge an aspirated foreign body | |
|---|---|
| Infants | Adults and children ≥ 1 year old |
| Initial maneuver: Back blows | |
|
|
| Next step: chest thrusts | Next step: abdominal thrusts [21][22] |
|
|
Suspected partial upper airway FBA
- Sit the patient upright.
- Encourage coughing to dislodge FB.
- Monitor for signs of deterioration.
- Signs of increased work of breathing
- Signs of poor gas exchange (e.g., cyanosis)
- Weak or ineffective cough
- Inability to dislodge the FB and patient remains stable: urgent ENT referral for planned removal of an upper airway FB
Suspected partial lower airway FBA
- Optimize oxygenation (see “Basic oxygen delivery systems”).
- Encourage coughing to dislodge the FB.
- Inability to dislodge the FB and patient remains stable: urgent pulmonology referral for planned removal of a lower airway FB
If at any time the patient becomes unresponsive despite treatment, start CPR, and, if trained, proceed to emergency airway procedures in FBA.
Diagnostics
Prioritize airway management and respiratory stabilization over diagnostics if there are any signs of respiratory distress or respiratory failure (see the “Initial management” sections above).
Imaging in suspected upper airway FBA
Neck x-ray (lateral view)
- Indications: suspected upper airway FB [23]
-
Findings
- Radiopaque foreign objects may be visible.
- Widened prevertebral shadow, loss of cervical lordosis (secondary signs) [24]
An x-ray may not detect a FB due to radiolucency or if the aspirated object is further down than suspected.
Laryngoscopy [25]
- Indications: next management step after failed first-aid attempts to dislodge an upper airway FB
- Findings
- Additional considerations: Nasal endoscopy can be used to remove a nasal FB or ensure there is no FB remnant in the upper airway that can be re-aspirated.
Imaging in suspected lower airway FBA
Chest x-ray [2]
-
Indications
- Initial screening modality in suspected lower airway FBA
- Exclusion of alternative diagnoses
- Views
-
Findings
- FB may be visualized if radiopaque (∼ 25%).
- Lung parenchyma changes suggestive of FBA are described in the table below.
-
Disadvantages
- False reassurance if chest x-ray is normal
- Insufficient detail for planning removal of FB; further imaging usually necessary
| Chest x-ray findings suggestive of FBA [2] | ||
|---|---|---|
| Early findings | Late findings | |
| Partial airway obstruction |
|
|
| Complete airway obstruction | ||
Chest x-ray may be normal in patients with FB aspiration.
If there is a high suspicion of FBA, CT chest or bronchoscopy should be performed even if the chest x-ray is inconclusive.
CT chest without contrast (∼ 100% sensitivity) [2]
-
Indications
- Second-line test in suspected lower airway FBA with a normal or inconclusive chest x-ray
- To guide planned removal of FB [2]
-
Findings
- Similar to chest x-ray
- Additionally includes: [27]
- Focal bronchial wall thickening adjacent to the FB
- Tree-in-bud opacities [28]
- Disadvantages: false-negative CT if the FB is very small or in patients with severe dyspnea [27]
Bronchoscopy [2]
Bronchoscopy is the gold standard diagnostic and therapeutic modality for a suspected lower airway FBA.
-
Indications
- Preferred modality in patients with signs of respiratory distress suspected to be due to a lower airway FB [2]
- Next step in stable patients high clinical suspicion of lower airway FBA despite inconclusive imaging.
-
Findings
- Direct visualization of the FB
- Granulation tissue if localized irritation has occurred
- Disadvantages: requires sedation and/or anesthesia
Investigation of the underlying causes
In adults with suspected neurological or neuromuscular abnormalities, consider a clinical swallow evaluation and other diagnostics for dysphagia. [29][30]
Treatment
Emergency management of suspected FBA is covered in the “Initial management” sections above.
This section describes procedures to remove a FB in stable/stabilized patients if CPR or initial maneuvers to dislodge the aspirated FB have failed.
Planned removal of an upper airway FB
- Indication: stable patients with an upper airway FB if attempted maneuvers to dislodge an aspirated FB have failed
-
Anesthetic considerations [15][31]
- Local anesthesia (1% topical lidocaine) can be considered in alert, cooperative patients with an oropharyngeal FB.
- If general anesthesia is required, IV induction with spontaneous breathing or smooth mask inhaled anesthesia is preferred. [5]
- Modalities: laryngoscopy (or nasal endoscopy)
- Procedure: Under direct visualization, the object is grasped and removed with forceps.
- Risks: Dislodgement of the object can lead to complete airway obstruction; keep equipment on hand to create an emergency surgical airway if needed.
Avoid positive pressure ventilation (e.g., bag-mask ventilation) during anesthesia induction in patients with suspected upper airway FBA as it can dislodge the FB more distally. [31]
Planned removal of a lower airway FB
Bronchoscopy (gold standard) [2]
- Indication: stable patients with confirmed/suspected lower airway FB if first-aid attempts to dislodge the FB have failed
- Type: flexible bronchoscopy or rigid bronchoscopy (see “Bronchoscopy choice in FBA”)
- Procedure: retrieval of the FB under direct vision [2]
-
Risks [32]
- Complete airway obstruction during removal; keep equipment on hand to create an emergency surgical airway if needed.[2]
- Pneumothorax
- Bleeding
- Infection (see “Aspiration pneumonia”)
- Injury of the tracheal/bronchial wall
-
Additional considerations: management of granulation tissue [2]
- Consider parenteral corticosteroids (e.g., methylprednisolone ) prior to bronchoscopy to reduce inflammation and assist FB removal. [2][33]
- Removal of granulation tissue during bronchoscopy may be required to prevent airway stenosis.
| Bronchoscopy choice in FBA [2][34] | |||
|---|---|---|---|
| Indications | Advantages | Disadvantages | |
| Flexible bronchoscopy |
| ||
| Rigid bronchoscopy |
|
|
|
Surgical management [2][33]
-
Indications
- Failure of bronchoscopy to remove the FB
- Destruction of surrounding lung tissue (e.g., bronchiectasis) in delayed presentations [35][36]
- Procedure: thoracotomy with bronchotomy or segmental resection
Acute management checklist
All patients
- Assess for signs of complete airway obstruction.
- Prioritize airway management and oxygenation.
Suspected complete airway obstruction
Unresponsive patient
- Start CPR
- Failure to dislodge FB with CPR: Proceed to emergency airway procedures for FBA.
Responsive patient
- Initiate maneuvers to dislodge the aspirated FB.
- Initial maneuver (all ages): Perform back blows.
- If ineffective
- Adults and children ≥ 1 year old: Perform abdominal thrusts.
- Infants: Perform chest thrusts.
Suspected partial upper airway FB obstruction or suspected lower airway FBA
- Encourage coughing.
- Provide oxygen if hypoxic.
- Urgent ENT consult (upper airway) or pneumology (lower airway)
- Stable patients: Obtain imaging to assist in planned removal of FB.
- All patients will require removal of the FB.
- Upper airway: laryngoscopy or nasal endoscopy
- Lower airway: bronchoscopy or rarely surgical resection
- Consider steroid therapy in lower airway FBA with granulation tissue.
- Adult patients with FBA should receive a workup for an underlying cause.
Complications
- Atelectasis
- Postobstructive pneumonia, lung abscess
- In complete obstruction
- Suffocation, asystole, and death
- Hypoxia: brain damage
References:[37]
We list the most important complications. The selection is not exhaustive.
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