Foreign Bodies in the Airway

Epidemiology and Etiology

Choking is a leading cause of morbidity and mortality among children, especially those younger than 4 yr of age. Most victims of foreign body aspiration are older infants and toddlers ( Fig. 414.1 ); males have been found to be victims up to 1.7 times more likely than females. Studies show that children younger than 4 yr of age account for 61.7–70% of airway foreign body cases. The most common objects on which children choke are food items (59.5–81% of all choking cases). Nuts, seeds, hot dogs, hard candy, gum, bones, and raw fruits and vegetables are the most frequently aspirated food items. From 2001 to 2009, an average of 12,435 children ages 0-14 yr in the United States were treated in emergency departments for choking on food without fatality. Common inorganic objects on which children choke include coins, latex balloons, pins, jewelry, magnets, pen caps, and toys. Globular, compressible, or round objects such as hot dogs, grapes, nuts, balloons, marshmallows, meats, and candies are particularly hazardous due to their ability to completely occlude the airway.

Young children are more at risk to aspirate a foreign body largely because of their developmental vulnerabilities and their underdeveloped ability to swallow food. Infants and toddlers often use their mouths to explore their surroundings, and children generally are more likely to be distracted, playing, or ambulatory while eating. An infant is able to suck and swallow and is equipped with involuntary reflexes (gag, cough, and glottis closure) that help to protect against aspiration during swallowing. Dentition develops at approximately 6 mo of age with the eruption of the incisors. Molars do not erupt until approximately 1.5 yr of age; mature mastication takes longer to develop. Despite a strong gag reflex, a child's airway is more vulnerable to obstruction than an adult's airway. Young children are more likely to experience significant blockage by small foreign bodies due to their smaller airway diameter. Mucus and secretions may form a seal around the foreign body, making it more difficult to dislodge by forced air. In addition, the force of air generated by an infant or young child's cough is less effective in dislodging an airway obstruction. It is recommended that children younger than 5 yr of age should avoid hard candy and chewing gum and that raw fruits and vegetables be cut into small pieces. Other factors, such as developmental delays or disorders causing neurologic or muscular issues, can also put children at higher risk for foreign body aspiration.

Clinical Manifestations

Foreign bodies of the airway have variable presentations and complications, depending on the characteristics, duration, and location of the foreign body. The clinical manifestations range from an asymptomatic state to severe respiratory distress. The most serious complication of foreign body aspiration is complete obstruction of the airway, which may be recognized in the conscious child as sudden respiratory distress followed by an inability to speak or cough.

There are typically three stages of symptoms that result from aspiration of an object into the airway:

• 1

  Initial event: Paroxysms of coughing, choking, gagging, and possibly airway obstruction occur immediately after aspiration of the foreign body. The child is sometimes able to expel the foreign body during this stage.

• 2

  Asymptomatic interval: The foreign body becomes lodged, reflexes fatigue, and the immediate irritating symptoms subside. The lack of symptoms can be particularly misleading to the provider when a child presents in this stage and accounts for a large percentage of delayed diagnoses and overlooked foreign bodies . A large meta-analysis of more than 30,000 patients showed that diagnosis is delayed more than 25 hr in almost 40% of airway foreign body cases.

• 3

  Complications: Obstruction, erosion, or infection develops, which again directs attention to the presence of a foreign body. In this third stage, complications include fever, cough, hemoptysis, pneumonia, and atelectasis. Acute or chronic complications have been reported in almost 15% of cases of foreign bodies of the airway.