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''---Federico, Monica J., et al.. "Respiratory Tract & Mediastinum." ' Current Diagnosis & Treatment: Pediatrics, 24e'  Eds. William W. Hay, Jr., et al. New York, NY: McGraw-Hill.''

  

Foreign body aspiration occurs when a foreign body lodges somewhere within the respiratory tract. Objects can enter the esophagus through the mouth, or the trachea through the mouth or nose.

Causes

Most cases of foreign body aspiration are seen in children aged 6 months to 3 years old due to the tendency for children to place small objects in the mouth and nose. Small, round objects including nuts, hard candy, popcorn kernels, beans, and berries are common causes of foreign body aspiration.

Signs and Symptoms

Signs of foreign body aspiration vary based on the site of obstruction, the size of the foreign body, and the severity of obstruction. Signs of foreign body aspiration are usually abrupt in onset with coughing, choking, and/or wheezing; however, symptoms can be more progressive if the foreign body does not cause a large degree of obstruction of the airway.

Classically, patients present with acute onset of choking. In these cases, the obstruction is classified as a partial or complete obstruction. Signs of partial obstruction include choking with drooling, stridor, and the ability to speak. Signs of complete obstruction include choking with inability to speak or cough, and signs of respiratory distress such as cyanosis.

If the foreign body does not cause a large degree of obstruction, patients may present with chronic cough, asymmetrical breath sounds on exam, or recurrent pneumonia of a specific lung lobe. The right lower lobe of the lung is the most common site of recurrent pneumonia in foreign body aspiration. This is due to the fact that the anatomy of the right main bronchus is wider and steeper than that of the left main bronchus.

Diagnosis

If foreign body aspiration is suspected, finger sweeping in the oral cavity is not recommended due to the increased risk of displacing the foreign object further into the airway.

Most patients receive a chest x-ray to determine the location of the foreign body. However a negative chest x-ray cannot rule out foreign body aspiration. Rigid bronchoscopy is indicated when two of the three following criteria are met: report of foreign body aspiration by the patient or a witness, abnormal lung exam findings, or abnormal chest x-ray findings. While, x-ray can be used to visualize the location and identity of a foreign body, rigid bronchoscopy under general anesthesia is the gold-standard for diagnosis since the foreign body can be visualized and removed with this intervention.

Treatment

Treatment of foreign body aspiration is determined by the severity of obstruction of the airway involved. In partial obstruction, the patient can usually clear the foreign body with coughing. In complete obstruction, acute intervention is required to remove the foreign body. Non-invasive interventions are recommended as the first step in treatment. For children less than 1 year of age, the patient should be placed face down over the rescuer's arm. Back blows should be delivered with the heel of the hand, then the patient should be turned face-up and chest thrusts should be administered. The rescuer should alternate back blows and chest thrusts five at a time. The Heimlich maneuver should be used in patients older than 1 year of age to dislodge a foreign body. If the patient becomes unresponsive during physical intervention, cardiopulmonary resuscitation (CPR) should be started. In the event that the above measures do not restore adequate ventilation to the patient, need for treatment by trained personnel becomes necessary. Intubation, tracheostomy, or needle cricothyrotomy can be done to restore an airway for patients who have become unresponsive due to airway compromise.

If non-invasive measures do not dislodge the foreign body, and the patient can maintain adequate ventilation, rigid bronchoscopy under general anesthesia should be performed. After the foreign body is removed, patient's should receive nebulized beta-adrenergic medication and chest physiotherapy to clear further secretions from their airway.

Complications

If a foreign body remains in the airway, potential complications can develop. The patient may develop inflammation of the airway walls or a lung abscess.

''---Lucia, Dominic, and Jared Glenn.. "Pediatric Emergencies." CURRENT Diagnosis & Treatment: Emergency Medicine, 8e Eds. C. Keith Stone, and Roger L. Humphries.New York, NY: McGraw-Hill.''

Signs and Symptoms

Signs and symptoms of foreign body aspiration can vary depending on the location and severity of occlusion. 20% of foreign bodies become lodged in the upper airway, while 80% become lodged in the mainstem or lobar bronchus. Foreign bodies above the larynx often present with stridor, while objects below the larynx present with wheezing. Increased respiratory rate may be the only sign of foreign body aspiration in a child who cannot verbalize or report if they have swallowed a foreign body.

Diagnosis

Lateral neck, chest, and bilateral decubitus end-expiratory chest x-rays should be obtained in patients suspected of having aspirated a foreign body. Signs on x-ray that can be indicative of foreign body aspiration include visualization of the foreign body or hyperinflation of the affected lung.

Treatment

Laryngoscopy should be performed in unresponsive patients if non-invasive airway clearance techniques are unsuccessful. Laryngoscopy involves placing a device in the mouth to visualize the back of the airway. If the foreign body can be seen, it can be removed with forceps. An endotracheal tube should then be placed in order to prevent airway compromise from resulting inflammation after the procedure.

If signs of partial obstruction are present, supplemental oxygen, cardiac monitoring, and a pulse oximeter should be applied to the patient. Efforts should be made to keep the patient calm and avoid agitating the patient to prevent further airway compromise.

''---Won, Christine, et al.. "Upper Airway Obstruction in Adults." Fishman's Pulmonary Diseases and Disorders, Fifth Edition Eds. Michael A. Grippi, et al. New York, NY: McGraw-Hill, 2015''

Causes

In adults, foreign body aspiration is most prevalent in populations with impaired swallowing mechanisms such as the following: neurological disorders, alcohol use, sedative use, advanced age (most common in the 6th decade of life), and loss of consciousness.

Complications

Chemical bronchitis, mucosal reactions, and the development of granulation tissue are possible complications after foreign body aspiration.

''---Weinberger, Paul M., and David J. Terris.. "Otolaryngology: Head & Neck Surgery." CURRENT Diagnosis & Treatment: Surgery, 14e Ed. Gerard M. Doherty. New York, NY: McGraw-Hill, 2014.''

Foreign body aspiration is the fifth most common cause of unintentional-injury related deaths in the United States.

Causes

Children aged 1-4 lack molars and cannot grind food small enough for proper swallowing, leading to increased risk of foreign body aspiration.

Signs and Symptoms

Foreign bodies above the vocal cords tend to present with signs of difficulty and pain with swallowing and excessive drooling. Foreign bodies below the vocal cords tend to present with pain and difficulty with speaking and breathing. Tracheal foreign bodies can present with inspiratory and expiratory stridor.

Diagnosis

X-ray findings of obstructive emphysema, atelectasis, or consolidation can be signs of foreign body aspiration.

---''Chesnutt, Asha N., et al.. "Pulmonary Disorders." Current Medical Diagnosis & Treatment 2019 Eds. Maxine A. Papadakis, et al. New York, NY: McGraw-Hill''

Signs and Symptoms

In adults, foreign body aspiration can present similarly to other airway pathologies such as asthma, COPD, and lung cancer.

Complications

If a foreign body remains in the airway, many different complications can arise. Some of the more common complications from retained foreign body include atelectasis, pneumonia, hyperinflation of the airway distal to the foreign body, bronchiectasis, and abscess.