You are in: eMedicine Specialties > Emergency Medicine > EAR, NOSE, AND THROAT Foreign Bodies, TracheaArticle Last Updated: Jul 6, 2007AUTHOR AND EDITOR INFORMATIONSection 1 of 10
  Author: David W Munter, MD, MBA, Assistant Clinical Professor of Emergency Medicine, Medical Director and Chair, DePaul University Medical Center; Partner, Emergency Physicians of Tidewater, LPC; President of the DESA Consulting Group David W Munter is a member of the following medical societies: American College of Emergency Physicians, American College of Physician Executives, Medical Society of Virginia, and Norfolk Academy of Medicine Editors: Edmond A Hooker II, MD, DrPH, FAAEM, Assistant Professor, Department of Health Services Administration, Xavier University; Associate Clinical Professor, Department of Emergency Medicine, University of Louisville; Assistant Clinical Professor, Department of Emergency Medicine, Wright State University; Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine; Paul Blackburn, DO, FACOEP, FACEP, Program Director, Department of Emergency Medicine, Maricopa Medical Center; Assistant Professor, Department of Surgery, University of Arizona; John D Halamka, MD, MS, Associate Professor of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center; Chief Information Officer, CareGroup Healthcare System and Harvard Medical School; Attending Physician, Division of Emergency Medicine, Beth Israel Deaconess Medical Center; Rick Kulkarni, MD, Medical Director, Assistant Professor of Surgery, Section of Emergency Medicine, Yale-New Haven Hospital Author and Editor Disclosure Synonyms and related keywords: trachea obstruction, airway obstruction, foreign body aspiration, aspiration, tracheobronchial foreign body aspiration, foreign body in the trachea, tracheobronchial foreign bodies INTRODUCTIONSection 2 of 10
  Background Foreign body aspiration can result in a spectrum of presentations, from minimal symptoms, often unobserved, to respiratory compromise, failure, and even death. This article is not intended to distinguish in detail acute airway obstruction from foreign body aspiration; for these patients, emergency life-saving interventions are needed. The epidemiology of tracheobronchial foreign bodies is bimodal, with peaks at the extremes of age. Children aged 1-3 years are particularly at risk because of their increasing independence, lessening of close parental supervision as they become older, and increasing activity and curiosity and because of hand-mouth interactions. Often, foods such as grapes and pieces of hot dogs that are easily handled by older children can be aspirated and occlude the airway. Smaller objects, such as peanuts, are easily aspirated into the bronchi by children. Elderly patients, particularly those with primary neurologic disorders and decreased gag reflexes due to alcohol, seizures, strokes, parkinsonism, trauma, and senile dementia, are also at risk of aspiration; any number of objects, food, and stomach contents can be aspirated. A third category of at-risk individuals is those undergoing procedures with sedation, particularly dental procedures or emergency intubation. The diagnosis is often missed initially, especially in children where the history may be vague and the patient cannot verbalize the events. In as many as 30% of patients, symptoms are treated as those of other common diseases, especially in patients with minimal symptoms. A high index of suspicion is required to make the diagnosis, especially in children and patients who are debilitated. For excellent patient education resources, visit eMedicine's Esophagus, Stomach, and Intestine Center and Procedures Center. Also, see eMedicine's patient education articles, Choking, Swallowed Object, and Bronchoscopy. Pathophysiology Aspirated foreign bodies most commonly are lodged in the right main stem and lower lobe. Aspiration has been documented in all lobes, including the upper lobes, though with less frequency. In the In adults, vegetable matter, meat, and bones rank highest, followed by dental and medical appliances. Aspiration of teeth after trauma is occasionally observed. Mortality Annual death rates from aspiration of foreign bodies range from 350-2000 in the
Male predominance is found in most studies, particularly in children. Approximately 60% of patients in the United States are male, depending on the study. Interestingly, in studies from outside the United States, females often predominate. Age Age frequency is bimodal, with individuals aged 1-3 years and those in the seventh decade of life at higher risk of foreign body aspiration. CLINICALSection 3 of 10
History The history leads to diagnosis in most cases. In adults, aspiration occurs with choking after eating or choking when holding a foreign body in the mouth. Aspiration should also be suspected in adults with respiratory distress associated with sedation from drugs, alcohol, or trauma; after medical procedures such as sedation or intubation; after facial trauma; and in patients with decreased ability to handle secretions. In particular, patients with strokes, either new or old, are at high risk for aspiration. Suspicion of foreign body aspiration in children is raised with sudden paroxysms of coughing when not directly supervised, sudden choking after eating (particularly when an older sibling feeds a younger sibling), or choking and/or coughing when a known, small object or food particle (particularly peanuts) is within reach of the child. In children undergoing treatment of new-onset asthma, bronchitis, or pneumonia that is not responding to appropriate treatment (ie, bronchodilators, steroids, antibiotics), consider the possibility of foreign body aspiration, particularly with unilateral wheezing. Physical Choking or coughing is present in 95% of patients presenting with foreign body aspiration. Stridor is commonly present with upper airway or upper tracheal foreign bodies. Patients may present with respiratory distress, pneumonia, pulmonary edema, or wheezing. Children present similarly. Approximately 50% of children have inspiratory stridor or expiratory wheezing, with prolongation of the expiratory phase, and medium-to-coarse rhonchi. Tachypnea; nasal flaring; intercostal, subcostal, and suprasternal retractions; and differences in percussion between hemithoraces also are common findings. Fever and central cyanosis are less common. Only rarely do children with a positive history have an examination with completely normal findings. Stridor in children or adults indicates a partial upper airway or tracheal occlusion and is an ominous sign. These patients require prompt interventions. Causes In children, the primary factors leading to aspiration are underlying curiosity about the world and the oral phase of children aged 1-3 years. Loose, small objects and food found around the household increase risk. An older sibling feeding younger children is an important historical clue. Objects that tend to stay in the mouth for prolonged periods of time, such as gum, sunflower seeds, or hard candy, also increase risk. Eating while lying supine, especially just prior to falling asleep, increases risk of aspiration. Baby powder can be a particularly dangerous aspiration. A symptom-free period may occur before suffocation. Immediate lavage of bronchial system is required in severe cases. In adults, factors that increase risk are underlying primary neurologic disorders, such as senile dementia, mental retardation, seizures, strokes, and parkinsonism. Conditions that depress the central nervous system, cause coma, or depress the gag reflex, such as alcohol, narcotics, barbiturates, or benzodiazepines, can increase likelihood of aspiration. Meats, bones, and medical and dental appliances are the most commonly aspirated objects in adults. In patients who have sustained facial or dental trauma, including traumatic intubations, who have a missing tooth, the tooth must be presumed to have been aspirated, and radiographic evaluation is needed. DIFFERENTIAL DIAGNOSISSection 4 of 10
Pneumonia, Empyema and Abscess Acute asthma Airway obstruction Bronchiolitis Croup Epiglottitis embolus Laryngitis pertussis Pulmonary lesions and/or diseases Upper respiratory illness WORKUPSection 5 of 10
Lab studies CBC and sedimentation rate may be elevated, particularly with chronic foreign bodies. In patients going to the operating room for bronchoscopy, routine preoperative laboratory studies are indicated. Posteroanterior and lateral chest films are mandatory. Foreign bodies, atelectasis, air trapping, mediastinal shift, compensatory emphysema on the contralateral side, pneumonia, or pneumothorax may be observed. Hyperlucency and atelectasis are observed in 63% of cases in children. Bilateral decubitus films may be helpful in children. A foreign object may prevent normal pulmonary collapse when the involved hemithorax is dependent (or on the "down" side, on the radiography table). In very young children, however, decubitus films are not as helpful. In patients with stridor, a soft-tissue lateral film of the neck may be useful. Computed tomography (CT) is rapidly becoming the imaging study of choice in stable patients with suspected aspiration, especially with nonradiopaque objects or in questionable cases. CT is very accurate in identifying and localizing foreign bodies. Consider CT if plain films are not helpful. Procedures Bronchoscopy may be necessary to assist in making the diagnosis when other tests do not reveal the problem. TREATMENTSection 6 of 10
Prehospital care If the patient is coughing, wheezing, or is stridorous but maintaining an airway, do not attempt to intervene; transport to the nearest facility where definitive treatment can be provided. If severe airway compromise or total obstruction occurs, attempt chest compressions, back blows, abdominal thrusts, or the Heimlich maneuver. The method depends on the age of the patient. Emergency department care Initial supportive therapy includes oxygen administration, cardiac monitor, pulse oximetry, and intravenous line. Definitive airway management may be required. In stridorous patients, racemic epinephrine via a nebulizer may be a temporizing measure until bronchoscopy can be performed. In patients who are unstable, emergent management in the ED is needed. Magill forceps have been used with some success in the ED for foreign bodies located below the cords but above the cricoid ring. With the laryngoscope, this may be the quickest method of removing foreign bodies above the cricoid ring. The preferred method is an awake examination, allowing the patient to maintain his or her airway. In unstable patients, rapid sequence intubation may be needed. In these cases, be prepared with suction and Magill forceps. In emergent situations with tracheal foreign bodies below the level of the vocal cords, intubation may be required. One option is to insert the endotracheal tube all the way to the hub, thus pushing the foreign body down into a mainstem bronchus (normally, the right). The endotracheal tube is then removed to the normal position (normally 20-22 cm at the lips in adults), and the patient is ventilated after ensuring the tip of the tube is not occluded with the foreign body. Even though only one lung will be ventilated, sufficient air exchange and oxygenation should occur to allow the patient to be taken for formal bronchoscopy. Extraction by bronchoscopy is the treatment of choice for tracheal foreign bodies. Bronchoscopy is performed with general anesthesia in the operating room for children, with inhalational induction generally preferred. Adults may tolerate awake or sedated bronchoscopy if nebulized lidocaine (4%) is used. Complications of bronchoscopy generally are uncommon and self-limited. However, in-hospital mortality is reportedly 1-2%, partially attributable to large tracheal foreign bodies lost during a procedure. The lost foreign body may become lodged in the subglottic region, causing complete airway obstruction. If initial bronchoscopy is unsuccessful, a repeat attempt usually is performed. Rarely, a second attempt is unsuccessful, and thoracotomy is necessary. If the foreign body has expanded (as can occur with organic matter) or is larger than the subglottic region, a tracheostomy may be required. MEDICAL THERAPYSection 7 of 10
Preoperative steroids and antibiotics may reduce complications such as airway edema and infection. Prior to bronchoscopy, consider methylprednisolone succinate (125 mg IV in adults and 2 mg/kg IV; not to exceed 125 mg in children) or dexamethasone (Decadron) (10-12 mg in adults and 0.03-0.3 mg/kg in children) and broad-spectrum antibiotics such as cefazolin (1 g IV in adults and 25 mg/kg IV; not to exceed 1 g in children) or nafcillin (1 g IV in adults and 25 mg/kg IV; not to exceed 1 g in children), which provide coverage for hemolytic streptococci and Staphylococcus aureus. DISCHARGESection 8 of 10
Admit patients with suspected foreign body aspiration to the hospital. Discharge depends on the individual clinical course and whether complications such as pneumonia, abscess, and hypoxia develop or persist. MULTIMEDIASection 9 of 10
REFERENCESSection 10 of 10
Foreign Bodies, Trachea excerpt Article Last Updated: Jul 6, 2007 | |||||||||||||||||||||
