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VISIT US AT
BOOTH #576
AT THE ACEP
SCIENTIFIC ASSEMBLY
BOSTON, MA
OCTOBER 26-28

Inhaled Foreign Bodies In
Pediatric Patients: Proven
Management Techniques In
The Emergency Department
Abstract

Adam E. Vella, MD, FAAP
Associate Professor of Emergency
Medicine, Pediatrics, and Medical
Education, Director Of Pediatric
Emergency Medicine, Icahn School
of Medicine at Mount Sinai, New
York, NY

Associate Editor-in-Chief
Vincent J. Wang, MD, MHA
Associate Professor of Pediatrics,
Keck School of Medicine of USC;
Associate Division Head, Division
of Emergency Medicine, Children's
Hospital Los Angeles, Los Angeles,
CA

Editorial Board
Jeffrey R. Avner, MD, FAAP
Professor of Clinical Pediatrics
and Chief of Pediatric Emergency
Medicine, Albert Einstein College
of Medicine, Children’s Hospital at
Montefiore, Bronx, NY
Steven Bin, MD
Associate Clinical Professor
of Emergency Medicine and
Pediatrics, UCSF School of
Medicine; Medical Director, Division
of Pediatric Emergency Medicine,
UCSF Benioff Children's Hospital,
San Francisco, CA
Richard M. Cantor, MD, FAAP,
FACEP
Professor of Emergency Medicine
and Pediatrics, Director, Pediatric
Emergency Department, Medical
Director, Central New York Poison
Control Center, Golisano Children's
Hospital, Syracuse, NY

Authors
Megan Maraynes, MD
Director, Pediatric Emergency Department, Ochsner Medical Center
Emergency Department, School of Medicine of the University of
Queensland/Ochsner Clinical School, New Orleans, LA
Konstantinos Agoritsas, MD
Director, Pediatric Emergency Medicine, Kings County Hospital
Center, Brooklyn, NY; Clinical Assistant Professor, State University
of New York Downstate Medical Center, Brooklyn, NY
Peer Reviewers

Foreign body inhalation affects thousands of children every year, and
it remains a significant cause of morbidity and mortality in children.
Inhaled organic or inorganic foreign bodies can become lodged in the
posterior nasopharynx, larynx, trachea, or bronchi. Presentation of foreign body inhalation can range from nonspecific respiratory symptoms
to respiratory failure associated with a choking episode. In this issue, an
in-depth review of the etiology, pathophysiology, diagnosis, and treatment of inhaled foreign bodies is presented. Risk factors for foreign body
inhalation and clinical clues to diagnosis, as well as emergent management of inhaled foreign bodies are reviewed. A systematic approach,
as described in this issue, will aid in timely and accurate diagnosis and
treatment of inhaled foreign bodies, thereby limiting future complications and morbidity.

Editor-in-Chief

October 2015

Volume 12, Number 10

Ilene Claudius, MD
Associate Professor of Emergency
Medicine, Keck School of Medicine
of USC, Los Angeles, CA

Alson S. Inaba, MD, FAAP
Associate Professor of Pediatrics,
University of Hawaii at Mãnoa
John A. Burns School of Medicine,
Division Head of Pediatric
Ari Cohen, MD
Emergency Medicine, Kapiolani
Chief of Pediatric Emergency Medicine
Medical Center for Women and
Services, Massachusetts General
Children, Honolulu, HI
Hospital; Instructor in Pediatrics,
Harvard Medical School, Boston, MA
Madeline Matar Joseph, MD, FAAP,
FACEP
Marianne Gausche-Hill, MD, FACEP,
Professor of Emergency Medicine and
FAAP
Pediatrics, Chief and Medical Director,
Professor of Clinical Medicine,
Pediatric Emergency Medicine
David Geffen School of Medicine
Division, University of Florida Medical
at UCLA; Vice Chair and Chief,
School-Jacksonville, Jacksonville, FL
Division of Pediatric Emergency
Medicine, Harbor-UCLA Medical
Center, Los Angeles, CA
Michael J. Gerardi, MD, FAAP,
FACEP, President
Associate Professor of Emergency
Medicine, Icahn School of Medicine
at Mount Sinai; Director, Pediatric
Emergency Medicine, Goryeb
Children's Hospital, Morristown
Medical Center, Morristown, NJ
Sandip Godambe, MD, PhD
Vice President, Quality & Patient
Safety, Professor of Pediatrics and
Emergency Medicine, Attending
Physician, Children's Hospital of the
King's Daughters Health System,
Norfolk, VA

Stephanie Kennebeck, MD
Associate Professor, University of
Cincinnati Department of Pediatrics,
Cincinnati, OH
Anupam Kharbanda, MD, MS
Research Director, Associate
Fellowship Director, Department
of Pediatric Emergency Medicine,
Children's Hospitals and Clinics of
Minnesota, Minneapolis, MN
Tommy Y. Kim, MD, FAAP, FACEP
Associate Director of Emergency
Medicine and Pediatrics, Loma
Linda University Medical Center and
Children’s Hospital, Loma Linda, CA

Melissa Langhan, MD, MHS
Associate Professor of Pediatrics,
Ran D. Goldman, MD
Fellowship Director, Director of
Professor, Department of Pediatrics,
Education, Pediatric Emergency
University of British Columbia;
Medicine, Yale School of Medicine,
Co-Lead, Division of Translational
New Haven, CT
Therapeutics; Research Director,
Robert Luten, MD
Pediatric Emergency Medicine, BC Professor, Pediatrics and
Children's Hospital, Vancouver, BC,
Emergency Medicine, University of
Canada
Florida, Jacksonville, FL

Steven Bin, MD
Associate Clinical Professor of Emergency Medicine and Pediatrics,
UCSF School of Medicine; Medical Director, Division of Pediatric
Emergency Medicine, UCSF Benioff Children’s Hospital, San
Francisco, CA
Martin I. Herman, MD, FAAP, FACEP
Sacred Heart Children’s Hospital, Pensacola, FL; Florida State
University School of Medicine, Pediatric Residency Department,
Tallahassee, FL
Prior to beginning this activity, see “Physician CME Information”
on the back page.

Garth Meckler, MD, MSHS
AAP Sponsor
Associate Professor of Pediatrics,
Martin I. Herman, MD, FAAP, FACEP
University of British Columbia;
Division Head, Pediatric Emergency Sacred Heart Children's Hospital,
Pensacola, FL; Florida State
Medicine, BC Children's Hospital,
University School of Medicine,
Vancouver, BC, Canada
Pediatric Residency Department,
Joshua Nagler, MD
Tallahassee, FL
Assistant Professor of Pediatrics,
Harvard Medical School; Fellowship International Editor
Director, Division of Emergency
Lara Zibners, MD, FAAP
Medicine, Boston Children’s
Honorary Consultant, Paediatric
Hospital, Boston, MA
Emergency Medicine, St Mary's
James Naprawa, MD
Associate Clinical Professor
of Pediatrics, The Ohio State
University College of Medicine;
Attending Physician, Emergency
Department, Nationwide Children’s
Hospital, Columbus, OH

Hospital, Imperial College Trust;
EM representative, Steering Group
ATLS®-UK, Royal College of
Surgeons, London, England

Pharmacology Editor

James Damilini, PharmD, MS, BCPS
Clinical Pharmacy Specialist,
Joshua Rocker, MD
Emergency Medicine, St. Joseph's
Assistant Professor of Emergency
Hospital and Medical Center,
Medicine and Pediatric, Hofstra
Phoenix, AZ
North Shore-LIJ School of Medicine,
Hempstead, NY; Associate Director, Quality Editor
Division of Pediatric Emergency
Medicine, Cohen Children's Medical Steven Choi, MD
Medical Director of Quality, Director
Center, New Hyde Park, NY
of Pediatric Cardiac Inpatient
Steven Rogers, MD
Services, The Children’s Hospital at
Assistant Professor, University of
Montefiore; Associate Vice President,
Connecticut School of Medicine,
Montefiore Network Performance
Attending Emergency Medicine
Improvement; Assistant Professor of
Physician, Connecticut Children's
Pediatrics, Albert Einstein College of
Medical Center, Hartford, CT
Medicine, Bronx, NY
Christopher Strother, MD
CME
Editor
Assistant Professor, Emergency
Medicine, Pediatrics, and Medical
Deborah R. Liu, MD
Education; Director, Undergraduate
Assistant Professor of Pediatrics,
and Emergency Department
Keck School of Medicine of USC;
Simulation; Icahn School of Medicine
Division of Emergency Medicine,
at Mount Sinai, New York, NY
Children's Hospital Los Angeles,
Los Angeles, CA

Case Presentations

52.1% among infants aged < 1 year. When considering inhaled or aspirated foreign bodies, organic
food substances are the most common. Hard candy
was the most commonly inhaled food substance
(64%), and coins were the most frequently inhaled
nonfood substance (18%). Coins accounted for 18.2%
of choking-related episodes among children aged 1
to 4 years.8 However, these data do not distinguish
between choking episodes resulting in coins lodged
in the esophagus versus the airway.

Foreign body inhalation can present variably,
ranging from nonspecific respiratory symptoms to
respiratory failure associated with a choking episode. Delayed diagnosis of > 24 hours is common
and is associated with increased complications and
mortality.9 In a 2012 meta-analysis of 1063 papers
published over a 30-year period, delayed diagnosis
of > 24 hours occurred in an estimated 40% of patients, and complications occurred in approximately
15% of these patients.9 A 2005 retrospective study
cited pneumonia, bronchiectasis, and bronchoesophageal fistula as complications of diagnosis delayed
> 1 month. Misdiagnosis and parental delay in seeking care were cited as common reasons for delayed
diagnosis, although all patients presented with a
chief complaint of chronic cough.10

A mother runs past triage screaming, “My daughter is
choking!” You run over to assess the child, who is coughing
but has good air entry bilaterally, no retractions, and appears generally well in between coughs. The mother reports
that her 3-year-old was eating trail mix and started coughing and gasping for air. You debate the need for imaging
and wonder how long you should observe this child.

A resident approaches you to present a 6-year-old boy
brought in by his father after the child swallowed a small
magnetic toy. The father tells you his son coughed and
gagged, and now reports that it feels like there is something in his throat. What imaging should you obtain, and
what consultants should you call, if any?

You are evaluating a 2-year-old girl who has had
1 week of fever, coughing, and increasing respiratory
distress with no known history of foreign body ingestion.
You obtain an x-ray that shows significant air trapping in
the right lung field, as well as right middle lobe pneumonia. What should you do to stabilize this patient? Is there
a role for bronchodilators, racemic epinephrine, and/or steroids? Is any other imaging needed to rule out an inhaled
foreign body?

Introduction

Critical Appraisal Of The Literature

Inhaled foreign bodies remain a significant cause
of morbidity in children, with reported mortality
between 0 and 1.8%.1-3 Prior to the advent of advanced endoscopic techniques, mortality rates were
reported to be as high as 24%.4

Exploring their surroundings with their mouths
is a normal part of development that puts children at
higher risk of accidental foreign body inhalation than
adults. Children aged < 3 years are at greater risk
for inhalation of foreign bodies than older children.
These young children have immature oropharyngeal
coordination, poorly developed or no molar chewing,
higher respiratory rates, are more likely to be active
and playing while eating, and more likely to experience reflex inhalation while laughing or crying.5-7

According to the United States Centers For
Disease Control and Prevention (CDC), an estimated
17,000 children aged < 14 years presented to the
emergency department (ED) for choking-related episodes in 2001 (29.9 persons/100,000 population). Approximately 10% of these patients were admitted to
the hospital. Choking rates were highest for infants
aged < 1 year and decreased with age, with a slight
peak in the 5-year-old to 9-year-old age group. Overall, 59.5% of these children were treated for choking
on a food substance, 31.4% on a nonfood substance,
and 9% on an undetermined substance. The incidence of choking on food versus nonfood substances
varied with age. Food substances accounted for
75.7% of choking-related episodes in children aged 5
to 14 years, 58.4% in children aged 1 to 4 years, and
Copyright © 2015 EB Medicine. All rights reserved.

A literature search was performed in PubMed using
a combination of the search terms pediatrics, child,
infant, toddler, inhaled, aspirated, tracheobronchial foreign body, and aspiration pneumonia. Over 150 articles
published in the English language were reviewed,
and 89 were included in this issue.

Many case series and a significant number of
retrospective studies were available, but very few
prospective studies were found. There is a lack of
uniformity of definitions and management recommendations from center to center, and between specialties. Additionally, there is a paucity of emergency
medicine literature, as most articles originate from
otolaryngology and surgical literature.

Etiology And Pathophysiology
Most inhaled foreign bodies are reported in children
aged < 3 years, with some literature citing more than
half of all cases being in this age group.5,9,11-13 There
is a slight predominance commonly reported in
boys.13,14 Inhaled foreign bodies occur less frequently in infants than in the 1-year-old to 3-year-old age
group, and some literature suggests that occurrence
in infants aged 0 to 6 months may be associated with
inadequate supervision, inappropriate feeding practices, or nonaccidental trauma.6

Across the literature, organic objects were
reported to be the most commonly aspirated sub2

Reprints: www.ebmedicine.net/pempissues

stances. Although the CDC reports candy as being
the most common cause of choking episodes, the
majority of the literature indicates nuts and seeds are
the most frequently inhaled objects.12,15,16 Overall,
organic materials may be associated with a longer
length of hospitalization.17

Magnets were reported to be the most common
cause of inorganic foreign body aspiration, as well
as small objects meant for adult use, such as screws
and pins.9,18 (See Figures 1 and 2.) Smooth and
round metallic objects, such as magnets, pose an extra challenge for removal as they are difficult to grip
with standard forceps.19 Semi-rigid, rounded organic
objects, such as peanuts, have been shown to cause
higher severity foreign body-related injuries.16,20 Balloons (including rubber glove balloons) have been
reported to cause deadly choking episodes.21 As
described in a 2013 case series, blowgun darts have
become a cause of accidental foreign body inhalation
in older children.22 While less common, pen caps
are a reported inhaled foreign body in school-aged
children.23 In addition, multiple case reports identify
headscarf pins as dangerous inhaled foreign bodies
in school-aged children of certain cultures.24

The 1994 Child Safety Protection Act was enacted in an effort to prevent foreign body aspiration.
The act instituted a ban on any toys that could pose
choking or aspiration hazards for children aged
< 3 years. Any toy with small parts, marbles, or balls
measuring < 4.44 cm in size must carry a label that
the item contains small parts and is not recommended for young children.25

There are 3 typical stages in foreign body aspiration. The first is the impaction phase, characterized
by choking, gagging, and coughing paroxysms. This
may also be referred to as “penetration syndrome,"
characterized by a sudden onset of choking and
coughing, with or without vomiting.26 These symp-

toms subside during the second, or asymptomatic,
phase when the foreign body becomes lodged. This
second phase can last from hours to weeks. The third
phase is known as the complications phase, when
late sequelae such as erosion, infection, pneumonia,
and abscess can occur. According to a retrospective
study, the most common reason for late diagnosis
was misdiagnosis, usually as bronchitis.27 The use
of antibiotics and steroids for presumed infection or
inflammation can also mask symptoms and further
delay diagnosis.28,29

The most common anatomic location for a foreign
body to lodge is the bronchi (80%-90%), followed
by the trachea (3%-12%), and the larynx (2%-12%).5
Although some literature notes the right main stem
bronchus as the most common location for bronchial
foreign bodies (due to the close proximity to the vocal
cords and the less acute angle from the trachea),30
there are various other studies that report comparable
rates of right and left bronchial obstruction.5,11,14,31
The larynx is generally described as the least common
location for a foreign body to become lodged, except
in children aged < 1 year.

Differential Diagnosis
The main task in creating a differential diagnosis is differentiating an aspirated foreign body from an ingested
foreign body, and subsequent differentiation from
other conditions that can present similarly. While aspirated foreign bodies typically present with respiratory

Figure 2. Screw In The Left Mainstem
Bronchus

Figure 1. Airway Foreign Body With
Atelectasis Of The Left Lung

Reprinted from the Atlas of Pediatric Emergency Medicine, 2nd ed.,
Binita Shah, Michael Lucchesi, John Amodio, Mark Silverberg, eds.
Copyright 2013, with permission from McGraw-Hill Education.

October 2015 • www.ebmedicine.net

Reprinted from the Atlas of Pediatric Emergency Medicine, 2nd ed.,
Binita Shah, Michael Lucchesi, John Amodio, Mark Silverberg, eds.
Copyright 2013, with permission from McGraw-Hill Education.

3

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symptoms, esophageal foreign bodies can also cause
respiratory distress from compression on the trachea.
Although coughing is generally a good indicator of an
aspirated foreign body, it can also indicate an ingested
foreign body. Conversely, both aspirated and ingested
foreign bodies can be asymptomatic.

When considering alternative diagnoses to an
aspirated foreign body, it is useful to organize the
possible diagnoses based on the symptoms and the
suspected location. (See Tables 1 and 2.) Radiographic imaging may be the best way to differentiate
between an airway versus a gastrointestinal foreign
body, as ingested foreign bodies (such as coins) are
more often radio-opaque, while aspirated foreign
bodies are usually radiolucent.

Laryngeal foreign bodies can cause cyanosis and
hypoxia with respiratory arrest if the obstruction is
complete. Partial laryngeal obstruction can present as dysphonia, hoarseness, croupy cough, and
stridor. Croup has been known to mimic a laryngeal
foreign body and vice versa.32,33 Croup, epiglottitis,
and even airway edema from anaphylaxis can present similarly; late symptoms are due to tissue edema
and irritation.5

A tracheal foreign body can present with dysphonia, dysphagia, dry cough, and biphasic stridor.
In these cases, the foreign bodies are usually too

large to pass to the bronchus.34 (See Figure 3.) Also
consider compression from an esophageal foreign
body, vascular malformation, airway edema, neoplasm, or abscess.

A bronchial foreign body may be asymptomatic,
or it may present with asymmetric or decreased
breath sounds, coughing, and wheezing, as well as
fever and superimposed pneumonia. These symptoms can also present in the case of pulmonary abscess, pneumonia, asthma, bronchiectasis, congenital
lobar emphysema, and cavitary tuberculosis.9,35-37
Radiographic signs of pneumonia, mass, and abscess
may be indistinguishable from complications of a
retained aspirated foreign body, so emergency clinicians must maintain a high index of suspicion when
deciding whether or not to obtain further imaging or
bronchoscopy.

Asthma exacerbation and foreign body inhalation
may be clinically and radiographically indistinguishable. In a 2012 retrospective study, patients with a
history of asthma who presented with respiratory
symptoms as a result of foreign body aspiration were
shown to have a significant delay in time between a
suspected choking episode and otolaryngology evaluation.38 This suggests that a conservative approach in
patients with asthma is not justified, and reinforces
using the clinical history as an important tool in
maintaining a high index of suspicion. Diagnosis can
be extremely difficult in the case of toddlers presenting with wheezing and upper respiratory infection
symptoms in the winter months, when a misdiagnosis of asthma may occur.39

In a retrospective study by Huankang et al that
included 1007 patients, bronchial foreign bodies

Table 1. Physical Examination Findings
Based On Anatomical Location
Location

Physical Examination Findings

Laryngeal

Hoarseness, stridor, croupy cough

Tracheal

Biphasic stridor, dysphonia, dysphagia

Bronchial

Coughing, wheezing, decreased breath sounds

Figure 3. Sunflower Seed Lodged In The
Subglottis

Table 2. Differential Diagnosis Based On
Signs And Symptoms
Signs/Symptoms

Differential Diagnosis

Coughing







Wheezing

• Asthma
• Bronchiolitis
• Vascular malformation

Stridor/hoarseness/dysphonia/
dysphagia







Croup
Abscess
Vascular malformation
Esophageal foreign body
Epiglottitis

Asymmetric breath sounds







Asthma
Pneumonia
Pulmonary abscess
Cavitary tuberculosis
Congenital lobar emphysema

Esophageal foreign body
Pneumonia
Asthma
Bronchiolitis
Croup

Copyright © 2015 EB Medicine. All rights reserved.

Used with permission from Wolters Kluwer Health, Inc. Jacob AuBuchon, Catherine Krucylak, David J Murray. Subglottic airway foreign
body: a near miss. Anesthesiology. Volume 115, Issue 6. Page 1300.

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were more frequently misdiagnosed than tracheal
foreign bodies.40 Tracheal foreign bodies were more
likely to present with dyspnea, while bronchial
foreign bodies were more likely to present with
decreased breath sounds. In both groups, coughing
was the most common presenting symptom. Chest
fluoroscopy abnormalities were more often observed
in the bronchial foreign body group, while lateral
neck x-ray abnormalities were found more in the
tracheal foreign body group.40

a surgical airway. This can include a tracheostomy,
cricothyroidotomy, or needle cricothyroidotomy. The
latter two are the feasible options for EMS workers
and emergency clinicians. The exact age at which
surgical cricothyroidotomy is preferred over needle
cricothyroidotomy is controversial. Most emergency
physicians would not perform surgical cricothyroidotomy and would favor needle cricothyroidotomy
in children aged < 8 to 12 years (depending on the
size and physical maturity of the child).44 When
performing a needle cricothyroidotomy, the needle is
inserted through the cricothyroid membrane into the
trachea, connected to an oxygen source using a 3-mL
syringe and a 7.5-mm endotracheal tube, and then
hooked up to an oxygen source, such as a bag-valve
mask or a conventional ventilator machine. Alternately, percutaneous translaryngeal jet ventilation
can be utilized to deliver oxygen to the airways via
a needle cricothyroidotomy using a high-pressure
gas source. The latter, however, is controversial and
is thought to put patients at an increased risk for
complications, such as tension pneumothorax and
pneumomediastinum, due to the high-pressure air
in a closed loop system.44

Obstruction Below The Vocal Cords
If the level of obstruction is determined to be below
the level of the vocal cords, the patient is in respiratory
failure, and there is no improvement with bag-valvemask ventilation, endotracheal intubation should be
performed. If the foreign body is in the trachea, an
endotracheal tube can be used to push the object into
the right mainstem bronchus in order to ventilate the
left lung.44 Recognition of vital sign instability during
resuscitation is crucial, since children are at a higher
risk than adults for bradycardia during airway manipulation due to their increased vagal tone. Additionally, children are at higher risk for hypoxia due to
their increased oxygen utilization and lower residual
capacity.44


Prehospital Care
Data from case reports indicate that parents and
medical professionals should not perform blind
finger sweeps in an attempt to dislodge a foreign
body, as this can result in further trauma to the
airway, or can advance the foreign body farther into
the trachea.41,42 Once a choking episode is established (the patient is no longer coughing or making
sounds), perform 5 back blows followed by 5 chest
compressions in a child aged < 12 months or 5 back
blows followed by abdominal thrusts in a child aged
≥ 12 months.43 In a patient in respiratory arrest, a
foreign body may be revealed by direct visualization by emergency medical services (EMS) personnel
attempting to intubate in the field. In the case of a
coughing or wheezing patient, standard supportive
care en route to the hospital includes supplemental
oxygen, patient positioning for comfort, a trial of
bronchodilators (if available), and bag-valve-mask
ventilation, if necessary. If complete obstruction is
present and bag-valve-mask ventilation is unsuccessful, EMS personnel with the appropriate training
may need to perform a surgical airway.

Emergency Department Evaluation
Initial Evaluation
The same principles that apply to prehospital care
also apply to the initial ED evaluation. Assessment
of airway, breathing, and circulation should be approached according to the Pediatric Advanced Life
Support algorithm. Intravenous access and airway
stabilization should be initiated, if necessary.

Evaluation Of The Stable Patient

History
Before ordering any diagnostic studies in a stable
patient, obtain a thorough history. Numerous studies
point to a history of a choking episode as the most
sensitive indicator of foreign body aspiration.45-47 In
one of the few prospective studies to date, a history
of choking was the most common presenting symptom, followed by prolonged cough, dyspnea, and
nonresolving pneumonia.45 However, this study is
limited by a small sample size, where only 56 of the
98 patients included were found to have had inhaled
foreign bodies. A 2012 retrospective study reported
a history of choking as the parameter with the best
diagnostic value, citing a sensitivity of 97%, a positive
predictive value (PPV) of 89%, and a negative predictive value (NPV) of 80%.46 Lack of a reported choking
episode, however, does not exclude the possibility of

Evaluation Of The Unstable Patient
In an unstable patient with complete airway obstruction, direct visualization using a laryngoscope can
be attempted. In these circumstances, Magill forceps
should be available at the bedside in case the foreign
body is visualized and removal is feasible. If complete airway obstruction is confirmed, the location of
the obstruction should be determined, if possible.
Complete Obstruction At The Level Of The Larynx
In a case of complete obstruction at the level of the
larynx, if removal is unsuccessful, the next step is
October 2015 • www.ebmedicine.net

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Diagnostic Studies

an inhaled foreign body.48,49 Absence of a witnessed
choking episode, lack of physical examination findings, negative radiologic studies, as well as younger
age (< 2 years), are all associated with delayed
diagnosis (> 72 hours).49 In a retrospective review of
early-diagnosed and late-diagnosed cases, a witnessed choking event was associated with earlier
diagnosis of foreign body aspiration.11 Conversely,
patients with nonspecific symptoms such as coughing and wheezing without a history of a choking
episode have been found to be more likely to be diagnosed later.12 Other historical clues to consider are
the at-risk age groups mentioned in the “Etiology
And Pathophysiology” section, as well as a history
of jumping or playing while eating.

Radiographic Studies To Assess For Signs
Of An Aspirated Foreign Body
A 2009 retrospective review of 207 children who underwent rigid bronchoscopy to rule out foreign body
aspiration found high sensitivities, but low specificities, for the use of historical clues in the diagnosis of
foreign body aspiration.50 The highest specificities
were from radiographic studies. Chest radiography
is the preferred initial diagnostic test.5,51 Because
80% to 96% of aspirated foreign bodies are radiolucent, inspiratory and forced expiratory films are optimal to assess for radiographic signs of an aspirated
foreign body, as opposed to visualizing an actual
object. A typical radiographic finding is obstructive
emphysema due to partial or complete bronchial
obstruction, in which one would see unilateral hyperinflation due to blockage of an air passage during
expiration.51

Other radiographic signs include air trapping,
abnormal heart shadow, mediastinal shift, pneumomediastinum, pneumothorax, and subcutaneous
emphysema.6,52-55 (See Figures 4 and 5.) In a 2004
retrospective review, Girardi et al reported 2 previously undocumented radiographic findings: hyperinflation or obstructive emphysema with atelectasis

Physical Examination
The next step in evaluation is a physical examination, which should start with a comprehensive head,
eye, ear, nose, and throat examination, including
thorough examination of the oropharynx and posterior pharynx. Physical examination signs suspicious
for an inhaled foreign body include stridor, hoarseness, coughing, wheezing, tachypnea, dyspnea,
and asymmetrical breath sounds. Decreased breath
sounds and wheezing are the most common physical examination findings.50

Figure 5. Right-Sided Hyperexpansion And
Mediastinal Shift
Figure 4. Subcutaneous Emphysema And
Pneumomediastinum

Right-sided hyperexpansion (left arrow) and mediastinal shift to the
left (right arrow) in a 2-year-old with a peanut in the right mainstem
bronchus.
Reprinted from the Journal of Pediatric Surgery, Volume 41, Issue 11.
Christoph M. Heyer, Melanie E. Bollmeier, Leo Rossler, Thomas G.
Nuesslein, Volker Stephan, Torsten T. Bauer, Christian H.L. Rieger.
Evaluation of clinical, radiologic, and laboratory prebronchoscopy
findings in children with suspected foreign body aspiration. Pages
1882-1888. Copyright 2006, with permission from Elsevier.

Subcutaneous emphysema (top arrow) and radiolucent air tracking
along the pericardial and diaphragmatic curves (bottom arrow) in a
3-year-old with an eraser stuck in the right mainstem bronchus.
Reprinted from the American Journal of Otolaryngology, Volume 34,
Issue 1. Melissa Hu, Rebecca Green, Anil Gungor. Pneumomediastinum and subcutaneous emphysema from bronchial foreign body aspiration. Pages 85-88. Copyright 2013, with permission from Elsevier.

Copyright © 2015 EB Medicine. All rights reserved.

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in the same hemithorax, and aeration within an area
of atelectasis.56 Pneumonia and atelectasis are more
commonly seen by x-ray in delayed cases.57 In a 2012
retrospective review of 138 patients who underwent
rigid bronchoscopy and were found to have radiolucent foreign bodies, the most common radiographic
finding was air trapping,58 the most common radiologic finding in the majority of studies.30,59 Despite
the utility of x-ray as a screening methodology, between 20% and 50% of patients with foreign bodies
may have negative chest x-rays.38,60

Since infants and young toddlers are unlikely
to be able to cooperate with inspiratory and expiratory films, right and left decubitus views have been
conventionally used to differentiate air trapping
between the lungs, where inadequate deflation on
the dependent side suggests obstruction and air
trapping. However, a retrospective study by Assefa
et al found a sensitivity of 27%, specificity of 67%,
PPV of 75%, and NPV of 20%.61 The authors suggested that, even in the setting of a normal decubitus
film, a witnessed choking episode followed by the
sudden onset of respiratory symptoms remains the
most important indication for bronchoscopy. One
limitation to this study is the very small sample size
(41 patients over a period of 5 years).61

specificities, but are somewhat limited by small
sample sizes.37,64-66 An advantage of CT is that it is a
rapid test that can aid in determining the location of
a foreign body, thus decreasing time in the operating
room. Additionally, CT can visualize complications
of a retained aspirated foreign body, such as atelectasis, bronchiectasis, and pneumothorax, with greater
sensitivity and specificity than conventional radiography.51, 67 (See Figure 6.) Disadvantages of CT
include radiation exposure, cost, and the need for
sedation and its associated dangers in children with
inhaled foreign bodies.


Laboratory Markers As Predictive Indicators
Of Inhaled Foreign Bodies

Only one study was found that mentioned laboratory markers as predictive indicators, noting an
association between increased white blood cell count
to > 10,000/dL and an aspirated foreign body.30
The study was retrospective, with a relatively small
sample size of 160, and cited a sensitivity of 39%,
specificity of 81%, PPV of 86%, and NPV of 30%.
The authors of the study concluded that there is not
enough evidence to support the use of laboratory
markers in the diagnosis of an inhaled foreign body.

Use Of Fluoroscopy When Inspiratory And
Expiratory Films Cannot Be Performed
Fluoroscopy is a viable alternative in children on
whom inspiratory and expiratory films cannot be
performed. This method allows fluoroscopic visualization of respiratory movements, including decreased movement of the diaphragm on the affected
side, and mediastinal shift. However, fluoroscopy is
an operator-dependent technique, which weakens its
utility for detecting a foreign body in the ED during
off hours, especially when computed tomography
(CT) is available.51 In a small prospective study, the
sensitivity of fluoroscopy was slightly lower than
chest radiography, while the specificity was significantly higher, at 94%.45


Figure 6. Foreign Body In The Lower Trachea,
Shown By Coronal Reconstruction

Computed Tomography To Identify Foreign
Bodies

Different studies report high, but variable, sensitivities and specificities for CT, which is reported to
be nearly 100% sensitive and 67% to 100% specific
for detecting an aspirated foreign body. Thus, CT is
more sensitive than x-ray.62 A 2013 prospective study
by Manach et al comparing multidetector CT scan
with endoscopy for identifying respiratory foreign
bodies found a sensitivity of 94%, specificity of 95%,
positive likelihood ratio of 18.1, and negative likelihood ratio of 0.06.63 Multiple studies support the
use of virtual bronchoscopy CT in screening patients
for an inhaled foreign body prior to bronchoscopy.
These studies demonstrate high sensitivities and
October 2015 • www.ebmedicine.net

Reprinted from the Journal of Pediatric Surgery, Volume 47, Issue 11.
Wang Gang, Pan Zhengxia, Li Hongbo, Li Yonggang, Dai Jiangtao,
Wu Sheng, Wu Chun. Diagnosis and treatment of tracheobronchial
foreign bodies in 1024 children. Pages 2004-2010. Copyright 2012,
with permission from Elsevier.

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Clinical Pathway For Management Of Inhaled Foreign Bodies
Asymptomatic child presents to the ED

Symptomatic child presents to the ED

Witnessed choking episode?
YES

NO

Obtain CXR (Class II)

Discharge home with
close follow-up

Normal

Stable

Unstable/asphyxia

Obtain history and
perform physical
examination (Class I)

Emergent airway
management

Consult specialist
to perform rigid
bronchoscopy for
removal (Class III)

Obtain CXR (consider
AP/lateral neck softtissue films) (Class II)

Abnormal*

Normal

Observe, discharge
when stable (Class I)

Abnormal*
Observe (Class I)

• Consult specialist
to perform flexible
bronchoscopy if
clinical suspicion is
high (Class III)
• Consider CT if
clinical suspicion
is low or other
diagnoses are being
considered (Class III)

• Observe (Class I)
• Consult specialist to
perform bronchoscopy
if clinical suspicion is
high (Class III)
• Consider CT if clinical
suspicion is low or
other diagnoses are
being considered
(Class III)

• Consult specialist to perform flexible bronchoscopy
if clinical suspicion is high (Class III)
• Consider CT if clinical suspicion is low or other
diagnoses are being considered (Class III)

Foreign body
visualized?

NO

YES

Rigid bronchoscopy for
removal (Class III)
*

Abnormal findings include air trapping, atelectasis, bronchiectasis, pneumomediastinum, subcutaneous emphysema, or pneumothorax.
Abbreviations: AP, anterior-posterior; CT, computed tomography; CXR, chest
x-ray; ED, emergency department.

Observe (inpatient
or outpatient, at
physician's discretion)
(Class I)

Class Of Evidence Definitions
Each action in the clinical pathways section of Pediatric Emergency Medicine Practice receives a score based on the following definitions.
Class I
• Always acceptable, safe
• Definitely useful
• Proven in both efficacy and effectiveness

Level of Evidence:
• One or more large prospective studies are
present (with rare exceptions)
• High-quality meta-analyses
• Study results consistently positive and
compelling

Class II
• Safe, acceptable
• Probably useful

Level of Evidence:
• Generally higher levels of evidence
• Nonrandomized or retrospective studies:
historic, cohort, or case control studies
• Less robust randomized controlled trials
• Results consistently positive

Class III
• May be acceptable
• Possibly useful
• Considered optional or alternative treatments

Level of Evidence:
• Generally lower or intermediate levels of
evidence
• Case series, animal studies,
consensus panels
• Occasionally positive results

Indeterminate
• Continuing area of research
• No recommendations until further research

Level of Evidence:
• Evidence not available
• Higher studies in progress
• Results inconsistent, contradictory
• Results not compelling

This clinical pathway is intended to supplement, rather than substitute for, professional judgment and may be changed depending upon a patient’s individual
needs. Failure to comply with this pathway does not represent a breach of the standard of care.
Copyright © 2015 EB Medicine. 1-800-249-5770. No part of this publication may be reproduced in any format without written consent of EB Medicine.

Copyright © 2015 EB Medicine. All rights reserved.

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Specialty Consultation

ing patients with a history of possible foreign body
aspiration but no signs or symptoms.77 Definitive
treatment is endoscopic removal but, rarely, thoracotomy and tracheotomy are necessary if endoscopic
removal fails and the patient is unstable. If endoscopic removal is not successful and the patient is
stable, but rigid bronchoscopy is not available, the
patient should be transferred to a center with bronchoscopy capabilities.1,4,78 Complications of treatment by endoscopic removal include hypoxia, tissue
trauma, and perforation.1 Surgical intervention is an
important option in the cases of sharp, inorganic foreign bodies, as they may be more difficult to extract
bronchoscopically.79

Although not in the scope of an emergency clinician's practice, case reports have described foreign
body removal using catheterization, in a cardiac
catheterization laboratory under fluoroscopy, if
bronchoscopic removal fails. Thatte et al describe 2
such cases, 1 of which was successful. The other case
was unsuccessful and resulted in surgical lobectomy.80 In another case report by Varshney et al, a
urology basket was used in conjunction with flexible bronchoscopy to successfully retrieve bronchial
foreign bodies in 2 patients.81 Additionally, balloon
catheters have been used in bronchial foreign body
removal.82,83 Adjuncts such as epinephrine, beta
agonists, and steroids for airway edema are referred
to anecdotally in the surgical literature.68,78 Another
case report described a patient coughing up an aspirated peanut after receiving nebulized salbutamol.84

Consultation with otolaryngology, pulmonary, or
surgical specialists should be considered, depending
on institutional policy and the location of the retained
foreign body. In most circumstances, if the foreign
body is above the level of the vocal cords, otolaryngology should be consulted to perform endoscopy. In
cases of bronchial foreign bodies where rigid bronchoscopy is required, otolaryngology or pulmonology should be consulted, depending on institutional
protocol. Rigid bronchoscopy is generally thought to
be safe and effective when performed under general
anesthesia in the operating room, with a first-pass
success rate of up to 99%.1 Otolaryngology literature
suggests that flexible bronchoscopy should be used
initially in cases of low suspicion of an aspirated
foreign body (eg, the absence of unilateral breath
sounds, atelectasis, or obstructive emphysema on a
chest x-ray). If negative, rigid bronchoscopy and its
associated cost and complications (including bradycardia, hypoxia, pneumothorax, perforation, bleeding, and even bronchial rupture) can be avoided.68 If a
foreign body is found on flexible bronchoscopy, then
rigid bronchoscopy must be performed for removal.69,70 In some institutions, flexible bronchoscopy can
be performed at the bedside by a senior emergency
physician, although it is largely within the scope of
surgical subspecialty practice.

Treatment

Special Populations

While spontaneous expulsion prior to or during
intervention has been reported,71 the definitive
treatment of an aspirated foreign body is removal
by bronchoscopy, either by an otolaryngologist or
another subspecialist. Although rigid bronchoscopy
is the standard treatment, there is a recent move
toward flexible bronchoscopy to avoid the complications of rigid bronchoscopy.72 Limitations to flexible
bronchoscopy include foreign bodies that are too
large to pass through the bronchoscope and sharp
objects that cannot be gripped.13,73-75 Both methods
generally require sedation and manual or mechanical ventilation (with their inherent complications),
although a randomized controlled trial suggested
that the use of dexmedetomidine may allow for
spontaneous ventilation during bronchoscopy,
due to respiratory sparing properties.76 In cases of
delayed diagnosis, rigid bronchoscopy may be negative (eg, a case where an organic foreign body was
resorbed or dissolved).55

Cohen et al recommended observation and close
follow-up in patients with a history suggestive of
foreign body inhalation but no symptoms or radiographic findings.31 Likewise, Mani et al performed a
retrospective study that demonstrated no increased
morbidity from delaying bronchoscopy and observOctober 2015 • www.ebmedicine.net

Older children with developmental delay seem to be
at a higher risk of aspiration of foreign bodies for the
same reasons as younger children: a persistence of the
need to explore the environment with their mouths, as
well as oropharyngeal coordination issues and communication barriers. Children with neuromuscular
disorders may also have swallowing coordination
issues, weakness of the oropharyngeal muscles, and a
depressed gag reflex. A case report describing a patient
who was misdiagnosed with progressively worsening
sleep apnea over a period of 5 years and was eventually found by CT to have a retained aspirated foreign
body suggests that children with Prader-Willi syndrome may also be at higher risk.85

Controversies And Cutting Edge
While no published studies were found on the use of
ultrasound to identify aspirated foreign bodies, the
use of ultrasound in the ED is becoming ubiquitous,
and there is a potential application for ultrasound
in the detection of foreign bodies. The use of ultrasound to identify endotracheal tube placement is
well established in animal86 and human models.
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Disposition

Techniques to identify endotracheal tube placement
include direct transtracheal visualization, lung sliding, and diaphragm visualization to assess symmetric lung movement with breaths.86-89 Theoretically,
all of these techniques are applicable to tracheal or
even bronchial foreign bodies to assess air trapping,
hyperinflation, and decreased diaphragmatic movement on the side of obstruction.

For a patient with a foreign body definitively identified on imaging or a high enough suspicion to
proceed with bronchoscopy (eg, witnessed aspiration
or sudden onset of severe respiratory distress), disposition from an inpatient service should be determined by the subspecialty service. No patient with an
airway foreign body should be discharged from the
ED. In patients in whom there is some suspicion of a
foreign body but no definitive physical examination
or imaging findings, observation in the ED or inpatient observation unit for 12 to 24 hours is appropriate
to watch for onset of respiratory distress or changes in
radiologic images (such as new-onset air trapping or
opacification). Alternatively, depending on the emergency clinician's index of suspicion, the patient can
be discharged home to be observed by the parents.
Discharge instructions for patients in whom a foreign
body is suspected, but not diagnosed, should always
include concise instructions to seek medical care if the
child develops fast breathing, fever, persistent cough,
chest pain, persistent vomiting, or any other concerns.

Time- And Cost-Effective
Strategies
• Chest radiography is the first line of investigation in the management of a patient with a
suspected inhaled foreign body. Normal chest
radiography does not exclude the diagnosis of
an inhaled foreign body, and additional investigations are sometimes necessary.
• CT has high sensitivity in detecting inhaled
foreign bodies, and it can be used in diagnosing
inhaled foreign bodies in selected low-suspicion
cases. With multidetector CT, the speed of performing a CT scan has increased dramatically,
and there are fewer requirements for sedation.
In addition, multidetector CT imaging can obviate the need for rigid bronchoscopy and the
risks associated with the procedure. However,
the associated adverse risks of ionizing radiation
should be kept in mind when considering CT.
• Flexible bronchoscopy is routinely used to
evaluate a child with recurrent pneumonia or
chronic cough, but recently, it has been shown
to be effective and safer than rigid bronchoscopy for excluding the presence of a foreign
body in patients for whom there is a low
suspicion of foreign body inhalation. The use of
flexible bronchoscopy can reduce the necessity
of performing rigid bronchoscopy. The decision of whether or not to use flexible or rigid
bronchoscopy is best made in conjunction with
all subspecialists involved, which may include
emergency medicine clinicians, otolaryngologists, surgeons, or pulmonologists.
• The American Academy of Pediatrics recommends that anticipatory guidance should be
provided to parents when their child is 6 months
of age. At this age, children begin to develop the
fine motor skills needed to pick up small objects.
It is important to advise parents not to offer small
food items, such as peanuts, until the child is old
enough to chew properly. It is also important to
advise parents to discourage their child from eating while running, laughing, or playing, and to
encourage their child to sit upright while eating.
Copyright © 2015 EB Medicine. All rights reserved.

Summary
Aspirated foreign bodies remain a significant cause
of morbidity and mortality in children. The highest
rates are in children aged < 3 years. Food accounts for
most inhalations, and coins are associated with 18% of
choking-related episodes. Foreign body inhalation presents variably, thus the history and physical examination
should guide the workup. A high index of suspicion
should be maintained in at-risk groups, while being
mindful of minimizing unnecessary procedures and
radiation. Although chest radiography can be diagnostic for foreign body inhalations, most inhaled objects
are radiolucent, and, thus, there are limitations to this
technique. CT imaging, fluoroscopy, and bronchoscopy
can be performed in cases with a high index of suspicion
and when basic chest radiography is inconclusive.

Once a foreign body is suspected or confirmed,
clinical management includes recognition, acute
emergency interventions, and supportive care. In
most centers, rigid bronchoscopy is used to remove a
foreign body, while flexible bronchoscopy can be used
for evaluation in cases of low suspicion of an inhaled
foreign body. Disposition after bronchoscopy is at the
discretion of the subspecialty services. Disposition
from the ED should include discharge instructions
advising parents to seek medical care if any signs or
symptoms suspicious for a foreign body arise.

There is significant cost associated with foreign
body inhalation, justifying the need for increased
prevention efforts. Current educational prevention
efforts in the United States are led by the National
Safety Council, the CDC, and the American Academy
of Pediatrics.
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Risk Management Pitfalls For Management Of Inhaled Foreign Bodies
1. “The x-ray appears normal, so there can’t be a
foreign body.”
Normal x-ray findings do not exclude radiolucent foreign body aspiration. Additionally,
radiographic signs may be delayed > 24 hours.
Most aspirated foreign bodies are organic,
which includes food products, paper, and other
mostly radiolucent objects. Radio-opaque objects
include glass and metal; however, many plastic
objects will not be radio-opaque.

6. “He has no symptoms, so let's just discharge
him.”
Foreign body inhalation may be asymptomatic
for hours to weeks after the event. History and
index of suspicion, in addition to the presence of
symptoms, should guide the decision to image
and/or observe the patient.
7. “He is wheezing and the x-ray shows atelectasis. He isn’t really improving in the ED, but
it’s probably just asthma. Let’s admit him for
steroids, bronchodilator therapy, and observation.”
While there may be a role for bronchodilator
therapy in the event of an inhaled foreign body,
any patient with abnormal x-ray findings who
fails to improve with bronchodilator therapy
should be assessed for a possible inhaled foreign
body. Inspiratory/expiratory films, fluoroscopy
or CT, as well as a thorough history and physical
examination, may help elucidate the diagnosis.

2. “No one saw him choke or cough, so a foreign
body is not on my differential.”
While a witnessed choking episode is helpful
in suspecting the diagnosis of foreign body
inhalation, it is not present in the majority
of cases, and, therefore, its absence does not
exclude an inhaled foreign body.
3. “Some kids are just prone to pneumonia; it
doesn’t mean it’s a foreign body.”
Recurrent or nonresolving unilateral pneumonia
should raise the emergency clinician’s suspicion
for a retained inhaled foreign body, and workup
should be done before the assumption is made
that the child is simply prone to pneumonia.
Infection usually occurs distal to the site of
obstruction, as a late complication.

8. “This child will never cooperate with inspiratory and expiratory films; let’s just do a CT.”
An x-ray may show signs of air trapping or a
radio-opaque foreign body without inspiratory/
expiratory films. Additionally, although the
sensitivity of decubitus films is debatable,
they may show air trapping that would be an
indication for bronchoscopy, thus avoiding a
CT. Disadvantages of CT are the cost and time
of testing, the possible need for sedation with its
inherent risks, and the risks of radiation.

4. “I thought patting the choking toddler, who
was coughing and gasping, on the back would
help to dislodge the foreign body he was choking on, but instead, his status worsened and he
stopped breathing.”
In infants aged < 12 months, chest compressions or
back blows are the preferred method to dislodge
a foreign body. In older children, abdominal
thrusts are preferred. However, these methods
are indicated in cases of complete obstruction and
should not be attempted if a patient is coughing
or able to speak (partially obstructed), as these
methods can cause complete obstruction.

9. “There is no way my child could have inhaled
a toy. It just wouldn’t fit!”
According to the 1994 Child Safety Protection
Act, any toy with small parts (defined as < 4.44
cm) is considered a choking hazard to small
children.
10. “The child has stridor, but the chest x-ray is
negative, so there is no foreign body, right?”
Stridor is indicative of a tracheal or laryngeal
foreign body, both of which may not be seen on
chest films. Anterior-posterior and lateral neck
films should be obtained in the case of stridor.
The index of suspicion should drive the decision
to order a bronchoscopy for a foreign body
rather than image alone.

5. “I saw a patient bite off a piece of a ‘glove balloon’ and start coughing right in front of me. What
is the harm of trying to get it out with my finger
while it still may be in his posterior pharynx?”
By the time a patient is coughing, the foreign
body is probably at least at the level of the larynx.
Blind finger sweeps can not only further dislodge
any material that is left in the posterior pharynx,
but can cause significant trauma to the delicate
tissues. In this case, direct visualization with
direct laryngoscopy and the use of Magill forceps
for removal at the bedside may be indicated.
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Case Conclusions

Otorhinolaryngol. 2012;76 Suppl 1:S84-S91. (Review)

You decided to x-ray the 3-year-old girl and saw normal
posterior-anterior and lateral x-rays with no visualized
foreign body. However, due to her persistent cough, you
observed the child for 24 hours to assess for worsening
respiratory distress. Her cough resolved, and there was
no need for a repeat x-ray. You counseled the mother on
“danger foods” and the risks for choking, such as playing
or jumping while eating.

Because magnet ingestion or inhalation is a true
emergency due to the risk for pressure necrosis, you
obtained anterior-posterior and lateral x-rays to confirm
the location of the magnet in the trachea of the 6-year-old
boy. You called for an emergent otolaryngology consult
for removal using rigid bronchoscopy.

The x-ray findings of air trapping in the 2-year-old
girl raised your suspicion for an inhaled foreign body,
even though there was no radio-opaque foreign body
seen on x-ray. You stabilized the patient with supplemental oxygen and intravenous antibiotics for her
pneumonia and respiratory distress. You then decided
to obtain a CT, on which a foreign body was seen with
surrounding edema and pneumonia in the right mainstem bronchus. The patient was sent for bronchoscopy,
and a peanut was removed.

Eren S, Balci AE, Dikici B, et al. Foreign body aspiration
in children: experience of 1160 cases. Ann Trop Paediatr.
2003;23(1):31-37. (Retrospective review; 1160 patients aged
< 15 years)

4.

Tamiru T, Gray PE, Pollock JD. An alternative method
of management of pediatric airway foreign bodies in the
absence of rigid bronchoscopy. Int J Pediatr Otorhinolaryngol.
2013;77(4):480-482. (Case review; 7 patients)

8.

United States Centers for Disease Control and Prevention.
Ten leading causes of death and injury. Available at http://
www.cdc.gov/injury/wisqars/leadingcauses.html. Accessed 5/1/15. (CDC web-based injury statistics query and
reporting system)

12. Higuchi O, Adachi Y, Ichimaru T, et al. Foreign body aspiration in children: a nationwide survey in Japan. Int J Pediatr
Otorhinolaryngol. 2009;73(5):659-661. (Retrospective survey
study; 163 cases)
13. Singh H, Parakh A. Tracheobronchial foreign body aspiration
in children. Clin Pediatr (Phila). 2014;53(5):415-419. (Review)
14. Pan H, Lu Y, Shi L, et al. Similarities and differences in aspirated tracheobronchial foreign bodies in patients under the
age of 3 years. Int J Pediatr Otorhinolaryngol. 2012;76(6):911914. (Retrospective chart review; 316 patients aged < 3
years)
15. Oncel M, Sunam GS, Ceran S. Tracheobronchial aspiration
of foreign bodies and rigid bronchoscopy in children. Pediatr
Int. 2012;54(4):532-535. (Retrospective review; 184 patients
aged < 16 years)
16. Sih T, Bunnag C, Ballali S, et al. Nuts and seed: a natural
yet dangerous foreign body. Int J Pediatr Otorhinolaryngol.
2012;76 Suppl 1:S49-S52. (Data analysis; 17,000 patients
aged 0-14 years, 60 institutions)
17. Hidaka H, Obara T, Kuriyama S, et al. Logistic regression
analysis of risk factors for prolonged pulmonary recovery in
children from aspirated foreign body. Int J Pediatr Otorhinolaryngol. 2013;77(10):1677-1682. (Case review; 77 cases)
18. Shah BR, Lucchesi M. Atlas of Pediatric Emergency Medicine.
1st ed. New York: McGraw-Hill Medical Publishing Division; 2006. (Textbook)
19. Hada MS, Chadha V, Mishra P, et al. “Slam dunk”: a case report of an unusual metallic foreign body. J Bronchology Interv
Pulmonol. 2012;19(2):156-158. (Case report; 1 patient)
20. Berchialla P, Snidero S, Stancu A, et al. Predicting severity
of foreign body injuries in children in upper airways: an approach based on regression trees. Risk Anal. 2007;27(5):12551263. (Data analysis)
21. Dias E. An unusual case of foreign body aspiration in an infant. Ann Med Health Sci Res. 2012;2(2):209-210. (Case report;
1 patient)
22. Walz PC, Scholes MA, Merz MN, et al. The internet, adolescent males, and homemade blowgun darts: a recipe for
foreign body aspiration. Pediatrics. 2013;132(2):e519-e521.
(Case series; 3 cases)
23. Chen M, Zhang J, Liu W, et al. Clinical features and management of aspiration of plastic pen caps. Int J Pediatr Otorhinolaryngol. 2012;76(7):980-983. (Retrospective chart review; 44

5.* Rodriguez H, Passali GC, Gregori D, et al. Management of
foreign bodies in the airway and oesophagus. Int J Pediatr

Copyright © 2015 EB Medicine. All rights reserved.

Crawford NW. Foreign body aspiration in a child detected
through emergency department radiology reporting: a case
report. Eur J Emerg Med. 2007;14(4):219-221. (Case report; 1
patient)

11.* Chiu CY, Wong KS, Lai SH, et al. Factors predicting early diagnosis of foreign body aspiration in children. Pediatr Emerg
Care. 2005;21(3):161-164. (Retrospective review; 53 patients)

1.* Zhijun C, Fugao Z, Niankai Z, et al. Therapeutic experience
from 1428 patients with pediatric tracheobronchial foreign
body. J Pediatr Surg. 2008;43(4):718-721. (Retrospective case
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3.

7.

10. Saquib Mallick M, Rauf Khan A, Al-Bassam A. Late presentation of tracheobronchial foreign body aspiration in children.
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Evidence-based medicine requires a critical appraisal of the literature based upon study methodology and number of subjects. Not all references are
equally robust. The findings of a large, prospective,
randomized, and blinded trial should carry more
weight than a case report.

To help the reader judge the strength of each reference, pertinent information about the study, such as the
type of study and the number of patients in the study will
be included in bold type following the references, where
available. The most informative references cited in this
paper, as determined by the author, will be noted by an
asterisk (*) next to the number of the reference.

Passali D, Lauriello M, Bellussi L, et al. Foreign body
inhalation in children: an update. Acta Otorhinolaryngol Ital.
2010;30(1):27-32. (Review)

Shubha AM, Das K. Tracheobronchial foreign bodies in
infants. Int J Pediatr Otorhinolaryngol. 2009;73(10):1385-1389.
(Retrospective review; 102 patients aged < 3 years)

9.* Foltran F, Ballali S, Passali FM, et al. Foreign bodies in the
airways: a meta-analysis of published papers. Int J Pediatr
Otorhinolaryngol. 2012;76 Suppl 1:S12-S19. (Meta-analysis)

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30. Heyer CM, Bollmeier ME, Rossler L, et al. Evaluation of
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in children with suspected foreign body aspiration. J Pediatr
Surg. 2006;41(11):1882-1888. (Retrospective chart review; 160
patients)

49. Orji FT, Akpeh JO. Tracheobronchial foreign body aspiration
in children: how reliable are clinical and radiological signs in
the diagnosis? Clin Otolaryngol. 2010;35(6):479-485. (Retrospective chart review; 103 patients aged < 14 years)

31. Cohen S, Avital A, Godfrey S, et al. Suspected foreign body
inhalation in children: what are the indications for bronchoscopy? J Pediatr. 2009;155(2):276-280. (Prospective study; 142
patients aged 0-14 years)

50. Kiyan G, Gocmen B, Tugtepe H, et al. Foreign body aspiration in children: the value of diagnostic criteria. Int J Pediatr
Otorhinolaryngol. 2009;73(7):963-967. (Retrospective chart
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32. Ibrahimov M, Yollu U, Akil F, et al. Laryngeal foreign body
mimicking croup. J Craniofac Surg. 2013;24(1):e7-e8. (Case
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33. Atmaca S, Unal R, Sesen T, et al. Laryngeal foreign body mistreated as recurrent laryngitis and croup for one year. Turk J
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51.* Hitter A, Hullo E, Durand C, et al. Diagnostic value of various investigations in children with suspected foreign body
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34. AuBuchon J, Krucylak C, Murray DJ. Subglottic airway
foreign body: a near miss. Anesthesiology. 2011;115(6):1300.
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52. Hu M, Green R, Gungor A. Pneumomediastinum and subcutaneous emphysema from bronchial foreign body aspiration.
Am J Otolaryngol. 2013;34(1):85-88. (Case report)

35. Cakir E, Torun E, Uyan ZS, et al. An unusual case of foreign
body aspiration mimicking cavitary tuberculosis in adolescent patient: thread aspiration. Ital J Pediatr. 2012;38:17. (Case
report)

53. Gupta RK, Gupta A, Sanghvi B, et al. Subcutaneous emphysema: an unusual presentation of foreign body aspiration. J
Bronchology Interv Pulmonol. 2009;16(2):124-126. (Case report;
2 patients)

36. Aslan AT, Yalcin E, Ozcelik U, et al. Foreign-body aspiration
mimicking congenital lobar emphysema in a forty-eight-dayold girl. Pediatr Pulmonol. 2005;39(2):189-191. (Case report)

54. Kothari V, Sonkhya N, Sharma C, et al. Pneumothorax
secondary to foreign body inhalation in an infant. Indian J
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1 patient)

37. Veras TN, Hornburg G, Schner AM, et al. Use of virtual bronchoscopy in children with suspected foreign body aspiration.
J Bras Pneumol. 2009;35(9):937-941. (Case series; 2 patients)

55. Jhamb U, Sethi GR, Puri R, et al. Surgical emphysema: a rare
presentation of foreign body inhalation. Pediatr Emerg Care.
2004;20(5):311-313. (Case report; 1 patient)

38. Saliba J, Mijovic T, Daniel S, et al. Asthma: the great imitator
in foreign body aspiration? J Otolaryngol Head Neck Surg.
2012;41(3):200-206. (Retrospective chart review; 55 patients)

56. Girardi G, Contador AM, Castro-Rodriguez JA. Two new
radiological findings to improve the diagnosis of bronchial foreign-body aspiration in children. Pediatr Pulmonol.
2004;38(3):261-264. (Retrospective review; 133 patients aged
< 3 years)

39. Kugelman A, Shaoul R, Goldsher M, et al. Persistent cough
and failure to thrive: a presentation of foreign body aspiration in a child with asthma. Pediatrics. 2006;117(5):e1057e1060. (Case report)

57.* Sersar SI, Rizk WH, Bilal M, et al. Inhaled foreign bodies:
presentation, management and value of history and plain
chest radiography in delayed presentation. Otolaryngol Head
Neck Surg. 2006;134(1):92-99. (Retrospective review; 3300
patients aged > 10 years)

40. Huankang Z, Kuanlin X, Xiaolin H, et al. Comparison
between tracheal foreign body and bronchial foreign
body: a review of 1,007 cases. Int J Pediatr Otorhinolaryngol.
2012;76(12):1719-1725. (Retrospective chart review; 1007
patients)

58. Mortellaro VE, Iqbal C, Fu R, et al. Predictors of radiolucent
foreign body aspiration. J Pediatr Surg. 2013;48(9):1867-1870.
(Retrospective review; 138 patients)

41. Vunda A, Vandertuin L. Nasopharyngeal foreign body following a blind finger sweep. J Pediatr. 2012;160(2):353. (Case
report)

59.* Boufersaoui A, Smati L, Benhalla KN, et al. Foreign body
aspiration in children: experience from 2624 patients. Int J
Pediatr Otorhinolaryngol. 2013;77(10):1683-1688. (Retrospec-

42. Abder-Rahman HA. Infants choking following blind finger
sweep. J Pediatr (Rio J). 2009;85(3):273-275. (Case series; 3

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60. Cataneo AJ, Cataneo DC, Ruiz RL Jr. Management of
tracheobronchial foreign body in children. Pediatr Surg
Int. 2008;24(2):151-156. (Retrospective chart review; 164
patients)

76. Cai Y, Li W, Chen K. Efficacy and safety of spontaneous
ventilation technique using dexmedetomidine for rigid bronchoscopic airway foreign body removal in children. Paediatr
Anaesth. 2013;23(11):1048-1053. (Retrospective review; 80
patients)

61. Assefa D, Amin N, Stringel G, et al. Use of decubitus radiographs in the diagnosis of foreign body aspiration in young
children. Pediatr Emerg Care. 2007;23(3):154-157. (Retrospective review; 41 patients aged > 5 years)

77. Mani N, Soma M, Massey S, et al. Removal of inhaled foreign bodies--middle of the night or the next morning? Int J
Pediatr Otorhinolaryngol. 2009;73(8):1085-1089. (Retrospective
case review; 165 patients)

62. Bai W, Zhou X, Gao X, et al. Value of chest CT in the diagnosis and management of tracheobronchial foreign bodies.
Pediatr Int. 2011;53(4):515-518. (Prospective cohort study; 45
patients)

78. Li Y, Wu W, Yang X, et al. Treatment of 38 cases of foreign
body aspiration in children causing life-threatening complications. Int J Pediatr Otorhinolaryngol. 2009;73(12):1624-1629.
(Retrospective case review; 38 cases)

63. Manach Y, Pierrot S, Couloigner V, et al. Diagnostic performance of multidetector computed tomography for foreign
body aspiration in children. Int J Pediatr Otorhinolaryngol.
2013;77(5):808-812. (Multicenter prospective study; 303
patients aged 6-16 years)

79. Ulku R, Onen A, Onat S, et al. The value of open surgical approaches for aspirated pen caps. J Pediatr Surg.
2005;40(11):1780-1783. (Retrospective review; 19 cases)

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80. Thatte NM, Guglani L, Turner DR, et al. Retrieval of endobronchial foreign bodies in children: involving the cardiac
catheterization lab. Pediatrics. 2014;134(3):e865-e869. (Case
report; 2 patients)

64. Bhat KV, Hegde JS, Nagalotimath US, et al. Evaluation of
computed tomography virtual bronchoscopy in paediatric
tracheobronchial foreign body aspiration. J Laryngol Otol.
2010;124(8):875-879. (Prospective cohort study; 40 patients)

81. Varshney R, Zawawi F, Shapiro A, et al. Use of an endoscopic
urology basket to remove bronchial foreign body in the pediatric population. Int J Pediatr Otorhinolaryngol. 2014;78(4):687689. (Case report; 2 cases)

65. Hong SJ, Goo HW, Roh JL. Utility of spiral and cine CT scans
in pediatric patients suspected of aspirating radiolucent foreign bodies. Otolaryngol Head Neck Surg. 2008;138(5):576-580.
(Prospective case series; 51 patients)

82. Chung PH, Wong KK, Lan LC, et al. Peanut aspiration:
an avoidable life-threatening condition. Hong Kong Med J.
2012;18(4):340-342. (Case report; 2 patients)

66. Adaletli I, Kurugoglu S, Ulus S, et al. Utilization of lowdose multidetector CT and virtual bronchoscopy in children
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83. McAfee SJ, Vashisht R. Removal of an impacted distal airway foreign body using a guidewire and a balloon angioplasty catheter. Anaesth Intensive Care. 2011;39(2):303-304.
(Case report; 1 patient)

67. Gang W, Zhengxia P, Hongbo L, et al. Diagnosis and treatment of tracheobronchial foreign bodies in 1024 children.
J Pediatr Surg. 2012;47(11):2004-2010. (Retrospective chart
review; 1024 patients aged > 13 years)

84. Sabra O, El-Bitar M. The role of beta-2 agonists in foreign
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68. Ma G, Yang J, Liu S. Anesthetic management of bronchial
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after 5 months. Paediatr Anaesth. 2014;24(5):544-546. (Case
report; 1 patient)

85. Jacob SS, Jacob JJ, Paul TV. Foreign body aspiration in a boy
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86. Budhram G, Murman D, Lutfy L, et al. Sonographic confirmation of intubation: comparison of 3 methods in a pig
model. J Ultrasound Med. 2014;33(11):1925-1929. (Animal
study)

69. Righini CA, Morel N, Karkas A, et al. What is the diagnostic
value of flexible bronchoscopy in the initial investigation of
children with suspected foreign body aspiration? Int J Pediatr
Otorhinolaryngol. 2007;71(9):1383-1390. (Prospective study; 70
patients)

87. Weaver B, Lyon M, Blaivas M. Confirmation of endotracheal
tube placement after intubation using the ultrasound sliding
lung sign. Acad Emerg Med. 2006;13(3):239-244. (Cadaver
study; 68 intubations)

70. Ozguner IF, Buyukyavuz BI, Savas C, et al. Clinical experience of removing aerodigestive tract foreign bodies with rigid endoscopy in children. Pediatr Emerg Care. 2004;20(10):671673. (Retrospective review; 53 patients)

88. Werner SL, Smith CE, Goldstein JR, et al. Pilot study to
evaluate the accuracy of ultrasonography in confirming
endotracheal tube placement. Ann Emerg Med. 2007;49(1):7580. (Prospective randomized controlled pilot study; 33
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71. Tariq SM, Succony L, Bhatia RS. Spontaneous expulsion
of a sharp foreign body. J Bronchology Interv Pulmonol.
2012;19(4):319-322. (Case report; 1 patient)
72. Hasdiraz L, Oguzkaya F, Bilgin M, et al. Complications of
bronchoscopy for foreign body removal: experience in 1,035
cases. Ann Saudi Med. 2006;26(4):283-287. (Retrospective
chart review; 1035 pediatric patients)

89.* Gregori D, Scarinzi C, Berchialla P, et al. The cost of foreign
body injuries in the upper aero-digestive tract: need for a
change from a clinical to a public health perspective? Int J
Pediatr Otorhinolaryngol. 2007;71(9):1391-1398. (Multicenter
cost analysis; 2103 consecutive cases)

73. Cavel O, Bergeron M, Garel L, et al. Questioning the legitimacy of rigid bronchoscopy as a tool for establishing the
diagnosis of a bronchial foreign body. Int J Pediatr Otorhinolaryngol. 2012;76(2):194-201. (Retrospective chart review; 32
patients)
74. Rodrigues AJ, Scussiatto EA, Jacomelli M, et al. Bronchoscopic techniques for removal of foreign bodies in children’s
airways. Pediatr Pulmonol. 2012;47(1):59-62. (Retrospective
review; 78 patients)
75.* Tang LF, Xu YC, Wang YS, et al. Airway foreign body
removal by flexible bronchoscopy: experience with 1027
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(Retrospective review; 1027 patients)

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CME Questions

5. Which of the following is the most sensitive
indicator of foreign body aspiration?
a. Abnormal x-ray
b. Witnessed choking episode
c. Hypoxia
d. Tachypnea

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6. What is the best initial choice of imaging in the
case of suspected foreign body inhalation?
a. CT
b. Fluoroscopy
c. Decubitus x-rays
d. Inspiratory and expiratory x-rays
7. Which of the following are radiographic findings of foreign body aspiration?
a. Mediastinal shift
b. Subcutaneous emphysema
c. Pneumomediastinum
d. All of the above

1. The group most at risk for an inhaled foreign
body is:
a. 0 to 3 years
b. 4 to 6 years
c. 6 to 10 years
d. 15 to 18 years

8. Which of the following is the greatest limitation to performing inspiratory and expiratory
films?
a. They are operator dependent
b. They are not specific
c. They require patient cooperation
d. They take too long

2. Most inhaled foreign bodies are:
a. Paper
b. Magnets and plastic toys
c. Nuts and seeds
d. Beads and pins

9. You are evaluating a developmentally delayed
7-year-old for recurrent right middle lobe
pneumonia. The patient is stable, but you suspect a foreign body. What is the next best study
in evaluation of this patient?
a. Flexible bronchoscopy
b. Rigid bronchoscopy
c. CT
d. CBC with differential

3. A croupy cough can be indicative of foreign
body aspiration at the level of the:
a. Larynx
b. Trachea
c. Bronchi
d. a and b

10. You performed an x-ray on a patient with a witnessed choking episode to look for a foreign
body. The x-ray is normal, and the patient is
asymptomatic. How will you disposition this
patient?
a. Discharge home to be observed by the

parents, follow-up as needed
b. Observe in the ED for 12 to 24 hours and

then discharge home, follow-up as needed
c. Admit to the hospital for respiratory
monitoring
d. a or b

4. You are evaluating a 3-year-old who is in respiratory arrest after a choking episode. The first
step in management should be:
a. Overhead page the ear, nose, and throat
specialist
b. Attempt to visualize the foreign body using

direct laryngoscopy and remove it with

Magill forceps
c. Perform cricothyroidotomy
d. Perform endotracheal intubation

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Physician CME Information
Date of Original Release: October 1, 2015. Date of most recent review: September 15, 2015.
Termination date: October 1, 2018.

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