Authors: Nicola Goodall / Editor: Nikki Abela / Codes: C3AP6, PMP2, EP1, ResC4, SLO5 / Published: 08/08/2023
This topic takes me back to the time when I nearly missed the diagnosis as a foundation doctor….
Emma, a 2-year-old girl who is normally fit and well had been eating a picnic outside with her mum when she developed an unusual cough. Not a cough that her mum had considered as choking but seemed sudden in onset and was recurring intermittently. Emma was also making some strange throat clearing noises and her mum was concerned she was having an allergic reaction. She thought she could have been stung by one of the bees that had been around in the park. On assessment Emma had normal vital signs, she appeared well apart from occasional brief vocal noises and coughing. Auscultation of her chest appeared clear and there were no signs of swelling or skin changes suggestive of allergy. A chest X-ray was initially felt to be normal but on review with a senior clinician there was concern about atelectasis behind the left heart border. The possibility of an inhaled foreign body (FB) became more suspicious. The respiratory team were consulted and Emma was taken for a bronchoscopy where a piece of strawberry was removed from her left bronchus. Emma recovered well and was discharged after a short stay in hospital. I had perhaps been falsely reassured by her normal observations and examination alongside what I thought was a normal X-ray. Thankfully, in this case a second opinion meant the diagnosis wasn’t missed.
FB inhalation is a common cause of mortality and morbidity in children especially those under the age of 2.
FB inhalation in children is often not witnessed so must be considered in children with unexplained acute respiratory symptoms. Children under 2 are particularly good at exploring things that shouldn’t go in mouths as well as older children with developmental problems. Always ask the parent or carer about choking noises or the possibility that they might have inhaled something preceding their symptoms. (editor’s note: I especially do this for a child with stridor and no fever, or recurring stridor in spite of initial steroid).
Symptoms may present days to weeks after the inhalation. Delayed presentation is common with only 50-60% of cases presenting within 24hrs. Those presenting later, where FB inhalation is not initially considered, are likely to have symptoms of pneumonia with fever, which may show some improvement with antibiotics but often have persisting X-ray changes or recurring infection.
Ingestion of a FB into the gastrointestinal (GI) tract is of course another concern for our paediatric patients which may cause respiratory distress alongside GI symptoms. Button batteries are more likely to be ingested than inhaled but still important to consider, recognise and treat urgently. Foreign bodies in the nose which are not removed are also at risk of becoming inhaled particularly during sleep.
Common culprits which may be inhaled included things like nuts, fruit, seeds, popcorn, coins, plastic balloons and small toy parts. These small items may get lodged in the larynx or trachea but are more likely to be found in the bronchi, more so on the right. Mortality is higher with obstructions higher up the respiratory tract.
- Ask about a possible inhalation/ choking event and find out what items or food was around at the time their symptoms started
- Ask about unusual airway noises including stridor, wheeze or changes to voice
- Ask about drooling
- May be normal
- Assess for airway noises, tracheal deviation and work of breathing
- Assess for asymmetry in breath sounds or wheeze on auscultation
A triad of cough, wheeze and reduced breath sounds is felt to be highly specific to FB inhalation (~98%) but sensitivity is poor (27-43%)5.
- CXR may be normal
- CXR may also show air trapping, consolidation, atelectasis or signs of a radiopaque object. Ideally, obtain images during inhalation and exhalation (which may be difficult in a child) plus a lateral decubitus image if a FB is suspected. Imaging during expiration can show signs of air trapping if a FB is present.
This free article has some excellent CXR images to reference the changes seen.
- A neck X-ray should be considered in children with upper airway symptoms such as stridor or change to voice to assess for FB in the laryngotrachea.
- Bronchoscopy should be used in cases where there is high suspicion and this is usually coordinated with the Respiratory or ENT team.
Obstruction of the airway may present as a typical choking child with severe respiratory distress, coughing and may progress to an ineffective cough and eventually collapse. These children should have back blows and abdominal thrusts (or chest thrusts if under 1) as per your local resuscitation guidelines to attempt to dislodge the blockage. If the child becomes unresponsive with no signs of life, initiate CPR with attempts to remove the FB carried out by a skilled clinician.
Here is a link to the Resus Council guidelines.
In a more stable child closely monitor those with suspected inhalation for potential deterioration and refer to the local ENT or Respiratory team according to local pathways. They will likely need a scope to remove the debris or FB and will require antibiotics if they present with signs of infection, airway support depending on how much the foreign body has impeded their respiratory function. CT imaging may be considered as part of diagnostic work up.
- Ruiz FE. Airway foreign bodies in children. [Online] UpToDate. Updated: 2022.
- Tan HK, Brown K, McGill T, et al. Airway foreign bodies (FB): a 10-year review. International Journal of Pediatric Otorhinolaryngology. 2000 Dec;56(2):91-99.
- Eren S, Balci AE, Dikici B, Doblan M, Eren MN. Foreign body aspiration in children: experience of 1160 cases. Ann Trop Paediatr. 2003 Mar;23(1):31-7.
- Esclamado RM, Richardson MA. Laryngotracheal foreign bodies in children. A comparison with bronchial foreign bodies. Am J Dis Child. 1987 Mar;141(3):259-62.
- Singh H, Parakh A. Tracheobronchial foreign body aspiration in children. Clin Pediatr (Phila). 2014 May;53(5):415-9.
- Williams H. Inhaled foreign bodies. Archives of Disease in Childhood – Education and Practice 2005;90:ep31-ep33.