inhaled Foreign body

 

 

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Impaction in the larynx or main bronchus

• History
  • Sudden and catastrophic event.
  • Coughing, choking ± vomiting
  • Severe respiratory distress
  • Stridor
  • Cyanosis
  • Altered mental state
  • Drooling and voice changes

1.  

• Total obstruction will rapidly progress to unconsciousness and cardiorespiratory arrest
• May be present in a child in cardiorespiratory arrest who is impossible to ventilate.

If obstruction is total:

1. Open the airway and under direct vision (preferably using a laryngoscope) check in the mouth for a foreign body – if present remove it with magills forceps.
2. Place child prone with the head down.
3. Apply 5 blows with the open hand to the interscapular area.
4. Turn child face up.
5. Apply 5 chest thrusts using the same technique as for chest compression during CPR.
6. Check in the mouth to see if foreign body has appeared, and remove if possible.
7. If the obstruction is not relieved, continue with alternating back blows and chest thrusts.
8. Positive pressure “ventilation” can be tried in an attempt to force the foreign body into the left or right main bronchus.
9. A surgical airway may be tried if the obstruction is in or above the larynx and it is impossible to remove it through the mouth

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If obstruction is partial:

1. DO NOT perform the above manoeuvres.
2. Place child upright in the position they feel most comfortable.
3. Arrange for urgent removal of foreign body in the operating theatre.

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Impaction lower than the main bronchus:

• History
  • Children between the ages of 6 months and 4 years are at greatest risk.
  • Witnessed episode of choking, coughing or wheezing while eating or playing (many are unwitnessed)
  • Tachypnoea and respiratory distress
  • Cyanosis
  • Persistent wheeze (may be focal and partially respond to bronchodilators)
  • Persistent cough
  • Fever
  • Haemoptysis
  • Shortness of breath
  • Recurrent or persistent consolidation
  • May be asymptomatic after initial event before developing complications (pneumonia, abscess, bronchiectasis etc)

1. 1.  

• Symptoms may include
  • persistent wheeze
  • cough
  • fever
  • dyspnoea not otherwise explained.
  • Recurrent or persistent pneumonia may be the presenting feature.
  • The child may be asymptomatic after the initial event

 

Examination

1. Asymmetrical chest movement
2. Tracheal deviation
3. Chest signs such as wheeze or decreased breath sounds on effected side
4. The respiratory examination may be completely normal

 

Radiology

1. Request inspiratory and expiratory chest films.
2. Look for:
   1. Radio-opaque foreign body
   2. Segmental or lobar collapse
   3. Hyperinflation distal to obstruction causing air trapping
   4. Mediastinal shift
   5. Consolidation suggestive of pneumonia
   6. Pneumothorax
   7. Pulmonary abscess and bronchiectasis are signs of a chronic impacted FB
   8. The CXR may be normal

Management

1. DO NOT perform the above manoeuvres.
2. Place child upright in the position they feel most comfortable.
3. Arrange for urgent removal of foreign body in the operating theatre.

 

Prevention

• No child less than 15 months old should be offered foods such as popcorn, hard lollies, raw carrot or apples. Children under the age of 4 years should not be offered peanuts.
• Encourage the child to sit quietly while eating and offer food one piece at a time.
• Avoid toys with small parts for children under the age of 3 years.