Paediatric Foreign Body Aspiration

Acute upper airway obstruction

• Signs of partial obstruction
  • Stridor
  • Increased WOB
• Signs of deterioration
  • Hypoxia – worried, unsettled, restless
  • Fatigue or reduced consciousness
  • Increased WOB

Differential

• Harsh barking cough, febrile, miserable but otherwise well = Croup
• Absent cough with low-pitched expiratory stridor and drooling = epiglottitis
• Sudden onset in well child with coughing, choking and aphonia = FB
• Swelling of face, tongue, wheeze, rash = Anaphylaxis

• High fever, hyperextension of neck, dysphagia, drooling, toxic appearance and markedly tender trachea
  • Epiglottitis/bacterial tracheitis/retropharyngeal-peritonsillar abscess

Management

• Minimal handling
• Oxygen while awaiting definitive Rx
  • May be flow past high-flow or NRBM depending on tolerance

Impaction down to main bronchus level

• Sudden and catastrophic
• Coughing, choking and possibly vomiting
• Consider in cardiac arrest with difficult/impossible ventilation

Ineffective cough

• Place child prone with head down
  • 5 back blows to interscapular area
• Turn face up
  • 5 chest thrusts
• Check mouth for FB and remove if possible
• If obstruction continues, alternative back blows and chest thrusts
• If child becomes obtunded or hypoxia worsens
  • May require sedation for laryngoscopy
  • Options are:
    • IV/IO ketamine 1-2mg/kg or propofol 1.5-3mg/kg
    • IM ketamine 4mg/kg (slower and less predictable)
    • Can consider RSI with IV or IM paralysis to optimise intubating conditions
    • Depends upon IV access
    • Must have advanced airway equipment for intubation and surgical airway prepared and ready to go as sedation may turn partial obstruction into total obstruction -> Arrest
    • Ketamine carries a very real risk of laryngospasm in the presence of a foreign body
    • IM paralysis with suxamethonium 4mg/kg may take up to 3 minutes to take effect
  • If foreign body is above or in between cords -> Magill forcep removal
  • If FB below cords
    • PPV can be attempted to push FB down into left or right main bronchus
    • Bougie and ETT itself can help with this
    • Can push FB down into right main bronchus (most likely) and then preferentially ventilate left lung with dual lumen tube or with fibreoptic bronchoscopic guidance
  • Surgical airway if obstruction unable to be removed in or above larynx

If effective cough

• DO NOT perform back blows or chest thrusts
• Place child upright in position they are most comfortable in
• Minimal intervention
• Arrange for operating theatre gas induction

Impaction lower than main bronchus

• May have had episode of choking/wheezing/coughing or unwitnessed
• Persistent wheeze, cough, dyspnoea not explained
• Recurrent or persistent pneumonia may be the presenting symptom
• Child may be asymptomatic after event
• Examination
  • Asymmetrical chest movement
  • Tracheal deviation
  • Wheeze/reduced breath sounds
  • May be completely normal

• CXR (inspiratory and expiratory)
  • Look for atelectasis, opaque foreign body, localised emphysema in expiration (ball-valve obstruction)
  • May be normal
• If possibility of FB, arrange bronchoscopy

Prevention

• No child <15mo should be offered popcorn, hard lollies, raw carrot or apples
• Children <4yo should not be offered peanuts
• Encourage child to sit quietly while eating and offer one piece at a time
• Avoid toys with small parts for children under the age of 3yo

Last Updated on December 19, 2022 by Andrew Crofton