Inhaled object lodged in the upper or lower airway; pediatric peak at 1-3 years, adult risk with altered consciousness.
Also known as: foreign body aspiration, airway foreign body, choking, pediatric aspiration
Epidemiology
Predominantly a pediatric condition with peak incidence between 1 and 3 years. Approximately 80% of pediatric cases involve children under 3 years; food items (peanuts, seeds, hot dog pieces) and small toys are the most common objects. Adult aspiration occurs in patients with neurologic impairment, sedation, alcohol intoxication, dental procedures, or trauma; the right mainstem bronchus is the most common destination due to its more vertical orientation and wider lumen (in standing adults).
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Risk factors
- Pediatric: age 1-3 years, lack of molars, eating while running/playing, sibling-provided food (nuts, popcorn, hard candy, raw vegetables)
- Pediatric red flags for objects: button batteries (caustic injury within hours), magnets, sharp objects
- Adult: dementia, stroke, Parkinson disease, intoxication, sedation, dental work, trauma with loose teeth, tracheostomy
- Edentulous and elderly patients aspirating dental appliances or food boluses
Pathophysiology
Complete airway obstruction at the larynx or trachea causes immediate asphyxia and is rapidly fatal without intervention. Partial obstruction permits airflow but with stridor or wheezing. Bronchial impaction creates a one-way valve — air enters during inspiration (radial bronchial dilation) and trapping occurs on expiration, producing hyperinflation distal to the obstruction. Long-standing foreign bodies cause granulation tissue, post-obstructive pneumonia, bronchiectasis, and atelectasis.
Clinical presentation
Symptoms
- Sudden choking, coughing, gagging, or stridor during eating or playing (witnessed in only 30-40% of pediatric cases)
- Silent interval may follow, leading to delayed presentation days to weeks later
- Persistent cough, wheezing, dyspnea, recurrent pneumonia
- In adults: aspiration witnessed by family or staff after sedation, dental work, or seizure
- Hoarseness if laryngeal location
Signs / physical exam
- Inspiratory stridor (extrathoracic — laryngotracheal location)
- Expiratory wheeze or rhonchi (intrathoracic — bronchial location), often focal/unilateral
- Decreased breath sounds over the affected lung
- Cyanosis and respiratory distress with significant obstruction
- Universal choking sign (hands at throat) in conscious adults
Classic findings
Toddler with sudden cough and unilateral wheeze; inspiratory and expiratory CXR with air trapping that fails to deflate on the affected side.
Differential diagnosis
- Asthma exacerbation — Diffuse wheezing rather than focal; history of atopy; bronchodilator-responsive
- Croup — Viral prodrome, barking cough, inspiratory stridor, steeple sign on neck X-ray; ages 6 months-3 years
- Epiglottitis — High fever, drooling, toxic appearance, tripod position, thumb sign on lateral neck X-ray
- Bacterial tracheitis — Toxic appearance with high fever after viral URI; copious purulent secretions
- Anaphylaxis — Urticaria, angioedema, hypotension, respiratory distress after exposure; responds to epinephrine
- Retropharyngeal abscess — Fever, neck pain, dysphagia, drooling; widened prevertebral soft tissue on lateral neck film
- Recurrent pneumonia in same lobe — Consider chronic foreign body if recurrent same-segment pneumonia
Diagnostic workup
Labs
- Not diagnostic; obtain pre-procedure labs (CBC, type and screen, coagulation studies) before rigid bronchoscopy
Imaging
- Most aspirated foreign bodies are RADIOLUCENT (organic material, plastic) — a normal CXR DOES NOT exclude aspiration
- Inspiratory AND expiratory chest radiographs (or lateral decubitus films in young children): air trapping with mediastinal shift away from the affected lung on expiration is highly suggestive
- Look for indirect signs: hyperinflation, atelectasis, mediastinal shift, post-obstructive consolidation, focal hyperlucency
- Lateral neck X-ray for suspected upper airway foreign body
- Chest CT in stable patients with high clinical suspicion and equivocal radiographs
- Rigid bronchoscopy is both diagnostic and therapeutic for confirmed or strongly suspected cases — do not delay for advanced imaging when clinical certainty is high
Treatment
First-line
- Complete airway obstruction (cannot speak, cough, or breathe) — IMMEDIATE intervention per BLS/PALS:
- Adults and children >1 year: abdominal thrusts (Heimlich maneuver) until effective or patient becomes unresponsive
- Infants <1 year: alternating 5 back blows and 5 chest thrusts (NEVER abdominal thrusts in infants)
- Unresponsive patient: begin CPR, check mouth for visible foreign body during compressions, attempt to remove only if seen
- Direct laryngoscopy with Magill forceps for supraglottic objects
- Rigid bronchoscopy under general anesthesia is the GOLD STANDARD for bronchial foreign body retrieval — flexible bronchoscopy is reasonable in adults and at experienced pediatric centers
- Post-removal: bronchoscopic suctioning, evaluation for retained fragments, consider short course of corticosteroid if significant edema
Button battery aspiration
- EMERGENCY — caustic mucosal injury within 2 hours, perforation within hours
- Immediate rigid bronchoscopy or esophagoscopy regardless of symptoms
- Honey 10 mL every 10 min (in children >12 months) en route to ED if ingestion <12 hours and battery in esophagus per recent NASPGHAN/AAP guidance
Magnet aspiration or ingestion (especially multiple)
- High risk of pressure necrosis, perforation, fistula
- Immediate endoscopic removal; surgical exploration if perforation suspected
Chronic retained foreign body
- Rigid or flexible bronchoscopy for removal
- Treat post-obstructive pneumonia (amoxicillin-clavulanate, ampicillin-sulbactam, or alternative based on local sensitivities)
- Assess for bronchiectasis after resolution
Complications
- Asphyxia, hypoxic brain injury, death
- Post-obstructive pneumonia, empyema
- Bronchiectasis, chronic atelectasis
- Mucosal granulation tissue and bronchial stenosis
- Pneumothorax, pneumomediastinum (procedural or from forced expiration against obstruction)
- Button battery: tracheoesophageal fistula, aortoesophageal fistula, mediastinitis
PANCE pearls
- A normal chest X-ray does NOT rule out foreign body aspiration — most pediatric objects are radiolucent.
- Unilateral wheeze of acute onset in a toddler = foreign body aspiration until proven otherwise.
- Rigid bronchoscopy under general anesthesia in the operating room is the gold standard for pediatric retrieval.
- Right mainstem bronchus is the most common destination in standing adults; in supine patients the posterior segments of the upper and lower lobes are favored.
- Button batteries are a true emergency — caustic injury occurs within 2 hours, and outcomes are time-dependent.
References
- AAP / NASPGHAN — National Capital Poison Center / NASPGHAN Position Statement on Button Battery Ingestion (most recent update)
- AHA BLS/PALS — American Heart Association BLS and PALS Guidelines for Foreign Body Airway Obstruction (latest cycle)
- CHEST — Hewlett JC et al. Foreign Body Aspiration in Adult Airways: Therapeutic Approach. J Thorac Dis 2017;9:3398-3409 (referenced in CHEST adult interventional pulmonology materials)