What is Airway Foreign Bodies?
When someone accidentally inhales an object and it gets stuck in their airways, their symptoms can vary a lot, which can sometimes lead to a delay or mistake in diagnosis. Different factors can influence how severe this problem is, such as the kind of object that was inhaled, where it is lodged in the airways, whether someone saw it happen, the age of the patient, and when it happened. For instance, if the upper airways are blocked, a person might show typical signs of choking and severe difficulty in breathing. However, if the blockage is further down, symptoms might be milder and longer lasting, like a slight wheeze, cough, feeling of discomfort, or a general shortness of breath. These symptoms can sometimes be mistaken for asthma or other respiratory illnesses that are less urgent.
Inhaling a foreign object is actually the fourth most common cause of death amongst children below school age. It’s a major reason why children are taken to the emergency room and is therefore a key focus for preventing such incidents, ensuring public health, and correctly identifying and treating the issue. To prevent choking, restrictions have been placed on things that children might accidentally swallow. For instance, a law was put in place in 1973 that specifies the size that toys for children under three years old can be.
Despite these rules, choking in young children still happens, even with warnings on packaging and TV and internet ads about the choking risks of toys. But in the US, there are no rules about food items that could be risky for choking, though many inhaled items are actually foods. Round foods like peanuts, seeds, and fruits are often swallowed by children, while hotdogs and sweets are often the cause of choking deaths. To prevent inhaling foreign objects, it’s very important to educate parents, babysitters, teachers, and caregivers. Symptoms like a new cough or wheeze, drooling, changes in voice, or strange postures should alert medical professionals and parents to the possibility of an inhaled object, even if no one saw it happen.
What Causes Airway Foreign Bodies?
If a foreign object gets stuck in the throat or the windpipe, it can lead to breathing problems or can even get sucked further into the airways. This can result in symptoms like shortness of breath, wheezing, or coughing. Basically, anything small enough to fit into the mouth can potentially be inhaled.
This is especially a concern for babies and young children, who often explore their surrounding by putting things in their mouth. It’s really important for parents to watch what objects their child can access when they’re not supervised. On top of this, babies and young children’s ability to swallow hasn’t fully developed yet. This makes them more likely to inhale or choke on food while they’re eating. Peanuts are the object most commonly inhaled in Western countries, while hotdogs cause the most deaths.
Boys are more likely to inhale objects than girls. Round, smooth objects like nuts, beans, grapes, and hotdogs or sausages pose the highest risk of being inhaled. One way to prevent this is to change the shape of these foods into something more angular that’s easier to chew and swallow. For example, you could cut grapes into quarters.
Risk Factors and Frequency for Airway Foreign Bodies
Kids, particularly boys, and people with developmental delays are more likely to inhale foreign objects unintentionally. The elderly are also at risk. In Western countries, the most frequently inhaled food items are peanuts, hotdogs and hard candies. Apart from food, smooth and round objects such as marbles and rubber balls are also commonly inhaled. Children’s chances of inhaling foreign bodies increase due to their lack of molars for properly chewing food.
Most of the data on this topic comes from single-center studies. However, more comprehensive studies and nationwide data analyses have been carried out recently. These studies estimate that for every 100,000 people, around 0.66 will suffer from foreign-body airway obstruction (FBAO). In the US, 17,000 emergency visits in the year 2000 from children under 14 were due to inhaling foreign bodies. Astonishingly, foreign body aspiration is the leading cause of accidental death in infants and is the fourth leading cause of death in preschool children under five.
- 80% of cases of foreign bodies being lodged in the airway occur in children under three, with the highest frequency in one- to two-year-olds.
- A study reported that children under five are responsible for 77.8% of foreign body aspiration cases, while 16% are caused by children aged five to fifteen and 6.2% are caused by those aged over fifteen.
- Children aged four or younger are especially at risk due to their inclination for oral exploration, their lack of molars, and an undeveloped swallowing reflex.
Signs and Symptoms of Airway Foreign Bodies
If there is a history or suspicion of breathing in a foreign object (aspiration), a full medical check-up is often needed. This check-up often includes a procedure known as rigid bronchoscopy.
Aspiration can occur in different ways. For instance, sudden choking, difficulty breathing, loud wheezing, and excessive drooling could indicate blockage of the major airways. People showing these signs should not be overly disturbed and must be immediately taken to an operating room. An extensive examination of their airways using rigid bronchoscopy is done here, with preparations for an emergency breathing hole set up (tracheostomy) as needed. It is recommended not to perform mouth exams or use small tube-like devices (endoscopes) to view the airways in the Emergency Department.
Constant difficulty in breathing over a long period could be due to the aspiration of a foreign object. This is especially common in children and individuals with developmental delays who may not be able to clearly communicate what happened. The object could be lodged in the narrower, more distant airways causing either a full blockage and pneumonia or a partial blockage leading to wheezing, coughing, and progressive breathing difficulty as the lining of the airways become more sensitive and swollen. Such patients may show symptoms weeks to months after the event, which may have gone unnoticed or been forgotten.
The structure of the airways in children is different from that in adults. The narrowest part of a child’s airway is the cricoid, while in adults, it’s the glottis. So, in children, particles might pass the vocal cords (glottis) only to get stuck further down the airway at the cricoid, leading to potentially serious health problems.
When it comes to aspiration of foreign objects, children are slightly more likely to inhale objects into the right main airway (bronchus). However, this likelihood increases with age due to the right main airway becoming more vertically aligned, like the windpipe (trachea), thus becoming the most direct part of the adult airway.
On examination, common signs of large airway obstruction include certain postures, drooling, wheezing, and stridor. In the case of smaller airway aspiration, the symptoms might be less obvious and can resemble those of asthma. If these symptoms persist despite treatment for infections and reactive airway diseases, a rigid bronchoscopy may be required to examine the airways.
Testing for Airway Foreign Bodies
If a patient, particularly a young child, is extremely distressed or uncooperative, the doctor shouldn’t try to do an image scan or any other procedure that could cause distress. Instead, the doctor should take the patient straight to the operating room for a careful examination of the patient’s airway under anesthesia. The doctor will need to have equipment ready for an emergency tracheostomy, which can create a new path for air to enter the lungs.
If the patient is calm and cooperative, the doctor might opt to start with chest X-rays. If the lungs aren’t expanding evenly or if the tissue around the lung looks flattened, it might indicate a blockage. What’s more, if air gets trapped in the lungs between breaths – a bit like a ball stuck in a valve – it could signify a foreign body blocking the airway. Radiopaque objects, or objects that show up on the x-ray images, can help the doctor find and pinpoint the cause of the problem. The doctor will draw some blood to check the patient’s blood count and electrolyte levels. This step is in preparation for possibly needing to use general anesthesia. However, a routine blood gas test, which measures oxygen and carbon dioxide levels, generally isn’t helpful in this situation and can be skipped.
With some patients, the doctor can conduct a more thorough examination of the head and neck, sometimes using a flexible laryngoscope to get a better look at the throat and voice box. This exam can identify other conditions that might be causing similar symptoms. For example, tonsillitis or an abscess near the tonsils could be the real culprit, and can be treated accordingly.
The doctor can use a stethoscope to listen to the sound of the patient’s breathing. If the doctor hears wheezing or detects places where the lungs are heavy with fluid, it can point to probable causes of the problem. Techniques like tapping on the chest wall or feeling chest vibrations can also help in the assessment.
CT scans should only be used for the most stable and calm patients, and only when a foreign body in the airway is less likely. The last thing a doctor wants is an airway emergency happening in the middle of a CT scan, which could put the patient’s life at risk.
Treatment Options for Airway Foreign Bodies
For severe upper airway obstructions, getting the airway open is crucial. However, it’s not advisable to use instruments to try and clear the airway or extract what’s causing the blockage unless the patient is awake, alert, and okay with the procedure. Plus, they can’t be experiencing any discomfort. This type of procedure is usually best done in an operating room where the situation can be more closely controlled. Sometimes, it may be necessary to insert a breathing tube past the blockage or even force the blockage into one of the major airways in the lungs. These actions are also ideally done in an operating room rather than an emergency department.
In critical situations, an emergency procedure known as a cricothyroidotomy could be performed. This procedure involves creating an opening in the neck to provide an airway and permit breathing when other options aren’t available.
If a lower airway obstruction is suspected, it is important to get a detailed history take a physical examination. Important factors to consider include whether a child has been left unsupervised around small objects, whether choking or sucking something into the lungs was witnessed, or whether new cough or respiratory symptoms appeared that can’t be explained otherwise. If treatment fails to relieve the symptoms, a more detailed examination of the airway may be required. In many cases, a technique known as rigid bronchoscopy is used to treat the problem. This technique can be used based on suspicion alone, as some people who breathe something into their lungs don’t have physical signs or symptoms.
When a foreign body is known to be in the lungs or is suspected, that object can be removed with rigid bronchoscopy under general anesthesia. If the object has recently been inhaled, then just retrieving it and following regular treatment instructions, including possibly using oral or inhaled corticosteroids, may be enough. However, if there are signs of infection due to the blockage, antibiotics can be started at that time.
What else can Airway Foreign Bodies be?
When a person seems to have inhaled a foreign object, doctors have to rule out other diseases that come with similar symptoms. These can be quite broad, varying in severity and can include issues like:
- Asthma
- Pneumonia
- Tuberculosis
- Epiglottitis (swollen part in the throat)
- Peritonsillar abscess (infection near the tonsils)
- Retropharyngeal abscess (infection in the throat)
- Postviral pericarditis or pleuritis (inflammation surrounding the heart or lungs following a viral infection)
- Bronchiolitis (inflammation of the tiny air passages in the lungs)
Even certain types of injuries, such as those affecting the lungs, airways, or diaphragm, can have similar symptoms to inhaling a foreign object. The wide range of symptoms makes this a challenging diagnosis—especially with children or people who struggle with communication.
What to expect with Airway Foreign Bodies
When a child swallows a foreign object, the situation usually turns out well if the object is removed promptly and without complications. Most children who are taken to the ER after swallowing an object tend to have good outcomes. However, swallowing a large object that blocks the windpipe or the nearby airway can lead to very serious consequences.
In a study involving 94 children who all were taken to the hospital three days after swallowing an object, everyone fully recovered from any complications, with the exception of one child who sadly died from respiratory failure.
Possible Complications When Diagnosed with Airway Foreign Bodies
When a foreign body is aspirated and requires treatment, about 25% of cases can lead to complications. However, most of these complications are usually mild if the treatment is performed early. If the intervention is done late, it might result in more serious complications. These complications may include issues like hypoxia or anoxic brain injury (especially when there is a blockage in the trachea or main bronchus), injury to the bronchial tubes, narrowing of the airway, formation of abscesses, or a punctured lung. Even though these complications are rare, they can be significant.
Apart from a very small number of cases that can unfortunately result in death due to breathing problems, typically children will recover with proper treatment for these delayed complications.
Common complications when intervention is delayed:
- Hypoxia or anoxic brain injury
- Bronchial injury
- Airway stenosis
- Abscess formation
- Pneumothorax
Preventing Airway Foreign Bodies
The Consumer Product Safety Commission is involved, along with federal regulations, in setting standards for packaging and warning labels on products. These measures help to keep everyone, especially children, safe. Besides, having parents and other adults who take care of children informed about the potential risks of hard, round foods is crucial. It’s necessary to encourage kids to chew their food slowly to ensure they are eating in a safe manner. Moreover, always supervising young children during meal and snack times enhances their safety while eating.
