Foreign Body Aspiration

Introduction & Epidemiology - Tiny Trespassers

• Foreign Body Aspiration (FBA): Inhalation of an object into the airway, lodging typically below the vocal cords.
• Peak Incidence: 6 months - 3 years.
  • Due to oral exploratory behaviour, immature dentition, and uncoordinated swallowing.
• Common Culprits:
  • Organic (most frequent): Peanuts (common in India), seeds, vegetable pieces. Cause significant inflammation.
  • Inorganic: Small toys, coins, button batteries (⚠️ high risk of corrosion/perforation).
• Usual Suspect Location: Right main bronchus > Left main bronchus.

  ⭐ The majority of aspirated foreign bodies lodge in the right main bronchus due to its wider diameter and more vertical orientation.

• Risk Factors: Male sex, underlying neurological disorders, developmental delay.

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Clinical Features - Chokes & Wheezes

Key: Sudden onset. Varies by FB location/obstruction.

• Laryngeal FB:
  • Acute distress, stridor, hoarseness, aphonia.
  • May be life-threatening.
• Tracheal FB:
  • Asthmatoid wheeze, audible slap, palpable thud.
  • Biphasic wheeze.
• Bronchial FB (most common, R > L):
  • Persistent cough.
  • Localized/unilateral wheeze (often unresponsive to bronchodilators).
  • Unilateral ↓air entry.
  • 📌 CUD Triad: Cough, Unilateral wheeze, Decreased air entry (often incomplete).
  • Recurrent/non-resolving pneumonia, atelectasis.

⭐ Unilateral persistent wheezing in a child, especially if sudden in onset and unresponsive to bronchodilators, is highly suggestive of bronchial foreign body aspiration.

Diagnosis - Spotting Stowaways

• History: Sudden onset choking, coughing, or gagging, especially if witnessed.
• Clinical Examination:
  • Classic Triad: Unilateral wheeze, cough, decreased air entry.
  • Stridor (laryngeal/tracheal FB), hoarseness, or asymptomatic interval possible.
• Imaging:
  • Chest X-ray (PA & Lateral):
    • Radio-opaque FB visible.
    • Indirect signs for radiolucent FB: Unilateral hyperinflation (ball-valve), mediastinal shift (expiratory film), atelectasis/collapse.
    • Inspiratory/Expiratory films or lateral decubitus views (affected side down) can accentuate findings.
    • Normal CXR in 15-30% of cases.
  • CT Scan: Useful for radiolucent FBs or equivocal X-ray findings.

⭐ A normal chest X-ray does not rule out foreign body aspiration, especially with a strong history.

• Definitive Diagnosis & Treatment:
  • Rigid Bronchoscopy: Gold standard for both diagnosis and removal.

Management & Prevention - Eviction & Escape

Eviction (Management):

• Stable Patient:
  • X-ray (insp/exp, lat decubitus) may show air trapping, atelectasis.
  • Rigid bronchoscopy: Gold standard for diagnosis & removal.
• Unstable Patient (Acute Choking):
  • <1 yr: 5 back blows, then 5 chest thrusts.
  • >1 yr: Heimlich maneuver (abdominal thrusts).
  • Ineffective: Direct laryngoscopy, Magill forceps.
  • Advanced airway (e.g., cricothyroidotomy) if fails.
• Post-Eviction:
  • Observe; steroids/antibiotics if indicated.

⭐ > Rigid bronchoscopy is the definitive diagnostic and therapeutic procedure for most foreign body aspirations.

Prevention (Escape):

• Age-appropriate food; avoid nuts/seeds/hard candy < 4 yrs.
• Keep small objects (toys, coins, button batteries) out of reach.
• Supervise children during meals and play. 📌 Mnemonic (Prevention): "Small PARTS" (Peanuts And Round Things Supervise).

High-Yield Points - ⚡ Biggest Takeaways

• Peak incidence: 6 months - 3 years; organic FBs (e.g., peanuts) most common.
• Right main bronchus is the most frequent site of lodgement.
• Classic triad: Sudden cough, wheeze, ↓ air entry (unilateral); often incomplete.
• Expiratory chest X-ray: Shows air trapping (hyperinflation) & mediastinal shift.
• Rigid bronchoscopy: Gold standard for diagnosis and removal.
• Ball-valve obstruction causes unilateral hyperinflation; complete obstruction causes atelectasis.
• Beware of asymptomatic interval post-choking episode.