Updated: 9/10/2019

Foreign Body Aspiration

Topic
Review Topic
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Questions
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Evidence
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Snapshot
  • A frantic mother brings her 2-year-old child to the emergency department after he swallowed an earring. Radiographs are shown.foreign body aspiration
Introduction
  • Aspirated solid or semi-solid object, usually lodged in the larynx or trachea
    • most often food, but can range from small toys to coins to pens, and so on
  • May be life-threatening is large enough to completely obstruct the airway
  • Can lead to chronic, recurrent infection if retrieval is delayed
  • Epidemilogy
    • usually presents after 6 months of age
  • Risk factors include
    • institutionalization
    • advanced age
    • poor dentition
    • alcohol
    • sedative use
Presentation
  • Symptoms
    • severe obstruction may present with
      • respiratory distress
      • aphonia
      • cyanosis
      • loss of consciousness
      • and death in quick succession
    • partial, long-term obstruction may present with
      • less severe respiratory symptoms
      • dysphagia
      • fever
      • hemoptysis
      • dyspnea
      • chest pain
      • symptoms indicative of secondary infection
  • Physical exam
    • unresolved pneumonia
    • decreased breath sounds
    • wheezing
Evaluation
  • Foreign body
    • CXR
      • shows hyperinflation of the affected side
    • ABG
      • necessary for appropriately evaluating ventilation
      • may be useful for following progression of respiratory failure when it is of concern
  • Acid/alkali 
    • after initial stabilization:
      • chest radiograph
      • gastrografin swallow
      • endoscopy
Differential
  • Chronic URI, pneumonia, tonsillitis, pneumonia, pneumothorax, emphysema, respiratory failure
Treatment
  • Medical intervention
    • endoscopic (flexible or rigid) retrieval of foreign body
      • flexible broncoscopy is both diagnostic and therapeutic 
      • rigid broncoscopy is preferred in children due to wider instrument lumen (as compared to flexible counterpart), which allows for ventilation and easier removal of objects 
    • surgical removal
      • indicated when endoscopy is impossible or unsuccessful
  • If the object is thought to be in the esophagus, based on imaging and clinical presentation:
    • Observe for 24 hours with serial radiographs and remove endoscopically if the object does not pass distally within that time frame 
    • If object causes symptoms or time-point of ingestion is unknown - attempt immediate endoscopic removal
    • If the ingested item appears relatively benign and has already progressed inferior to the diaphragm on imaging, observe and wait for spontaneous passage 
Prognosis, Prevention, and Complications
  • Prognosis
    • very good to excellent if identified and resolved early
  • Prevention
    • limit exposure to objects approved for specific age group (i.e. toys, etc)
  • Complications
    • may lead to chronic pneumonia
    • can cause sudden respiratory failure and death
 

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Questions (3)
Lab Values
Blood, Plasma, Serum Reference Range
ALT 8-20 U/L
Amylase, serum 25-125 U/L
AST 8-20 U/L
Bilirubin, serum (adult) Total // Direct 0.1-1.0 mg/dL // 0.0-0.3 mg/dL
Calcium, serum (Ca2+) 8.4-10.2 mg/dL
Cholesterol, serum Rec: < 200 mg/dL
Cortisol, serum 0800 h: 5-23 μg/dL //1600 h:
3-15 μg/dL
2000 h: ≤ 50% of 0800 h
Creatine kinase, serum Male: 25-90 U/L
Female: 10-70 U/L
Creatinine, serum 0.6-1.2 mg/dL
Electrolytes, serum  
Sodium (Na+) 136-145 mEq/L
Chloride (Cl-) 95-105 mEq/L
Potassium (K+) 3.5-5.0 mEq/L
Bicarbonate (HCO3-) 22-28 mEq/L
Magnesium (Mg2+) 1.5-2.0 mEq/L
Estriol, total, serum (in pregnancy)  
24-28 wks // 32-36 wks 30-170 ng/mL // 60-280 ng/mL
28-32 wk // 36-40 wks 40-220 ng/mL // 80-350 ng/mL
Ferritin, serum Male: 15-200 ng/mL
Female: 12-150 ng/mL
Follicle-stimulating hormone, serum/plasma Male: 4-25 mIU/mL
Female: premenopause: 4-30 mIU/mL
midcycle peak: 10-90 mIU/mL
postmenopause: 40-250
pH 7.35-7.45
PCO2 33-45 mmHg
PO2 75-105 mmHg
Glucose, serum Fasting: 70-110 mg/dL
2-h postprandial:<120 mg/dL
Growth hormone - arginine stimulation Fasting: <5 ng/mL
Provocative stimuli: > 7ng/mL
Immunoglobulins, serum  
IgA 76-390 mg/dL
IgE 0-380 IU/mL
IgG 650-1500 mg/dL
IgM 40-345 mg/dL
Iron 50-170 μg/dL
Lactate dehydrogenase, serum 45-90 U/L
Luteinizing hormone, serum/plasma Male: 6-23 mIU/mL
Female: follicular phase: 5-30 mIU/mL
midcycle: 75-150 mIU/mL
postmenopause 30-200 mIU/mL
Osmolality, serum 275-295 mOsmol/kd H2O
Parathyroid hormone, serume, N-terminal 230-630 pg/mL
Phosphatase (alkaline), serum (p-NPP at 30° C) 20-70 U/L
Phosphorus (inorganic), serum 3.0-4.5 mg/dL
Prolactin, serum (hPRL) < 20 ng/mL
Proteins, serum  
Total (recumbent) 6.0-7.8 g/dL
Albumin 3.5-5.5 g/dL
Globulin 2.3-3.5 g/dL
Thyroid-stimulating hormone, serum or plasma .5-5.0 μU/mL
Thyroidal iodine (123I) uptake 8%-30% of administered dose/24h
Thyroxine (T4), serum 5-12 μg/dL
Triglycerides, serum 35-160 mg/dL
Triiodothyronine (T3), serum (RIA) 115-190 ng/dL
Triiodothyronine (T3) resin uptake 25%-35%
Urea nitrogen, serum 7-18 mg/dL
Uric acid, serum 3.0-8.2 mg/dL
Hematologic Reference Range
Bleeding time 2-7 minutes
Erythrocyte count Male: 4.3-5.9 million/mm3
Female: 3.5-5.5 million mm3
Erythrocyte sedimentation rate (Westergren) Male: 0-15 mm/h
Female: 0-20 mm/h
Hematocrit Male: 41%-53%
Female: 36%-46%
Hemoglobin A1c ≤ 6 %
Hemoglobin, blood Male: 13.5-17.5 g/dL
Female: 12.0-16.0 g/dL
Hemoglobin, plasma 1-4 mg/dL
Leukocyte count and differential  
Leukocyte count 4,500-11,000/mm3
Segmented neutrophils 54%-62%
Bands 3%-5%
Eosinophils 1%-3%
Basophils 0%-0.75%
Lymphocytes 25%-33%
Monocytes 3%-7%
Mean corpuscular hemoglobin 25.4-34.6 pg/cell
Mean corpuscular hemoglobin concentration 31%-36% Hb/cell
Mean corpuscular volume 80-100 μm3
Partial thromboplastin time (activated) 25-40 seconds
Platelet count 150,000-400,000/mm3
Prothrombin time 11-15 seconds
Reticulocyte count 0.5%-1.5% of red cells
Thrombin time < 2 seconds deviation from control
Volume  
Plasma Male: 25-43 mL/kg
Female: 28-45 mL/kg
Red cell Male: 20-36 mL/kg
Female: 19-31 mL/kg
Cerebrospinal Fluid Reference Range
Cell count 0-5/mm3
Chloride 118-132 mEq/L
Gamma globulin 3%-12% total proteins
Glucose 40-70 mg/dL
Pressure 70-180 mm H2O
Proteins, total < 40 mg/dL
Sweat Reference Range
Chloride 0-35 mmol/L
Urine  
Calcium 100-300 mg/24 h
Chloride Varies with intake
Creatinine clearance Male: 97-137 mL/min
Female: 88-128 mL/min
Estriol, total (in pregnancy)  
30 wks 6-18 mg/24 h
35 wks 9-28 mg/24 h
40 wks 13-42 mg/24 h
17-Hydroxycorticosteroids Male: 3.0-10.0 mg/24 h
Female: 2.0-8.0 mg/24 h
17-Ketosteroids, total Male: 8-20 mg/24 h
Female: 6-15 mg/24 h
Osmolality 50-1400 mOsmol/kg H2O
Oxalate 8-40 μg/mL
Potassium Varies with diet
Proteins, total < 150 mg/24 h
Sodium Varies with diet
Uric acid Varies with diet
Body Mass Index (BMI) Adult: 19-25 kg/m2
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(M3.PD.46) A 3-year-old girl with no significant past medical history presents to the clinic with a 4-day history of acute onset cough. Her parents have recently started to introduce several new foods into her diet. Her vital signs are all within normal limits. Physical exam is significant for decreased breath sounds on the right. What is the most appropriate definitive management in this patient? Review Topic

QID: 103337
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Chest x-ray (CXR)

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Rigid broncoscopy

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Inhaled bronchodilators and oral corticosteroids

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Flexible broncoscopy

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Empiric antibiotic therapy

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(M2.PD.39) A 4-year-old girl is rushed to the emergency department by her concerned parents after she ingested a US nickel. At the time of her initial ED evaluation, 1 hour had passed since the incident. Initial radiographs suggest that the coin lies in the stomach (Figure A). The patient is currently asymptomatic, denying any abdominal pain, nausea/vomiting, or difficulty breathing. Which of the following is the next best step in the management of this patient? Review Topic

QID: 104581
FIGURES:
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Discharge patient with prescription for laxative and reassurance that the coin will pass in the stool

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Observation with serial radiographs until the coin passes

52%

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Urgent flexible endoscopy for attempted retrieval of the coin

13%

(3/23)

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Attempt bronchoscopy for confirmation of diagnosis and potential removal of coin

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Surgical removal of coin

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