Foreign Body Aspirations In Children Jeffrey Schor, MD,

Foreign Body Aspirations In Children Jeffrey Schor, MD,

Foreign Body Aspirations In Children Jeffrey Schor, MD, MPH, MBA, FAAP Managing Member PM Pediatrics 1/16/13 Epidemiology More than 17,000 ED visits for children younger than 14 years (2000)

More than 3500 deaths per year (2005-2007) 5th most common cause of unintentionalinjury mortality in the U.S. Leading cause of unintentional-injury mortality in children less than 1 year Who Is At Risk? Majority of aspirations in children younger than 3 years Love to put things in their mouth Lack of efficient molars

Activity while eating Boys outnumber girls 2:1 Other risks Anatomically abnormal airway Neuromuscular disease Poorly protected airway (e.g., alcohol or sedative overdose) What Gets Aspirated? Food

Infants and toddlers Peanuts (36-55%) and other nuts Seeds Popcorn Hot dogs Non-food items Older children Coins, paper clips, pins, pen caps

Dangerous Objects Round Balls, marbles More likely to cause complete obstruction Break apart easily Compressibility Smooth, slippery surface

Some Interesting Aspirations Metered dose inhaler Super ball Dogs toe nail Cockroach The sinking ship Where Does It Go? Majority lodge in bronchi

or distal trachea 60% in right lung, mostly mainstem Laryngeal and tracheal foreign objects less common but higher morbidity and mortality Usually larger or irregular objects

Site Of Aspiration: Caveats Objects can fragment and lodge in multiple sites (e.g., sunflower seeds) Children can aspirate several different objects concurrently (or sequentially) Foreign bodies can erode through the esophagus and cause respiratory symptoms What Happens When A Child

Aspirates? Stage 1 Choking episode paroxysms of coughing and gagging Occasionally, complete airway obstruction Stage 2 Accommodation of airway receptors decreased symptoms Stage 3

Chronic complications (obstruction, erosion, infection) General Signs And Symptoms Site of aspiration often determines symptoms May have generalized wheezing or localized findings Monophonic wheezing, decreased air entry Regional variation in air entry an important clue Often detected only if careful and thorough exam when

child is quiet and minimal ambient noise Classic triad in only 57% Wheeze, cough and decreased breath sounds 25-40% with normal exam Often Need High Level Of Suspicion To Diagnose Suggestive history more likely with youngest and oldest children

Witnessed choking episode has a sensitivity of 76-92% for diagnosing aspiration HOWEVER, only 50% of diagnoses occur in the first 24 hours 80% within first week Will sometimes take years Pursuing A Diagnosis Plain radiographic studies

10% of objects are radioopaque Normal in about 65% of studies Often indirect evidence of obstruction Various techniques to improve diagnostic likelihood Fluoroscopy CT/MRI Suggestive X-Ray Findings Laryngotracheal

Subglottic density or swelling Lower airway Hyperinflation on side of foreign body Atelectasis if complete obstruction Consolidation, abscesses and/or bronchectasis over time if retained Easy If Radioopaque

What About Here? Inspiration Expiration Ball-Valve Effects Ball Valve Air enters on inspiration blocked on expiration Obstructive emphysema,

mediastinal shift away Most common Stop Valve Complete obstruction No air enters distally collapsed lung (atelectasis) Another Example

Inspiratory Expiratory Consider Lateral Decubitus If Child Cannot Cooperate The Ultimate Diagnostic Tool Rigid Bronchoscopy Standard of care in most centers for evaluation

Allows visualization, ventilation, removal with multiple forceps and ready management of mucosal hemorrhage Successful in about 95% of cases Complications are rare (about 1%) Laryngeal and subglottic edema, atelectasis Dislodgement of foreign body into more dangerous position Hypoxic insults After Removal

View entire tracheobronchial tree for additional objects If retained for significant period gram stain and culture to guide management If clinical signs and symptoms persist, repeat bronchoscopy is warranted

What If It Cant Be Removed? Can have intense inflammation if retained for long period Antibiotics and systemic steroids often used to cool down the area repeat bronchoscopy Open thoracotomy occasionally required What About Flexible Bronchoscopy?

Excellent diagnostic tool Minimal trauma, no general anesthesia Reports of successful removal as well American Thoracic Society still recommends rigid bronchoscopy for removal Complications Of Retained

Foreign Bodies Hemoptysis Bronchiectasis Bronchial stenosis Pneumomediastinum/pneumothorax Persistent/recurrent pneumonias Acute/recurrent respiratory distress or failure Death THE DIAGNOSIS MUST BE EXCLUDED!

Tying It All Together A history of choking is highly suggestive of a foreign body aspiration Often unwitnessed so absence does not rule out

If the patient is in extremis, AHA guidelines and PALS apply If patient stable, radiographic studies may aid in the diagnosis but clinical suspicion most important Rigid bronchoscopy is the gold standard for both diagnosis and removal, if necessary

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