Foreign body aspiration and ingestion (pediatrics): Clinical sciences

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Introduction 0:00–0:26

Foreign body aspiration refers to the inhalation of an object, while foreign body ingestion refers to the swallowing of an object.
Most cases require timely evaluation and treatment to prevent serious complications, like airway obstruction or gastrointestinal tract perforation.
If a pediatric patient presents with a chief concern suggesting foreign body aspiration or ingestion, start with an ABCDE assessment to determine if they are stable or unstable.

Unstable 0:26–1:02

If the patient is unstable, stabilize the airway, breathing, and circulation. Next, obtain IV access and put your patient on continuous vital sign monitoring.
Finally, provide supplemental oxygen if needed. After starting acute management, obtain a focused history and physical examination to identify potential complications, like airway obstruction or gastrointestinal perforation.
Patients may report a witnessed foreign body aspiration with acute onset of symptoms, like the inability to speak or cough, as well as gasping or blood in the sputum.

Airway obstruction 1:02–2:04

The physical exam might demonstrate signs of respiratory distress, like tachypnea, nasal flaring, and retractions. These findings should immediately make you suspect an airway obstruction, so act quickly.
Perform rapid sequence intubation and an emergent rigid bronchoscopy to remove the foreign body. In cases where a bronchoscopy is not immediately accessible, consider cricothyroidotomy.
Here’s a clinical pearl! If a patient aspirates outside of a hospital setting, perform back blows and chest thrusts on an infant; or the Heimlich maneuver in an older child.
However, if the patient is able to speak or cough, then do not perform these maneuvers since they may convert a partial obstruction to a complete one.
Now let’s talk about different findings. Patients might report a known or suspected ingestion, typically of a sharp or magnetic object, or a button battery.

Esophageal or bowel perforation 2:04–3:43

They could also report symptoms like dysphagia; blood in the saliva; and neck, chest, or abdominal pain. The physical exam may reveal crepitus and swelling in the neck and upper chest; or abdominal tenderness with rebound pain or guarding.
With these findings, suspect esophageal or bowel perforation. Then obtain X-rays of the chest and abdomen.
X-rays may demonstrate a foreign body in the chest or abdomen, and possibly subcutaneous emphysema in the neck or chest.
You might also see pneumomediastinum, which is characterized by lucent streaks or air around mediastinal structures; or pneumoperitoneum with free air under the diaphragm.
If you see these findings, diagnose a foreign body ingestion with perforation. Next, begin broad spectrum IV antibiotics and obtain an emergent surgical consultation.
Here’s a high-yield fact! Button batteries can cause rapid mucosal damage, necrosis, and perforation.
As a result, a button battery in the esophagus requires immediate removal. In contrast, those in the stomach or beyond should be removed if the child is under 5 years old or if the battery is larger than 2 centimeters.
In all other cases, you can monitor closely with serial X-rays. Let’s go back to the ABCDE assessment and look at stable patients.

Stable/Foreign body aspiration 3:43–6:44

First, perform a focused history and physical examination. Here’s a clinical pearl!
Several factors increase the risk of foreign body aspiration or ingestion in children less than three years of age, such as developmental curiosity, immature swallowing coordination, absence of molars and premolars, and a narrow pharynx.
Additionally, children with developmental delay are at an increased risk of foreign body aspiration. Young children are more likely to aspirate or ingest small, cylindrical, and compressible items, such as coins, batteries, magnets, small toys, and balloons; as well as specific foods, like hot dogs, raw carrots, or nuts.
Keep in mind that some of these items are radiolucent, meaning that they can’t be seen on an X-ray. Now, patients are often asymptomatic, but history might reveal witnessed foreign body aspiration, coughing, choking, dyspnea, or blood in the sputum.
The physical exam might demonstrate stridor or wheezing, as well as the unilateral absence of breath sounds. At this point, suspect a foreign body aspiration.
Here’s another clinical pearl! Unwitnessed foreign body aspiration can cause a delay in diagnosis.
These patients may present with prolonged coughing or wheezing and appear to have an infection or reactive airway disease.
When a healthy child doesn’t respond to standard treatment for a respiratory infection or asthma, consider foreign body aspiration.
Alright, once you suspect a foreign body aspiration, obtain neck and chest X-rays. If you see a foreign body in the airway, diagnose foreign body aspiration and extract the object using rigid bronchoscopy.
On the other hand, if X-rays don’t identify a foreign body, assess the airway using flexible bronchoscopy, especially if you suspect that the patient aspirated a radiolucent object.
If you still don’t identify a foreign body, consider an alternative diagnosis, like asthma, respiratory infection, or gastroesophageal reflux.
Alternatively, if flexible bronchoscopy reveals a foreign body in the airway, diagnose foreign body aspiration, and extract the object with a rigid bronchoscope.
Time for a clinical pearl! While flexible bronchoscopy is a useful diagnostic tool, it cannot be used to remove foreign bodies.
However, it’s often used when the diagnosis is unclear. Also, it is smaller and less traumatic than rigid bronchoscopy and can be performed while the patient is awake.
Let’s switch gears and talk about foreign body ingestion. Patients are often asymptomatic, but history might reveal witnessed foreign body ingestion, coughing, or choking.

Foreign body ingestion 6:44–10:20

Additionally, they might have dysphagia, vomiting, or refusal to feed. Some patients might also develop drooling; blood in the saliva; and throat, chest, or abdominal pain.
The physical exam is often normal, but you might find stridor, wheezing, or abdominal tenderness. With these findings, suspect foreign body ingestion and obtain X-rays of the neck, chest, and abdomen.
Now, if X-rays show a foreign body in the gastrointestinal tract, you can confirm foreign body ingestion. Next, assess the location of the foreign body.
If it’s in the esophagus, start IV antibiotics and perform an upper endoscopy to remove the foreign body, since it’s unlikely the object will pass spontaneously.
Remember to obtain a surgical consultation if there’s radiographic evidence of esophageal injury. Here’s a high-yield fact!
Coins are the most commonly ingested foreign body, and since they are one of the few ingested items that will pass spontaneously, you can often monitor with serial X-rays.
If radiographs cannot distinguish a coin from a button battery, you’ll need to remove the object immediately. Now, if the object is in the stomach, you should base your management on the object’s size and type.
You can manage small, less threatening objects, like coins, with observation and serial X-rays. Meanwhile, large or dangerous objects, such as a toothbrush or pushpin, should be removed with upper endoscopy.
In general, anything larger than 1 by 3 centimeters; or longer than 3 to 5 centimeters; should be removed. Finally, if the foreign body is post pyloric, it will likely pass through the rest of the gastrointestinal tract spontaneously.
Here, you can typically observe with serial X-rays. However, if the object is large or dangerous, consider an upper endoscopy with duodenoscopy or colonoscopy.
Remember to obtain a surgical consultation if there’s evidence of bowel obstruction or perforation, or if an object doesn’t pass through the bowels within three days.
Here’s one last high-yield fact! Patients who ingest multiple magnets are at high risk of complications since magnets can attract to one another through multiple bowel walls, leading to ischemia, necrosis, perforation, or fistulas.
For this reason, ingested magnets require prompt endoscopic removal or surgical intervention. Alright, let’s go back to our X-rays of the neck, chest, and abdomen.
If you don’t identify a foreign body on X-rays, consider obtaining an endoscopy, particularly if the patient is symptomatic, or if there was a witnessed ingestion of a radiolucent object.
If the endoscopy doesn’t reveal a foreign body, consider alternative diagnoses such as gastroesophageal reflux, esophagitis, or appendicitis.
On the flip side, if a foreign body is identified, diagnose foreign body ingestion and extract the object during the endoscopic evaluation.
Alright, as a quick recap… If a patient with foreign body aspiration or ingestion is unstable, assess for airway obstruction or gastrointestinal tract perforation and provide emergent intervention.

Review 10:20–11:12

If the patient is stable evaluate with X-rays. Aspirated foreign bodies should be removed with a rigid bronchoscope.
Management of ingested foreign bodies requires you to assess the location. If it’s in the esophagus, remove it with endoscopy.
In the stomach, small objects can be observed with serial X-rays, while larger objects should be removed with endoscopy.
Lastly, if the object is post pyloric, it will probably pass on its own, so you can observe with serial X-rays, but sometimes, you might need to remove it with endoscopy.
Foreign body aspiration and ingestion (pediatrics) | Osmosis