Pediatric emergency medicine trisk 0674 0674
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Foreign bodies lodged in the lower tracheobronchial tree present a diagnostic
challenge due to the ubiquitous nature of the presenting symptoms (e.g., cough,
wheezing, respiratory distress), the frequency of the asymptomatic presentation,
and the potential for false-negative and false-positive screening radiographs.
Foreign bodies of the lower respiratory tract are more common in young children,
with a slight increased propensity for the object to lodge on the right side (52%).
Organic matter accounts for 81% of aspirations, with nuts and seeds being the
most common, followed by other food products (apples, carrots, popcorn), plants,
and grasses. Plastics and metals make up a minority of aspirated objects ( Fig.
32.2 ), and coin aspiration is rare.
The diagnosis of lower airway foreign-body aspiration is often delayed due to
nonspecific symptoms, and these patients may be incorrectly diagnosed with an
asthma exacerbation, pneumonia, or bronchiolitis. The classic clinical triad for an
aspirated foreign body (cough, focal wheeze, and decreased breath sounds) is
seen in only 14% to 39% of patients. The most common symptoms reported are
persistent cough (72% to 87%), difficulty breathing (60% to 64%), and wheezing
(52% to 60%). A history of a witnessed choking event is highly suggestive of
acute aspiration with a sensitivity of up to 93%. It is important to inquire about a
choking history since parents may not initially offer it. A significant proportion of
patients may not have a witnessed choking event, making the diagnosis more
difficult.
EVALUATION AND DECISION
Unknown Location
Generally, the symptom complex and history surrounding the event provide a clue
as to the likely location of the object within the respiratory or GI tract. Foreign
bodies in either location may present with airway symptoms, gagging, or
vomiting. Symptoms of cough and respiratory distress with tachypnea,
retractions, stridor, wheezing, or asymmetric aeration suggest a foreign body in
the upper or lower airway. Symptoms of gagging, vomiting, drooling, dysphagia,
or pain suggest esophageal impaction. Diagnosis can be challenging since foreign
bodies in either location may cause minimal symptoms. If the history and
physical examination do not provide the necessary clues, initial evaluation should
include a chest radiograph (including the neck and upper abdomen) to evaluate
for a radiopaque foreign body. Additional views, including an expiratory chest
radiograph or lateral decubitus films (discussed below) may help diagnose an
aspirated foreign body ( Fig. 32.3 ).
