Pediatric Anesthesia 2009 19 (Suppl. 1): 109–117 doi:10.1111/j.1460-9592.2009.03006.x Review article Pediatric airway foreign body retrieval: surgical and anesthetic perspectives KAREN B. ZUR MD* AND RONALD S. LITMAN DO† Departments of *Otolaryngology: Head & Neck Surgery and †Anesthesiology & Critical Care Medicine, University of Pennsylvania School of Medicine, The Children’s Hospital of Philadelphia, Philadelphia, PA, USA Summary Airway foreign body aspiration most commonly occurs in young children and is associated with a high rate of airway distress, morbidity, and mortality. The presenting symptoms of foreign body aspiration range from none to severe airway obstruction, and may often be innocuous and nonspecific. In the absence of a choking or aspiration event, the diagnosis may be delayed for weeks to months and contribute to worsening lung disease. Radiography and high resolution CT scan may contribute to the eventual diagnosis. Bron- choscopy is used to confirm the diagnosis and retrieve the object. The safest method of removing an airway foreign body is by utilizing general anesthesia. Communication between anesthesiologist and surgeon is essential for optimal outcome. The choice between maintenance of spontaneous and controlled ventilation is often based on personal preference and does not appear to affect the outcome of the procedure. Complications are related to the actual obstruction and to the retrieval of the impacted object. The localized inflammation and irritation that result from the impacted object can lead to bronchitis, tracheitis, atelectasis, and pneumonia. Keywords: foreign body; airway; pediatric; aspiration; bronchoscopy Introduction contributing to the susceptibility of this age group include incomplete dentition (presence of incisors to Pediatric airway foreign body aspiration is associ- tear foods but lack of cuspid molars necessary to ated with a high rate of airway distress, morbidity, grind food into a smooth bolus), immature swal- and mortality, especially in children younger than lowing coordination, and the tendency to be easily 3 years of age. In 2006, there were 4100 cases of distracted when eating (e.g. playing or running) (2). death related to foreign body aspiration in the With increased ambulation of the young child, there United States (1.4 per 100 000) (1). The peak age is less adult supervision and thus, the likelihood of for aspiration-related events is 1–2 years. Factors aspiration is higher. In this younger age group, the most commonly retrieved airway foreign bodies are Correspondence to: R.S. Litman, Department of Anesthesiology and food products, whereas in older children, the more Critical Care Medicine, The Children’s Hospital of Philadelphia, 34th St. & Civic Center Blvd, Philadelphia, PA 19104, USA likely culprits are nonorganic products (pen caps, (email: [email protected]). pins, etc.,) (3,4). Retrieval of these aspirated foreign Ó 2009 The Authors Journal compilation Ó 2009 Blackwell Publishing Ltd 109 110 K.B. ZUR AND R.S. LITMAN bodies is essential due to the risk of atelectasis, bronchiectasis, chronic pneumonias, and granula- tion tissue formation (5). Less commonly, an aspirated foreign body may lodge at or near the glottic inlet. A foreign body obstructing the glottis may present with acute airway distress, hoarseness and stridor. Partial glottic obstruction by smaller impacted objects may go unrecognized for weeks (6). Asphyxiation due to an impacted obstructing laryngeal foreign body carries a mortality rate of 45% (6). Survivors of such devastating events may carry a 30% chance of hypoxic encephalopathy. Life-saving measures may be needed at the site of the accident or upon arrival to the emergency room; reflex coughing by the child Figure 2 or the Heimlich maneuver may dislodge the object. A 15-month-old female presented with a ‘funny voice’. There was no associated airway distress. A piece of aluminum foil was found Smaller objects, such as small toys, pins (Figure 1) or embedded in the glottic airway. even aluminum foil (Figure 2) may get lodged and cause less severe symptoms such as hoarseness and of a choking or gagging event followed by a cough is stridor. highly suspicious for a foreign body aspiration. However, this initial event may be short lived and Presenting symptoms the child may be asymptomatic for one or more weeks, often leading the parents to forget about the The presenting symptoms of foreign body aspiration inciting episode (7). In the absence of a choking or may vary depending on its location, size, and aspiration event, the diagnosis may be delayed for chronicity. The child may be comfortable and in no weeks to months. As an example, one report apparent distress or may present in extremis with describes a 12-year-old female with a history of impending airway failure. Coughing, wheezing, dyspnea for 1 year, who became progressively shortness of breath, fever, and recurrent pneumonia worse in the 3 months leading to consultation with may each be the presenting symptom. Parental recall a pulmonologist. Clinically, she had shortness of breath and wheezing with exertion, but no symp- toms at rest. She also had a productive cough that did not respond to inhaled and oral steroids. Her physical examination was remarkable for monopho- nic wheezing on both inspiration and expiration, and mild obstruction on pulmonary function testing. Radiography demonstrated a resolving right lower lobe pneumonia. Due to the protracted symptoms, she underwent bronchoscopy which revealed a bead in the bronchus intermedius with endobronchial granulation tissue (5). This case is illustrative of the need for prompt action and high level of suspicion in patients with prolonged symptoms and no resolu- tion with standard treatment. A similar history was seen in one of our patients, a developmentally delayed child with no witnessed aspiration or choking episodes who presented to the emergency Figure 1 Lateral neck radiograph of a young toddler who presented with room with respiratory distress. Chest radiography acute onset of hoarseness and stridor. revealed a right sided pneumonia and a radiopaque Ó 2009 The Authors Journal compilation Ó 2009 Blackwell Publishing Ltd, Pediatric Anesthesia, 19 (Suppl. 1), 109–117 PEDIATRIC AIRWAY FOREIGN BODY RETRIEVAL 111 (a) retrieval, which had likely been embedded in the area for a prolonged period of time. Clinical findings On physical examination, there may be a multitude of findings, all of which are nonspecific for an aspiration event. Auscultation may reveal decreased breath sounds, wheezing (either focal or general- ized), or even a clear chest. In more complex cases where a superimposed pneumonia develops, dull- ness to percussion and crackles may be heard. In children, in whom the foreign body migrates distally, an initially abnormal auscultation and radiograph may become normal (8). As this suggests, a normal physical examination should not exclude the suspicion of an airway foreign body, as 14–45% of patients with abnormal bronchoscopic findings (i.e. foreign body) had a normal physical (b) exam preoperatively (9–11). Diagnostic modalities As previously mentioned, a high index of suspicion and a careful history and physical examination can correctly lead to a diagnosis of a foreign body in the airway. Sometimes, edema surrounding a lodged foreign body may reveal subglottic, tracheal or bronchial narrowing. Due to the nonspecific nature of these findings, the diagnosis relies on the bron- choscopy. Chest radiography provides a more defin- itive diagnosis when the object is radiopaque. With anterior and lateral views, it is possible to localize the site of obstruction. However, the most com- monly aspirated foreign bodies are organic (12) and unlikely to be visualized on radiography. Lateral decubitus views may be used to investigate the Figure 3 presence of lower airway obstruction. Their utility is (a) A developmentally delayed child presented with respiratory described below. distress. There was no known history of aspiration or choking. Four types of bronchial obstruction related to Chest radiography revealed pneumonia in the right lower lobe and a radiopaque object in the right distal bronchus (arrow). (b) A foreign body aspiration have been described (13). high resolution CT scan of the chest was performed, confirming The first type results in a bypass valve that partially the suspected foreign body. obstructs on both phases of respiration. The chest X-ray is normal because there is aeration (albeit object in the lower right lung field (Figure 3a). Due diminished) beyond the obstruction. Objects such as to the lack of history and presence of a pneumonic organic foreign bodies or small, flat items will have process, a high resolution CT scan was obtained and no abnormalities on radiography. revealed an aspirated tooth (Figure 3b). Bronchos- The second type of obstruction is the check valve. copy confirmed the diagnosis and allowed its In this situation, the air is inhaled but cannot be Ó 2009 The Authors Journal compilation Ó 2009 Blackwell Publishing Ltd, Pediatric Anesthesia, 19 (Suppl. 1), 109–117 112 K.B. ZUR AND R.S. LITMAN (a) (b) (c) Figure 4 (a) This infant was seen choking on a peanut. This posteroanterior chest radiograph reveals hyperinflation on the right and diminished volumes on the left, typical of a check-valve obstruction. (b) A left lateral decubitus film demonstrates persistent hyperinflation of the right lung field and diminished volume on the left. (c) A right lateral decubitus film demonstrates lack of mediastinal shift to the right, suggestive of a right main bronchus foreign body. A peanut was extracted from this location during subsequent bronchoscopy. expelled during exhalation. Both lung fields fill with in consolidation of the involved bronchopulmonary air on inspiration, but hyperinflation of the ipsilat- segment with subsequent collapse (Figure 5). eral affected lung occurs and is seen as such on the High resolution spiral computerized tomography chest X-ray (Figure 4a). To demonstrate this dichot- of the chest has been used to better outline the omy, inspiratory ⁄ expiratory films are needed.