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Home , Cricothyrotomy, Foreign body aspiration

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 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 , and may often be innocuous and nonspecific. In the absence of a or aspiration event, the diagnosis may be delayed for weeks to months and contribute to worsening 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 , tracheitis, , and .

Keywords: foreign body; airway; pediatric; aspiration;

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

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bodies is essential due to the risk of atelectasis, , chronic , 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 . 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 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, , 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 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

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(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, 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

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(a) (b) (c)

Figure 4 (a) This infant was seen choking on a peanut. This posteroanterior 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. In parenchymal pathology in cases where the diagnosis children, it is difficult to obtain reliable expiratory is elusive (Figure 3b) (14). films, so lateral decubitus films are obtained. In this condition, a mediastinal shift will occur toward the Management normal side if the difference in lung volume is significant. On left lateral decubitus film, the medi- The 1995 American Heart Association revision of astinum ⁄ heart structures should shift to the left pediatric included management of (Figure 4b), while on right lateral decubitus films the an aspirated foreign body (15). When the airway should shift to the right. But, if there obstruction is mild (the child can cough and make is an obstructing foreign body on the right main some sounds) no active management is indicated. bronchus, then on a right lateral decubitus film the The child should be allowed to clear the obstruction ipsilateral lung field (right) will remain inflated/ by coughing and observed for worsening of airway areated (Figure 4c) . obstruction. If the airway obstruction is severe (the The third type of bronchial obstruction related to child is unable to make a sound), the child should foreign body aspiration is the ball valve obstruction. receive subdiaphragmatic (Heim- This is caused by a partial obstruction by an object lich maneuver) until the object is expelled or the that intermittently prolapses and obstructs the child becomes unresponsive. Infants should receive affected bronchus. In this situation, mediastinal shift five back blows followed by five chest thrusts occurs toward the involved side and there is repeatedly until the object is expelled or the infant decreased air entry leading to early atelectasis and becomes unresponsive. Abdominal thrusts in infants collapse. are not recommended because of the possibility of The final type of obstruction is the stop valve damage to the relatively large liver. obstruction. This denotes a complete bronchial If symptoms of asphyxiation and laryngeal obstruction where air passage is impeded on both obstruction develop or persist, and the child is in a inhalation and exhalation. Such a condition results facility with trained staff, a temporary

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(a) (c)

(d)

(b)

Figure 5 (a) A 1-year-old female was witnessed choking on chicken. She became irritable and developed a fever overnight, and presented to the emergency room with decreased breath sounds on the left. This posteroanterior chest X-ray reveals decreased air entry on the left. (b) Bronchoscopy revealed purulent secretions in the left main bronchus. (c) Food matter is present after suctioning of the purulent secretions. (d) Following removal of the food matter, mild edema noted in the surrounding mucosa. can be performed by inserting an 18-gauge needle or and therapeutic bronchoscopy as soon as the diag- catheter to allow for oxygen and positive pressure nosis is considered. The surgeon performing the ventilation en route to the operating room (OR) for evaluation and extraction must ensure that the more definitive intervention under controlled bronchoscopy table is properly arranged (Figure 6a) conditions. The airway is evaluated thoroughly and that extraction forceps are available for imme- using microlaryngoscopy and bronchoscopy, and diate use (Figure 6b). There should be a thorough depending on the residual laryngeal or subglottic discussion with the anesthesia and nursing team to , a decision is made about keeping the child coordinate the procedure and communicate the intubated overnight or for a predetermined amount of plan. time vs a longer term airway intervention such as a Following induction of general anesthesia, the OR tracheostomy. table is rotated 90 away from the anesthesiologist, The management of suspected tracheobronchial and the airway is managed by anesthesia or surgical foreign body aspiration includes a formal diagnostic personnel (Figure 7). Constant communication about

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(a)

(b) Figure 7 The table is rotated 90 away from the anesthesiologist, and the airway is managed by anesthesia or surgical personnel.

subglottis, the anesthesia circuit is connected to allow oxygen delivery and positive pressure venti- lation if necessary. When the foreign body is visu- alized, the bronchoscope is maintained above the level of obstruction, ensuring that the patent bron- chus is ventilating via the side-ports. If purulence is seen, gentle suction is applied, with care not to further manipulate or push the foreign body distally. The Hopkins telescope is removed along with the attached camera, and an optical grasping forceps (when available) or a nonoptical foreign body forceps is then introduced gently. The foreign body Figure 6 is delicately grasped and every attempt is made to (a) Standard setup for bronchoscopy. From left to right, bottom row: ventilating bronchoscope, suction, Hopkins rod with camera extract it in one piece and avoid unnecessary attached, intubating laryngoscope. Second row, left to right: manipulation of the surrounding mucosa of the drape, 2% topical lidocaine solution, saline bowl and a tooth tracheal or bronchi. If the foreign body is smaller guard, defogging solution. (b) Optical forceps used to extract foreign bodies in the airway: up-biting forceps used for granula- than the diameter of the ventilating bronchoscope, tion in the airway (top); toothed forceps for coin extraction then the bronchoscope is left in situ while the foreign (middle); and forceps used for grasping organic foreign bodies body and the grasping forceps are removed. If such as peanuts (bottom). the foreign body is larger than the lumen of the bronchoscope, it is tightly grasped, brought to the tip the child’s airway status is vital. Tooth protection is of the bronchoscope, and the bronchoscope, forceps applied either with a moist gauze for the edentulous and foreign body are removed en-mass, with care infant, or with a plastic guard. A laryngoscope is not to dislodge the foreign body and lead to further inserted and suspended in the vallecula to expose obstruction. If this occurs, then it is re-grasped and the epiglottis, arytenoids and vocal folds which are retrieved. If during the extraction the foreign body then inspected for any mucosal abrasion or presence obstructs the subglottis or , then is must be of a foreign body. A bronchoscope is then inserted to pushed distally into a bronchus to allow ventilation visualize the distal airway. To avoid laryngeal through the healthy lung. If the foreign body cannot injury, the ventilating bronchoscope is rotated 90 be retrieved and is distal in the bronchus, then a to allow the beveled end to pass parallel to the vocal may be needed for removal of the folds. Once the ventilating bronchoscope is in the peripherally located object.

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In some circumstances, a small ventilating bron- preoperative laboratory testing. Radiographic stud- choscope that would allow the passage of optical ies of the neck and chest region should be reviewed grasping forceps is not possible, and expeditious to precisely locate the anatomic location of the foreign body retrieval with the ‘naked optical for- foreign body and assess the potential for airway ceps’ (with no ventilating bronchoscope in place) is obstruction during administration of general anes- possible but should be avoided if the surgeon is not thesia. efficient or comfortable with the compromised air- In most cases, a peripheral intravenous catheter way. Jet ventilation is not recommended due to the should be placed prior to arriving in the surgical risk of barotrauma and pneumothorax (16). suite. Intravenous access is important for preopera- After the foreign body is safely retrieved, a follow- tive hydration and administration of antibiotics, up bronchoscopy is immediately performed to rule- steroids, or anxiolytic medications, such as midazo- out the presence of an additional foreign body lam, when indicated. However, clinical judgment is [reported to occur in 5% of pediatric cases (12)] and essential, as sedative medications may exacerbate to rule out airway injury. The child is admitted to an existing upper airway obstruction and lead to life- inpatient care unit or intensive care setting and a threatening hypoxemia. Intravenous atropine or postoperative chest radiograph is obtained to mon- glycopyrrolate may be administered to dry airway itor for postoperative pulmonary compromise. It is secretions, to prevent vagal-induced bradycardia important to document resolution of trapped air, from insertion of the bronchoscope, and to attenuate atelectatic segments and pneumonias. Steroids are cholinergic-mediated bronchoconstriction during often administered intraoperatively to assist in airway manipulation. Preoperative communication reduction of airway inflammation (17). If a pneu- with the surgeon should review surgical and anes- monic process is active or if mucosal abrasion thetic techniques. occurred during the procedure, antibiotic therapy Various successful methods have been reported is indicated. Postoperative antibiotics and a short for anesthetizing children for bronchoscopy (16,19). course of steroids (2–3 days) (18) are also suggested The choice may be dependent upon one or more for management of granulation tissue that may have factors, including the condition of the patient, resulted from prolonged impaction of the foreign location of the foreign body, and personal preference body (5). of the anesthesiologist or surgeon. Induction of general anesthesia can be accom- Anesthetic considerations plished using inhaled sevoflurane or an intravenous hypnotic agent, with or without maintenance of Preoperative review should focus on the patient’s spontaneous ventilation, depending on the anes- previous anesthetics and optimization of comorbid thetic and surgical plan. Depending on the location conditions. Preparing the child with a foreign body of the foreign body, coughing or positive pressure for bronchoscopy should take into account any ventilation may result in its dislodgment, leading to underlying lung damage caused by mechanical or further pulmonary compromise. A rapid sequence chemical effects of the object. The pathophysiology induction and immediate and distal to the site of obstruction is such that the alveoli gastric suctioning are indicated if a full stomach is of the lung segment supplied by the obstructed suspected, and the child’s condition warrants imme- bronchus are collapsed or filled with fluid (17). Due diate bronchoscopy. If the child’s ventilatory status to persistent parenchymal changes, removal of the is stable, routine fasting guidelines should apply. obstructing endobronchial object does not result in The anesthetic plan will be largely determined by immediate resolution of the inflammation. Physical the a priori choice of spontaneous or positive exam is focused on upper airway anatomy and the pressure ventilation during the bronchoscopy. This severity of upper or lower airway obstruction. A choice is influenced by the personal preferences of nebulized bronchodilator such as albuterol may be the anesthesiologist and surgeon, who must agree on indicated to improve lower airway ventilation and the technique prior to administration of anesthesia. oxygenation when edema and bronchospasm are There are times, however, when this decision will be present. There are no specific requirements for made during the case, depending on the surgeon’s

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findings and the patient’s clinical condition. With A review of 94 cases of pediatric foreign body either ventilatory method, these procedures entail a aspiration suggested that there was no increased large percentage of time that the child’s airway is incidence of adverse events related to either spon- open (i.e. exposed to the atmosphere when the taneous or controlled ventilation, but that prospec- surgeon removes the optical eyepiece or removes the tive studies are needed to ascertain the outcomes bronchoscope). For this reason, a total intravenous related to each mode of ventilatory support (20). anesthesia (TIVA) technique is preferred to decrease Once the child is adequately anesthetized, and just OR pollution from inhalational agents and provide prior to performing rigid bronchoscopy, the OR an uninterrupted source of general anesthesia to the table is turned 90 away from the anesthesiologist, patient. while mask ventilation is continued from a side There are advantages and disadvantages of both position by the anesthesiologist or by the surgeon at spontaneous and controlled ventilation methods the head of the table until the surgeon is optimally during rigid bronchoscopy. If spontaneous ventila- prepared to instrument the airway (Figure 7). The tion is maintained, continuous ventilation is occur- goal of the entire process should be a smooth, ring, despite interruptions in the anesthesia coordinated, sharing of the child’s airway with a breathing circuit. For some obstructive lesions, combination of optimal oxygenation, ventilation, negative-pressure breathing may provide better and surgical exposure. oxygenation and ventilation. Disadvantages of spon- Following completion of the surgical procedure, taneous ventilation include the requirement to emergence of the child is performed with or without maintain a sufficient depth of anesthesia to obliterate the presence of an endotracheal tube, usually airway reflexes and prevent patient movement depending on the personal preference of the anes- during instrumentation, yet maintain sufficient ven- thesiologist. If there are no complicating medical or tilatory function and hemodynamic stability. Thus, surgical factors, then we prefer to allow the child to topical anesthesia to the airway is an important emerge from general anesthesia without the pres- component of this technique. ence of an endotracheal tube. As the child emerges A controlled ventilation technique, which usually there is the possibility of laryngospasm, thus, secre- consists of administration of a neuromuscular tions should be cleared often, and possibly the use of blocker, relies on intermittent positive-pressure an antisialagogue such as glycopyrrolate. breaths between apneic periods and via the venti- lating port of the bronchoscope. Its advantages Complications include the ability to provide optimal oxygenation and ventilation during the breathing phase, and Complications related to airway foreign body assurance of lack of patient movement to airway aspiration and retrieval can be categorized into manipulation. Its obvious disadvantage is that dur- those related to the actual obstruction, and those ing periods of apnea, even with preoxygenation, related to the surgical extirpation of the impacted there is a limited time before oxyhemoglobin desat- object. Prolonged significant obstruction may lead uration will occur, and the child will require addi- to hypoxia and cerebral insult. The localized tional positive-pressure breaths. Another significant inflammation and irritation that result from the disadvantage is the lack of assurance that positive- impacted object can lead to tracheitis bronchitis, pressure ventilation will be successful with an and atelectasis. As a result of the accumulation of obstructive lesion within the airway. In the case of secretions near the site of inflammation, pneumo- a foreign body lodged within the bronchial tree, a nia(s) may occur. Pneumomediastinum and pneu- theoretical disadvantage of positive pressure is the mothorax are thought to be due to the extension of unintentional movement of the object further dis- trapped air from alveolar rupture along perivascu- tally. This can worsen airway exchange or create a lar sheaths. The former has been reported to occur ball-valve effect with hemodynamic consequences about 13% of the time (21). Intraoperative compli- secondary to lung compression of vascular struc- cations include hypoxia, hypercarbia, hypotension tures. Fortunately, this complication is extremely and the need for postoperative oxygen supplemen- rare. tation (17).

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Conclusions 8 Barrios Fontoba JE, Gutierrez C, Lluna J et al. Bronchial foreign body: should bronchoscopy be performed in all patients with a Early recognition and suspicion of a foreign body choking crisis? Pediatr Surg Int 1997; 12: 118–120. aspiration is essential to avoid ineffective medical 9 Ciftci AO, Bingol-Kologlu M, Senocak ME et al. Bronchoscopy for evaluation of foreign body aspiration in children. J Pediatr therapy and repeat admissions. The prolonged Surg 2003; 38: 1170–1176. presence of a foreign body in the airway can lead 10 Even L, Heno N, Talmon Y et al. Diagnostic evaluation of to pneumonias and pulmonary parenchymal disease foreign body aspiration in children: a prospective study. J Pediatr Surg 2005; 40: 1122–1127. that may not be reversible. The prompt management 11 Metrangelo S, Monetti C, Meneghini L et al. Eight years’ and coordinated efforts between the members of the experience with foreign-body aspiration in children: what is surgical team, including nursing, anesthesia and the really important for a timely diagnosis? J Pediatr Surg 1999; 34: 1229–1231. bronchoscopist will help ensure that the child is 12 McGuirt WF, Holmes KD, Feehs R et al. Tracheobronchial managed safely and effectively. A normal radio- foreign bodies. Laryngoscope 1988; 98: 615–618. graphic finding and a nonagitated child do not 13 Chatterji S, Chatterji P. The management of foreign bodies in necessarily rule out the presence of an impending air passages. Anaesthesia 1972; 27: 390–395. 14 Hong SJ, Goo HW, Roh JL. Utility of spiral and cine CT scans airway obstruction and compromise. in pediatric patients suspected of aspirating radiolucent for- eign bodies. Otolaryngol Head Neck Surg 2008; 138: 576–580. 15 American Heart Association 2005 American Heart Association Conflicts of Interest (AHA) guidelines for cardiopulmonary resuscitation (CPR) and emergency cardiovascular care (ECC) of pediatric and The authors have declared no conflicts of interest. neonatal patients: pediatric basic life support. Pediatrics 2006; 117: e989–e1004. 16 Farrell PT. Rigid bronchoscopy for foreign body removal: References anaesthesia and ventilation. Paediatr Anesth 2004; 14: 84–89. 17 Gibson SE, Shott SR. Foreign bodies of the upper aerodigestive 1 National Safety Council. Report on in America 2008. tract. In: Myers CM, ed. The Pediatric Airway. Philadelphia: JB Available at: http://www.nsc.org/lrs/injuriesinamerica08. Lippincott, 1995: pp. 202. aspx Accessed December 16, 2008. 18 Baharloo F, Veyckemans F, Francis C et al. Tracheobronchial 2 Altkorn R, Chen X, Milkovich S et al. Fatal and non-fatal food foreign bodies: presentation and management in children and injuries among children (aged 0–14 years). Int J PediatrOtorhi- adults. Chest 1999; 115: 1357–1362. nolaryngol 2008; 72: 1041–1046. 19 Versichelen L, Herregods L, Donadoni R et al. Anesthesia for 3 Rimell FL, Thome A Jr, Stool S et al. Characteristics of objects foreign bodies in the tracheo-bronchial tree in children. Acta that cause choking in children. JAMA 1995; 274: 1763–1766. Anaesthesiol.Belg. 1985; 36: 222–229. 4 Darrow DH, Holinger LD. Aerodigestive tract foreign bodies 20 Litman RS, Ponnuri J, Trogan I. Anesthesia for tracheal or in the older child and adolescent. Ann Otol Rhinol Laryngol bronchial foreign body removal in children: an analysis of 1996; 105: 267–271. ninety-four cases. Anesth.Analg. 2000; 91: 1389–1391. 5 Daines CL, Wood RE, Boesch RP. Foreign body aspiration: an 21 Burton EM, Riggs W Jr, Kaufman RA et al. Pneumomediasti- important etiology of respiratory symptoms in children. num caused by foreign body aspiration in children. Pediatr J Allergy Clin Immunol 2008; 121: 1297–1298. Radiol 1989; 20: 45–47. 6 Lima JA. Laryngeal foreign bodies in children: a persistent, life-threatening problem. Laryngoscope 1989; 99: 415–420. 7 Fitzpatrick PC, Guarisco JL. Pediatric airway foreign bodies. Accepted 5 March 2009 J La State Med Soc 1998; 150: 138–141.

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