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Trauma & Injuries

Foreign Body in the Airway

Life-threatening emergency where an object is inhaled into the larynx, trachea, or bronchi, causing partial or complete airway obstruction. Most common in children <5 years.

Also known as: Aspirated Foreign Body, Choking, Inhaled Foreign Body

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Referral and warning signs

When to refer

IMMEDIATE URGENT Referral to Hospital (H/RR) with ENT/Pediatric Surgery/Pulmonology capabilities for: ALL cases of suspected foreign body aspiration, even if initial choking episode resolved (risk of retained FB). Any patient with persistent stridor, wheeze, cough, or respiratory distress after a choking event. Patients requiring advanced airway management or CPR.

Red flags

  • Witnessed choking event
  • Sudden onset respiratory distress, stridor, or wheeze in a young child
  • Inability to speak, cry, or cough effectively
  • Cyanosis
  • Loss of consciousness
  • Unilateral wheezing or decreased breath sounds

Signs and symptoms

  • Sudden onset (often while eating, playing, laughing, crying):
  • - Choking, gagging, gasping.
  • - Coughing (may be forceful initially, then weaken).
  • - Stridor (inspiratory noise - suggests laryngeal/upper tracheal obstruction).
  • - Wheezing (often unilateral if bronchial obstruction).
  • - Difficulty breathing (dyspnea), respiratory distress (nasal flaring, retractions, rapid breathing).
  • - Hoarseness or inability to speak/cry (laryngeal FB).
  • - Cyanosis (bluish discoloration).
  • - Altered consciousness, collapse (due to hypoxia).
  • - Asymmetric breath sounds or decreased air entry (usually right side if bronchial).
  • Delayed presentation possible (days/weeks later) with persistent cough, wheeze, recurrent pneumonia, lung collapse, or abscess, if initial choking episode was missed or object lodged distally.

Risk factors

  • Age < 5 years (peak 1-3 years).
  • Incomplete dentition, immature swallowing coordination.
  • Eating while playing, running, laughing.
  • Access to small objects (toys, food items like nuts, seeds, beans, popcorn, hot dogs, grapes).
  • Neurological impairment affecting swallowing/cough reflex.
  • Older siblings feeding younger children inappropriate foods.

Diagnosis

Clinical assessment

Based on history (witnessed choking event is key) and acute signs of airway obstruction. High index of suspicion required, especially in young children with sudden respiratory distress. Physical exam findings (stridor, wheeze, asymmetric breath sounds) support diagnosis. DO NOT DELAY treatment for investigations if severe obstruction.

Investigations

  • Investigations secondary to immediate life support.
  • Chest X-ray (AP and Lateral, possibly inspiratory/expiratory or lateral decubitus views): May show radio-opaque FB. May show indirect signs of radiolucent FB: Unilateral hyperinflation (air trapping), Atelectasis (lung collapse), Mediastinal shift. Normal CXR does NOT rule out FB aspiration.
  • Bronchoscopy (Rigid preferred for removal): Gold standard for diagnosis and removal. Performed under general anesthesia by specialist (ENT/Pulmonology/Thoracic Surgery).

Diagnostic criteria

Acute onset of choking/respiratory distress +/- witnessed aspiration event. Definitive diagnosis by visualization/removal via bronchoscopy.

Management

Non-pharmacological management

  • Acute Airway Obstruction Management (Based on BLS/PALS Algorithms):
  • - Assess Severity: Can patient cough effectively? Speak/cry?
  • - Mild Obstruction (Effective Cough): Encourage continued coughing. Do not interfere. Monitor closely.
  • - Severe Obstruction (Ineffective Cough, Unable to Speak/Cry, Cyanosis, Collapse):
  • - Infant (<1 year): Give cycles of 5 Back Blows followed by 5 Chest Thrusts.
  • - Child (>1 year) / Adult: Perform Abdominal Thrusts (Heimlich Maneuver). If pregnant or very obese, use Chest Thrusts.
  • - Continue cycles until object expelled or patient becomes unresponsive.
  • - If Patient Becomes Unresponsive: Start CPR (Chest Compressions). Before attempting breaths, look in the mouth for visible FB; if seen, attempt removal with fingers (adult) or Magill forceps (if available/trained). Avoid blind finger sweeps. Continue CPR until help arrives/object removed.
  • - Oxygen: Administer high-flow oxygen as soon as possible.
  • Post-Choking Event / Suspected Aspiration without complete obstruction:
  • - Keep patient calm, minimize distress.
  • - Allow patient to assume position of comfort.
  • - Give oxygen if needed/tolerated.
  • - URGENT referral to facility capable of bronchoscopy.
  • Removal via Bronchoscopy (Specialist Level): Definitive treatment to visualize and remove the foreign body under general anesthesia.

Pharmacological treatment

  • Medications have limited role in acute management.
  • Nebulized adrenaline/steroids generally not helpful unless significant secondary airway edema.
  • Antibiotics may be needed post-removal if secondary infection/pneumonia present.

Monitoring

Continuous monitoring of respiratory status (rate, effort, SpO2, breath sounds, color). Monitor level of consciousness. Post-bronchoscopy monitoring for complications.

Complications

  • Complete airway obstruction -> Hypoxia, Bradycardia, Cardiopulmonary arrest, Death.
  • Aspiration pneumonia.
  • Lung abscess.
  • Atelectasis (lung collapse).
  • Bronchiectasis (chronic lung damage).
  • Pneumothorax, Pneumomediastinum (esp. after removal attempts).
  • Airway trauma from FB or removal attempts.
  • Hypoxic brain injury.

Prevention

  • Age-appropriate foods: Avoid small, hard, round foods (nuts, seeds, whole grapes, hard candy, popcorn) in children <4-5 years.
  • Cut food into small pieces.
  • Supervise children closely during meals and playtime.
  • Keep small objects (toys, buttons, coins, batteries) out of reach.
  • Teach children not to run, play, or laugh with food in their mouth.
  • Learn choking first aid (BLS).

Patient education

  • Explain the danger of FB aspiration.
  • Teach choking first aid maneuvers.
  • Educate parents/caregivers on preventing aspiration (safe foods, supervision, keeping small objects away).
  • Explain the need for bronchoscopy if FB suspected, even if symptoms improve initially.

Uganda-specific notes

Groundnuts, beans, maize kernels are common culprits. Witnessed history is crucial. Access to pediatric bronchoscopy is limited to specialized centers. Early recognition, basic life support maneuvers, and rapid transfer are vital. A normal chest X-ray does not exclude an aspirated FB.

References

  • Uganda Clinical Guidelines (UCG) 2023

    Chapter 21, Section 21.3.1

  • Basic Life Support (BLS) / Pediatric Advanced Life Support (PALS) Guidelines

    (Standard International Guidelines)

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