Chapter 174. Airway Foreign Body Removal

The presence of an airway foreign body is a common cause of morbidity and mortality in children, especially those younger than 3 years of age. Over 70% of foreign body aspirations occur in children.1 The mortality rate following foreign body aspiration is estimated at 1% to 2%. In the year 2000, ingestion or aspiration of a foreign body was the cause of 160 unintentional deaths and more than 17,000 Emergency Department visits in the United States.2 Other reports have estimated the death toll as high as 2000 per year in the United States.1 The most likely cause of death is complete airway obstruction, generally at the level of the larynx or trachea. Food objects have been associated with 41% and nonfood substances have been associated with 59% of reported deaths.2 Globular objects such as hot dogs, candies, chewing gum, nuts, and grapes are the most commonly aspirated food objects.3 Rubber balloons and toys are the most commonly aspirated nonfood objects.3

Parents and caregivers should be educated and aware of the types of food and objects that pose a choking risk for children. They should become familiar with the methods to reduce this risk. All parents and caregivers should learn the techniques to treat a choking child. Basic life support classes are often available free or at a minimal cost at hospitals, churches, and community centers.

The management of airway foreign bodies requires specific expertise and training. Airway foreign bodies must be managed by an Otolaryngologist or other qualified Physician, depending on the institution, with experience in airway endoscopy and the knowledge to deal with the potential complications related to airway obstruction. Cases involving children require specialized expertise in pediatric airway endoscopy. Prior to the twentieth century, aspiration of a foreign body resulted in a 24% mortality rate. The morbidity and mortality associated with airway foreign body retrieval has greatly declined due to the development of safe endoscopic techniques, rod-lens telescopes, and optical forceps.

The burden of proof lies in the Emergency Physician's hands in order to diagnose an airway foreign body. Keep in mind that information gained from the history, physical examination, and radiologic studies may not clearly define the presence of a foreign body.4 Thirty-three percent of airway foreign body cases are neither observed nor suspected. The physical examination may be normal in up to 39% of patients. Radiographic studies may be normal in up to 20% of the patients. The only definitive test when considering the diagnosis of an airway foreign body is endoscopy to evaluate the entire laryngotracheobronchial tree.

The airway is divided into three anatomic regions: the larynx, the trachea, and the bronchi. The laryngeal aditus is formed by the epiglottis anteriorly, the aryepiglottic folds laterally, and posteriorly by the corniculate cartilages and upper border of the arytenoid muscle. The larynx extends from the level of the aditus to the lower border of the cricoid cartilage, where it is continuous with the trachea.5 The infant larynx is located higher in the neck than the adult larynx. The cricoid cartilage descends in the neck through childhood. Due to the superior position of the infant larynx, the epiglottis is located with the tip often resting on the soft palate.6 The infant larynx is approximately one-third the size of the adult larynx. Laryngeal foreign bodies are most common in infants due to the small size of the inlet. Refer to Chapter 6 for a more complete discussion regarding the differences between the child and adult larynx.

The trachea begins at the lower border of the cricoid cartilage, extending downward from about the level of the sixth cervical vertebra in adults or the fourth cervical vertebra in infants. The trachea extends inferiorly to the level of the carina. The inferior end of the trachea is located at the level of the fifth thoracic vertebra or the sternal angle. The trachea is 4 cm long in a full-term newborn infant and 11 to 13 cm long in an adult. The diameter of the trachea is 3.6 mm in a newborn and 12 to 23 mm in an adult.7

The trachea divides into two mainstem bronchi.7 The right mainstem bronchus is shorter, straighter, and larger in diameter than the left mainstem bronchus. This explains why right mainstem foreign bodies are more common than left mainstem foreign bodies. The mainstem bronchi divide into three lobar bronchi on the right and two on the left. The lobar bronchi divide into segmental bronchi. There are, usually, 10 segmental bronchi on the right, and 8 on the left.7

Airway foreign bodies commonly become lodged in one of three locations: the larynx, the trachea, or the bronchi. Laryngeal foreign bodies account for 4% to 5% of airway foreign bodies.8 Laryngeal foreign bodies have a mortality rate of 45% due to complete airway obstruction.9 Approximately one-third of survivors of transient airway obstruction suffer from hypoxic encephalopathy.

Most choking victims are able to generate a forceful cough to expel an airway foreign body. Some patients are unable to relieve the obstruction themselves. The use of the Heimlich maneuver has further decreased mortality.10 It should be emphasized that the relief of an airway obstruction should only be attempted if signs of a complete airway obstruction are observed.11 Only perform oral cavity finger sweeps if a foreign body is seen within the oral cavity.11 Immediate intervention is not only unnecessary, but may be potentially dangerous if a patient is able to breathe, speak, or cough.12

Laryngeal foreign bodies can present with only mild or moderate respiratory distress. They may be located, or wedged, between the laryngeal ventricles, the true vocal folds, or the immediate subglottis (Figure 174-1A). Plain radiographs of the neck will detect radiopaque foreign bodies (Figures 174-1B & C). Flexible awake fiberoptic laryngoscopy allows visualization of the larynx and supraglottic structures.

Tracheal foreign bodies account for 9% and bronchial foreign bodies account for 81% of airway foreign bodies.8 The classic diagnostic triad of a tracheobronchial foreign body consists of the sudden onset of paroxysmal coughing, wheezing, and diminished breath sounds on the affected side. However, these symptoms may only be present in 50% of cases. Approximately 33% of airway foreign bodies are neither observed nor suspected.13 Tracheal foreign bodies may present with audible biphasic or expiratory stridor. Audible expiratory wheezing is more likely associated with a main bronchus obstruction. Tachypnea and cyanotic episodes may occur, generally when larger obstructing objects are present. Small foreign bodies may travel distally to a secondary bronchus and produce the more subtle symptoms of mild wheezing, cough, pneumonia, or fever. No abnormalities are found in up to 39% of patients.4 It is estimated that only 70% of patients with a foreign body aspiration seek treatment within the first week of the aspiration.14

The most common airway foreign bodies are food items and toys. Peanuts account for nearly 40% of tracheobronchial foreign bodies15 (Figure 174-2). Other common foreign bodies include plastic toys, pins, tacks, watermelon seeds, sunflower seeds, nails, screws, carrots, and popcorn. More than 80% of airway foreign bodies are radiolucent and can be difficult to diagnose. The most common radiologic findings are identified using both inspiratory and expiratory chest radiographs. This can be in the form of a check valve with postobstructive hyperinflation and mediastinal shift to the contralateral side (Figure 174-3). It may also be seen in the form of a ball valve with atelectasis, collapse of the distal airways, and mediastinal shift to the ipsilateral side. Pneumonia can be present in 9% of cases, generally when the foreign body has been present for weeks or months. Chest radiographs can be normal in up to 11% to 20% of patients with tracheobronchial foreign bodies.4

Suspect an airway foreign body based upon the history, physical examination, and radiologic findings. However, the diagnosis is not always clear-cut. It is the responsibility of the Emergency Physician suspecting an airway foreign body to confer with the appropriate specialist and to strongly suggest endoscopy consisting of laryngoscopy and bronchoscopy. Endoscopy remains the gold standard to rule in or rule out an airway foreign body.

The indications for airway endoscopy must take into account the patient's history, physical examination, radiologic findings, and the suspected location of the foreign body. An accurate history is of the utmost importance in the diagnosis of foreign body aspiration as the remainder of the assessment, physical examination, and radiographic studies can be deceptively unremarkable. The characteristic history consists of an incipient choking or gagging episode. Caretakers often describe subsequent coughing spells when the event was witnessed. Aspiration must be assumed if the patient was eating peanuts, seeds, or beans during the episode. All witnessed aspirations with nuts or nondissolvable food matter require endoscopy and removal if the foreign material is identified.

The majority of patients presenting to the Emergency Department with airway foreign bodies are in stable condition. This allows time to adequately access the patient and formulate the best possible treatment plan. Infants and children with airway foreign bodies require an institution with the capability for comprehensive pediatric care. This includes a Physician who is experienced with airway endoscopy and foreign body retrieval in children, a facility with pediatric endoscopic equipment, pediatric anesthesia capabilities, and pediatric intensive care capabilities. This often will require transfer to a specialized pediatric center. Attempting removal of airway foreign bodies in a less-than-adequate environment can be catastrophic for the patient and is not advised. This same philosophy applies to adult airway endoscopy and to having qualified personal who are experienced in this area.

Follow basic life support protocols, including the section on a choking victim, in the rare situation of an acutely obstructed airway. Any patient with a suspected laryngeal foreign body or impending airway obstruction requires emergent endoscopy and control of the airway in the Operating Room, if possible. If urgent endoscopy is not possible and a laryngeal foreign body is suspected, direct laryngoscopy in the Emergency Department and removal of a visualized foreign body with a McGill forceps can be attempted. A cricothyroidotomy or percutaneous transtracheal jet ventilation may be required as a lifesaving measure for a laryngeal foreign body if attempts at resuscitation and/or removal are unsuccessful. However, these two procedures are unlikely to be beneficial if the foreign body is located in the distal tracheal or bronchi. If urgent endoscopy is not available, and a lifesaving measure is required due to total airway obstruction of a distal tracheal or bronchial foreign body, orotracheal intubation with the tube positioned into one of the mainstem bronchi may be lifesaving. Based on the facility and the situation of total airway obstruction, ECMO could also be lifesaving.

Emergency Department Equipment

• Intubation equipment
• Percutaneous transtracheal jet ventilator
• Cricothyroidotomy kit
• Suction source, tubing, and catheter
• Magill forceps
• Laryngoscope with a variety of blades or a video laryngoscope
• Topical anesthetic spray
• Fiberoptic nasopharyngoscope

Operating Room Equipment

The proper equipment must be selected based upon the patient's age and size, as well as the suspected composition of the foreign body. Laryngoscopes are selected to allow visualization of the larynx and the passage of a bronchoscope. Rigid, ventilating bronchoscopes with fiberoptic telescopes provide optimal visualization. This allows direct access to the airway, excellent visualization, continuous administration of anesthetic agent and oxygen, and a conduit for the introduction of instruments (forceps) to retrieve the foreign object. Multiple sizes of laryngoscopes and bronchoscopes are essential to have available in the operating room. Numerous extraction instruments (of different sizes and shapes) must be available and include smooth, toothed, cupped, angled, open mouth, and optical forceps. The optical forceps allow a magnified and direct view through the forceps improving visualization and ease of foreign body removal.

Timing of endoscopy and airway foreign body retrieval must be based upon each individual patient. Do not waste time if impending airway obstruction exists. Immediately notify and mobilize an Anesthesiologist, Otolaryngologist, and the Operating Room, as this is an emergent situation. It is appropriate to wait for NPO status to be present and the stomach empty prior to proceeding to the Operating Room if the diagnosis of an airway foreign body is highly suspected and the patient is stable. This is considered a timely approach and may take up to 6 hours for children or 8 hours for adults. Waiting this time in the stable patient decreases the risk of aspiration and further compromising the situation. It is also appropriate to wait, in a stable patient, in order to assemble the appropriate and best nursing and anesthesia team to care for the patient. Using personnel who are unfamiliar with endoscopy can create a compromised and stressful situation.

Emergency Department Techniques

The foreign body airway obstruction protocol based upon the Pediatric Basic Life Support textbook treats conscious infants (younger than 1 year of age) with four back blows while the infant is in a prone position on the rescuer's forearm, face down, and the head lower than the trunk. This is combined with four rapid chest thrusts (as in infant CPR), if the obstruction persists, while the infant is supine with the head lower than the body.11 Treat unconscious infants by opening the airway and attempting rescue breathing based on basic life support protocols.11 Treat children and adults with the standard Heimlich maneuver, using gentle thrusts in smaller children to decrease the likelihood of injury to the abdominal organs. Finger sweeps to remove a foreign body in the oral cavity should only be performed if the foreign body is directly visualized. Blind finger sweeps are not recommended as they can further impact the foreign body and obstruct the airway.

It is always best not to manipulate the airway or attempt intubation in a stable patient with an airway foreign body and who is moving air and breathing. The airway is best controlled in the Operating Room at the time of the actual foreign body removal. Once the airway is manipulated a foreign body can become dislodged, turning a partial airway obstruction into a complete airway obstruction. If this occurs in the Operating Room, the bronchoscopy equipment is available for urgent use by the endoscopist if needed.

Attempt orotracheal intubation in the Emergency Department if the airway obstruction progresses rapidly and the patient cannot ventilate. Intubation can be used to force the foreign body into one mainstem bronchus and allow ventilation of the other lung. One-lung ventilation will keep the patient alive until the foreign body can be removed in the Operating Room. Position the laryngoscope to visualize the larynx. If a foreign body is visualized, grasp the foreign body with a McGill forceps and remove it. If no foreign body is visualized, intubate the patient. Insert and advance the endotracheal tube as far as it will advance if the foreign body is not visualized or unable to be grasped. If the endotracheal tube will not pass, try a smaller size tube. Withdraw and position the endotracheal tube with the tip above the carina to optimize ventilation. As an alternative, properly insert and position the endotracheal tube above the carina then advance a bougie through the endotracheal tube in an attempt to move the foreign body distally. Always be prepared to perform a cricothyroidotomy or transtracheal jet ventilation. Transtracheal jet ventilation allows for short-term oxygenation, is temporary, and may allow time for safe transport to the Operating Room so that endoscopy and foreign body retrieval can be performed in a more controlled environment with appropriate equipment at hand. Refer to Chapters 11, 25, and 24 regarding the details of orotracheal intubation, cricothyroidotomy, and transtracheal jet ventilation, respectively.

Direct laryngoscopy and bronchoscopy in a child or adult with an airway foreign body is a dangerous situation. The procedure may result in a partial airway obstruction becoming a complete airway obstruction. Always have a cricothyroidotomy tray immediately available. All equipment must be selected, assembled, and ready for use.

It is possible to remove foreign bodies located within the hypopharynx in the Emergency Department. Typical foreign bodies that may be removed include pieces of food and fishbones. The patient must be stable and in no risk of airway compromise. Obtain anteroposterior and lateral soft tissue radiographs of the neck to localize, if possible, the foreign body. The use of CT scans to attempt to identify potential fish or chicken bones that may be lodged in the pharynx, hypopharynx, or esophagus is an option in the stable patient. Perform indirect laryngoscopy to identify the foreign body and its location. Refer to Chapter 173 regarding the complete details of laryngoscopy. Obtain intravenous access.

Place the patient in full monitoring (i.e., pulse oximeter, cardiac monitor, noninvasive blood pressure cuff). Apply a topical anesthetic spray to the oropharynx and the base of the tongue. Place the patient supine. Administer a small dose of an intravenous sedative if required. Slowly and gently insert a #3 Miller laryngoscope blade. An alternative to a traditional laryngoscope, if available, is a video laryngoscope. The video laryngoscope may provide a better field of view with less manipulation. Do not immediately insert the laryngoscope blade all the way. Stop frequently to lift the laryngoscope and look for the foreign body. This slow insertion and frequent looks will prevent the laryngoscope blade from pushing the foreign body further into the airway. Elevate the patient's tongue and jaw. Grasp the foreign body with a McGill forceps. Withdraw the McGill forceps followed by the laryngoscope.

Operating Room Techniques

The procedure begins with the induction of general anesthesia. It cannot be overemphasized that anesthesia should only be administered by an Anesthesiologist who is competent and comfortable with the situation. Pediatric patients require an Anesthesiologist with pediatric airway experience if the patient is stable. Full monitoring and mask induction allow the patient to maintain spontaneous respiration. Muscle relaxants are avoided as they can induce complete airway obstruction.

The Otolaryngologist begins the procedure. Place the patient supine with a shoulder roll to position the airway. Insert the laryngoscope into the larynx. Expose the larynx by elevating the laryngoscope. Topical anesthetic is applied to the larynx to avoid laryngospasm. The bronchoscope with telescope is then passed under direct vision through the mouth and into the laryngeal introitus. Ventilation can continue via a port on the scope. The foreign body is visualized. Forceps are inserted through the scope and used to grasp the foreign body. Small objects can be removed directly through the scope, whereas larger objects require simultaneously removing the bronchoscope along with the forceps and foreign body. The bronchoscope is passed again, after removal of the foreign body, to identify any mucosal injury or second foreign body that may occur in as many as 5% of patients.4 If purulent secretions are noted, a culture may be obtained and antibiotics administered appropriately.

A specific type of foreign body, such as a tack or sharp object, may become lodged in the larynx or upper trachea. Extraction with the forceps using standard endoscopic techniques may not be possible. Patients may require a tracheotomy and an open approach (laryngotomy) to remove the foreign body.

The use of a flexible fiberoptic bronchoscope to retrieve bronchial foreign bodies may be acceptable for Physicians who are well trained with this technique. The mainstay of tracheobronchial foreign body retrieval remains to be rigid bronchoscopy.

After the retrieval of an airway foreign body, most patients should be breathing spontaneously. An endotracheal tube may rarely, in the presence of significant laryngeal or tracheobronchial edema, need to remain in place temporarily. This would require admission to an intensive care unit. Humidified oxygen is helpful to keep the airway moist and prevent mucous crusts from forming. A postprocedural radiograph will help to determine any subcutaneous air, air in the soft tissues, a pneumothorax, or any changes to the lung fields following the extraction.

All patients who have undergone foreign body removal require at least a few hours of airway observation in a monitored setting. Racemic epinephrine treatments and intravenous Decadron can be administered as needed. Discharge from the hospital is acceptable when the patient is breathing comfortably and no longer in danger of airway compromise. Some patients may be discharged home the same day, while others may require multiple days of airway support and observation.

In cases where a bronchial foreign body has been present for a prolonged period of time, granulation tissue and severe inflammation can form around the foreign body making removal difficult or impossible. It may be necessary to treat the patient with intravenous steroids and antibiotics for 48 hours, with or without intubation, followed by a repeat bronchoscopy and a repeat attempt to remove the foreign body.

Complications from the foreign bodies themselves include hypoxia leading to cerebral anoxia if not identified. Intraoperative complications can occur in the hands of an inexperienced endoscopist or even an experienced endoscopist who loses control of a foreign body in the airway and is faced with obstruction or respiratory arrest. Cardiac arrhythmias can occur from hypoxia or direct pressure on the left main-stem bronchus. Postoperative problems can include laryngeal or tracheobronchial edema from the foreign body or the instrumentation of the airway. Mucosal irritation can instigate a tracheitis or bronchitis. Pneumonia can develop. Pneumomediastinum has been reported in as many as 13% of aspirations and a pneumothorax slightly less frequently.16

A foreign body pulled up from a main stem bronchus can become dislodged in the larynx or trachea and cause a complete airway obstruction. A foreign body in the hypopharynx can be pushed distally and result in a total airway obstruction. The foreign body needs to be quickly removed, pushed back down into one of the mainstem bronchi to allow ventilation of at least one lung, or a surgical airway performed. Failure to react appropriately in this situation can result in asphyxiation and death.

Airway foreign bodies pose a diagnostic and therapeutic challenge. The initial encounter in the Physician's office, clinic, or the Emergency Department must uncover any historical fact, physical abnormality, or radiographic abnormality that may lead to a definitive or presumed diagnosis of an airway foreign body. Endoscopy must be performed by a skilled team to allow safe and efficient removal of the foreign body. Hypopharyngeal foreign bodies may be safely removed in the Emergency Department by a trained Emergency Physician.