Foreign Body Aspiration
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Direct answer
A choking episode followed by cough, unilateral wheeze or reduced breath sounds in a toddler is foreign body aspiration until rigid bronchoscopy proves otherwise — the history, witnessed or elicited, is worth more than any single investigation. Most objects are radiolucent, so a normal chest radiograph never reassures; inspiratory–expiratory films or fluoroscopy demonstrate ball-valve air trapping, and the definitive procedure is removal by rigid bronchoscopy. Organic matter such as peanuts causes progressive inflammatory destruction, and a button battery in the airway or oesophagus is an immediate life-threatening emergency.
What you must remember
- Peak incidence is between one and three years — mouthing behaviour plus an immature swallowing-protective reflex; peanuts, seeds, betel nut and small toys dominate the Indian list.
- Site: laryngeal or tracheal objects cause stridor and critical obstruction; bronchial objects favour the right side, though distribution is more even in young children.
- The clinical triad of bronchial foreign body: paroxysmal cough, unilateral wheeze, and unilateral diminished breath sounds — but any element may be absent after the object settles.
- Radiology: most objects are radiolucent; look for hyperinflation with mediastinal shift away on the expiratory film, atelectasis with complete obstruction, and decubitus films in uncooperative infants.
- A witnessed choking event with a normal chest radiograph still justifies bronchoscopy — up to a third of proven aspirations have normal plain films.
- Peanut and other oily organic foreign bodies cause lipoid pneumonia and granulation tissue; symptoms smoulder for weeks and present as a non-resolving segmental pneumonia or bronchiectasis.
- Button batteries and paired magnets are emergencies: oesophageal batteries cause liquefactive necrosis within hours with risks of perforation and aorto-oesophageal fistula — remove immediately by endoscopy.
- Complete airway obstruction in a conscious child: back blows and chest thrusts under one year, abdominal thrusts (Heimlich) above one year; blind finger sweeps are condemned. Unconscious: basic life support.
- Definitive removal is by rigid bronchoscopy under general anaesthesia — the open bronchoscope ventilates while the surgeon works; flexible bronchoscopy is for diagnosis in stable, doubtful cases.
- Delayed complications of a retained foreign body: atelectasis, recurrent pneumonia, bronchiectasis and lung abscess — any child with localised, non-resolving pneumonia needs the airway interrogated.
A worked example
An eighteen-month-old was playing with a jar of peanuts while the family watched television; there was a sudden coughing fit, brief cyanosis, then the child settled with a quiet whistle on the right. Two weeks later he has a persistent right-sided wheeze treated as pneumonia twice. First, take the history seriously even at two weeks — this is the classic "forgotten foreign body". Second, image smartly: inspiratory and forced expiratory films showing right-sided hyperinflation with mediastinal shift to the left clinch the ball-valve effect; if the child cannot cooperate, bilateral decubitus views or fluoroscopy substitute. Third, arrange rigid bronchoscopy — removal of the peanut with suction of debris and lavage — and prepare for granulation tissue that a two-week delay makes likely.
Two companion scenarios earn separate marks. The infant who chokes and cannot cry needs the choking sequence now — five back blows alternating with five chest thrusts below one year, abdominal thrusts above. And the child who swallowed a disc battery, now drooling and refusing feeds, bypasses every queue: plain film to locate it and emergency endoscopic removal if it lies in the oesophagus, because transmural burns, perforation and fistula formation progress by the hour.
Where students slip
The predictable errors: accepting a normal radiograph as exclusion, waiting for the object to "pass" as gastrointestinal foreign bodies do, and ordering CT as the first step when the history plus expiratory film plus bronchoscopy form the real pathway. Candidates also mislabel the obstructed side — the affected lung over-inflates and the mediastinum shifts away from it on expiration. The final slip is therapeutic: blind finger sweeps or forceps extraction in an awake child risk laryngospasm and impaction.
Frequently asked questions
Which age group is at highest risk of foreign body aspiration?
Children between one and three years, due to mouthing behaviour, running and laughing while eating, and immature protective reflexes; nuts and seeds are the classic objects.
Why can a chest radiograph be normal in foreign body aspiration?
Because most aspirated objects are radiolucent and the obstruction is often a partial ball-valve; hyperinflation appears only on expiratory or decubitus imaging, and a substantial minority of proven cases have normal plain films.
What is the treatment of choice for a bronchial foreign body?
Rigid bronchoscopy under general anaesthesia for removal — it secures the airway and allows graspable extraction; flexible bronchoscopy has a diagnostic role in doubtful cases.
How is complete airway obstruction managed in a conscious infant?
Five back blows alternating with five chest thrusts, repeating until the object is expelled or consciousness is lost; blind finger sweeps are avoided.
Why is an aspirated peanut particularly dangerous?
Organic material swells and leaches oils, producing lipoid pneumonia, granulation tissue and progressive airway damage, so symptoms evolve over days to weeks and delayed removal is technically harder.