Approach to a Child with
Acute Foreign Body
Airway Obstruction
Learning Objectives:
• Recognize the risk factors for pediatric foreign body
aspiration
• Assess and manage acute foreign body airway
obstruction
• Understand anesthetic considerations for foreign body
removal
• Implement emergency airway management strategies
• Identify prevention strategies and post-operative care
Why Are Children at Higher Risk?
Anatomical Factors:
• Narrow airways: Pediatric trachea diameter 4mm vs 20mm in
adults
• Cricoid ring narrowest point (vs vocal cords in adults)
• Larger tongue relative to oral cavity
• Immature protective reflexes
Physiological Factors:
• Poiseuille's Law: Small reduction in radius = exponential
increase in resistance
• Higher oxygen consumption and limited respiratory reserve
Behavioral Factors:
• Oral exploration phase - everything goes in the mouth
• Poor chewing ability - lack of molars until age 2-3
• Eating while distracted - playing, crying, or laughing
• Natural curiosity and risk-taking behavior
Common Foreign Bodies by Age
Group
Infants (<1 year)
• Rare - only 7% of cases
• Usually related to feeding accidents or sibling
involvement
Toddlers (1-3 years) - Highest Risk Group
• Organic (85-90%)- seeds, peanuts, walnuts
• Inorganic (10-15%)- small toys, buttons, coins
Older Children (4-16 years)
• Mechanical objects increase (50% of inorganic FBs)
• Pen caps, toy parts, jewelry
Seasonal Pattern: Peak incidence in January-February
(holiday nuts/treats)
Location and Presentation Patterns
Anatomical Distribution:
• Right bronchial tree: 51% (wider, more vertical angle)
• Left bronchus: 33%
• Trachea: 7%
• Carina: 5%
Clinical Presentation - The Three
Phases
Phase 1: Penetration Syndrome (Initial)
• Sudden onset choking, coughing, gagging
• Witnessed aspiration in 70% of cases
• Duration: Minutes to hours
Phase 2: Asymptomatic Phase
• Apparent recovery - dangerous false security
• FB lodged but not completely obstructing
• Duration: Hours to days/weeks
Phase 3: Complications Phase
• Pneumonia, atelectasis, abscess formation
• Delayed diagnosis in 62% of cases >24 hours
• Chronic symptoms: persistent cough, wheeze, recurrent
infections
Diagnostic Approach
History Taking:
• Witnessed choking episode - most important
• Type of food/object involved- peanuts/button battery-
inflammatory reaction/perforation
• Time since aspiration
• Current symptoms and progression
• Fasting time
Physical Examination:
• Signs of respiratory distress
• Stridor - suggests laryngeal/tracheal FB
• Unilateral wheeze - bronchial obstruction
• Decreased air entry - common finding (78% of cases)
• Normal examination doesn't rule out FB
Laryngeal/Tracheal FB Bronchial FB Oesophageal FB (unless
tracheal compression)
Cough, choking Usually no cough Difficulty swallowing,
drooling
Respiratory distress Tachypnea FB sensation in throat/chest
ache
Cyanosis/desaturation Wheeze Hypersalivation
Stridor Absent breath sounds on Regurgitation/choking
affected side, increased
percussion due to air
trapping
Tachypnea Signs of lobar collapse, Retching, hiccups,
bronchial breathing, odynophagia
crepitations
Imaging:
• Chest X-ray: Only 3.4% show direct FB visualization
• Secondary signs: Atelectasis (27%), hyperinflation
(18%)
• Inspiratory/expiratory films: May show air trapping (on
expiration)
Important points to determine
• Location of foreign body (oesophagus or airway)
• Location in airway (upper/proximal or lower/distal
airway)
• Presence of respiratory distress
• Fasting time
Immediate Assessment - ABCDE
Approach
A - Airway:
• Complete obstruction: Silent, unable to cry/speak,
cyanosis
• Partial obstruction: Stridor, weak cry, able to cough
B - Breathing:
• Respiratory rate and pattern
• Chest wall movement and retractions
• Air entry - unilateral vs bilateral
C - Circulation:
• Tachycardia (hypoxia, distress)
• Blood pressure and perfusion
D - Disability:
• Conscious level - agitation vs drowsiness
• Neurological response
E - Exposure:
• Cyanosis - late sign
• Universal choking sign - hands to throat
Initial management of a child with an inhaled foreign
body
A child who is actively coughing with a witnessed
aspiration should be treated as per emergency choking
algorithm:
1. Effective cough- encourage cough, continue to check
for deterioration
2. Ineffective cough
-Conscious- 5 back blows, 5 abdominal thrusts (child
>1y) or 5 chest thrusts (<1y)
-Unconscious- open airway, 5 breaths, start CPR
Hospital Management - Initial
Stabilization
Immediate Actions:
• High-flow oxygen as tolerated
• Avoid agitation - keep child calm, with parents
• Continuous monitoring - pulse oximetry, ECG
• IV access if stable (don't delay for unstable patients)
Call for Help:
• Senior anesthetist - experienced in pediatric airways
• ENT surgeon - for bronchoscopy and surgical airway
• Pediatric team - for resuscitation support
• Operating room - prepare immediately
Avoid:
• Positive pressure ventilation - may push FB distally
• Sedation - may worsen respiratory drive
• Unnecessary procedures if child stable
Anaesthetic Considerations - Pre-operative Planning
Team Preparation:
• Experienced anesthetist mandatory
• ENT surgeon scrubbed and ready
• Difficult airway equipment available
• Surgical airway tray prepared
Fasting Status:
• If stable: Follow normal fasting guidelines (6 hours
solids, 2 hours clear fluids)
• If unstable: Consider gastric aspiration with large-bore
tube
• Emergency cases: Proceed with full stomach
precautions
Equipment Checklist:
• Rigid bronchoscope - multiple sizes
• Flexible bronchoscope - backup option
• Foreign body forceps - various types
• Smaller ETTs - expect airway edema
• Surgical airway equipment
Induction Strategy
Preferred Technique - Inhalational Induction:
• Agent: Sevoflurane in 100% oxygen
• Rationale: Maintains spontaneous ventilation, less
airway irritation
• Avoid: Positive pressure ventilation initially
• Avoid: N2O- lung hyperinflation
Key Principles:
1.Maintain spontaneous ventilation - critical for FB
proximal to carina
2.Avoid muscle relaxants until airway secured
3.Vocal cords and pharynx sprayed with lignocaine
4.Gentle technique - avoid coughing that may dislodge
FB
5.Prepare for emergency - surgical airway ready
Alternative Approaches:
• IV induction: Propofol if child cooperative and IV
access available
• RSI: Only if complete obstruction and patient
deteriorating
• Awake technique: Rarely used, for very unstable
patients
Gas induction/spont vent vs IV
induction/PPV
Bronchoscopy Techniques
Rigid Bronchoscopy (Gold Standard)
Advantages:
• Better visualization and instrument passage
• Ventilation possible through side port
• Larger working channel for FB removal
• Success rate: 97-99.7%
Technique:
• Storz ventilating bronchoscope preferred
• Connect T-piece to side port for ventilation
• Spontaneous or controlled ventilation based on preference
• Average duration: 16 minutes
Flexible Bronchoscopy
Advantages:
• Less invasive approach
• Better access to distal airways
• Shorter procedure time (36 vs 53 minutes)
• Success rate: 91-100% in experienced hands
Intraoperative Management
Anaesthetic Maintenance:
• Sevoflurane preferred for bronchodilation and rapid
recovery
• High fresh gas flows - compensate for leaks around
bronchoscope
• Propofol infusion alternative for TIVA technique
• Avoid: Desflurane (airway irritation)
Ventilation Strategy:
• Spontaneous ventilation: Safer for proximal FB
• Controlled ventilation: If procedure prolonged or patient
unstable
• Jet ventilation: Specialized technique, limited paediatric
use
• Manual ventilation: Via T-piece connected to
bronchoscope
Monitoring:
• Continuous pulse oximetry - early detection of
desaturation
• Capnography - verify ventilation adequacy
• Precordial stethoscope - monitor air entry
Intraoperative Complications and Management
The Dropped Foreign Body
Most serious complication - FB may move to complete
obstruction
Management:
1.Push FB distally into main bronchus
2.Ventilate unobstructed lung
3.Retrieve from new position
Desaturation During Procedure
Causes: Bronchoscope blocking ventilation, FB movement
Management:
1.Withdraw bronchoscope to trachea
2.Ventilate both lungs
3.Remove telescope to improve gas flow
4.Consider brief interruption of procedure
Bronchospasm
• Treatment: Salbutamol, deepen anaesthesia, consider steroids
Post-Bronchoscopy Management
Immediate Post-Procedure:
• Awake Extubation preferred
• Monitor for laryngeal edema - stridor, cough
• Chest X-ray - confirm lung re-expansion
• Oxygen therapy as needed
Complications to Watch:
• Post-procedure stridor - laryngeal edema
• Pneumothorax - from barotrauma
• Aspiration pneumonia - from retained secretions
• Airway bleeding - usually minor
Treatment:
• Nebulized epinephrine for stridor
• Dexamethasone for anti-inflammatory effect
• Antibiotics if signs of infection (88% receive antibiotics)
• Humidified oxygen and chest physiotherapy
Key Take-Home Messages
1.Foreign body aspiration is a leading cause of death in children <5
years
2.Peak incidence at 1-3 years - highest risk group for organic materials
3.Immediate recognition and appropriate first aid can be life-saving
4.Maintain spontaneous ventilation during anesthetic induction when
possible
5.Rigid bronchoscopy remains gold standard for FB removal
6.Team approach essential - anesthesia, ENT, pediatrics coordination
7.Prevention education is crucial for reducing incidence
8.Complications can occur even after successful removal - vigilant
monitoring required
References
• Clinical Practice Guidelines: Foreign bodies inhaled. RCH
Melbourne. 2021
• Inhaled foreign body in children anaesthesia
tutorial. WFSA. 2008
• The anaesthetic consideration of tracheobronchial
foreign body. PMC. 2009
• Pediatric Airway Foreign Bodies and Their Management
by Rigid Bronchoscopy. PMC. 2020
• Essential notes: the anaesthetic management of an
inhaled foreign body in a child. BJA. 2009
