Pediatric Foreign Bodies

Stridor – from partial airway obstruction and resultant turbulent airflow around the object / mass

  • Supraglottic Stridor
  • From nose, pharynx, epiglottis
  • Sonorous, gurlgling, coarse, expiratory stridor
  • Voice with muffled or ‘hot-potato’ quality
  • Glottic Stridor
  • From larynx & vocal cords
  • Biphasic high pitched stridor
  • Voice hoarse or weak
  • Subglottic Stridor
  • From subglottic trachea
  • High pitched inspiratory stridor
  • Voice hoarse or weak
  • Subtracheal - bronchi
  • Often expiratory noise such as wheezing

Offenders

  • Round foods – most common
  • Conformable objects – most deadly (ie. balloons, examination gloves, etc)
  • Most lodge in the bronchi and aren’t life threatening

Workup & Intervention

  • Keep the child calm and in a position of comfort / optimal ventilation
  • Allow the child to cough
  • Soft tissue lateral of the neck & CXR (if stable)
  • 2/3 of routine inspiratory CXRs in children with FOB aspiration are negative
  • Expiratory CXR can be helpful to evaluate for air trapping distal to obstruction
  • Partial airway obstruction – stable
  • Safe to wait for ENT to do rigid bronchoscopy in the OR
  • Partial airway obstruction –severe or rapidly progressing respiratory distress or respiratory failure
  • Consider awake look with sedation (ketamine – slow IV push over 1-2 min to prevent apnea)
  • Complete airway obstruction – unable to ventilate
  • BLS: < 1 year old – 5 back blows and 5 chest thrusts (with head below torso)
  • BLS: > 1 year old – if conscious, do Heimlich maneuver; if unconscious, do chest compressions
  • Use DL to look for object & remove with Magill forceps
  • If unable to see object and / or known to be in subglottic space or trachea, can try to remove it with suction viaETT (with Murphy’s eye cut off) and meconium aspirator
  • If object visible in subglottic space, can attempt to remove it with rigid bronchoscope
  • If unable to see object and / or in subglottic space or trachea, but can’t ventilate or remove object , attempt to intubate and push object into a mainstem bronchus with ETT
  • If object doesn’t seem to be in the airway but is still causing obstruction, it could be in the esophagus pushing on the soft cartilage of the trachea with resultant obstruction. Try BLS maneuvers to dislodge it into the oropharynx, or possibly esophageal bougiennage.
  • If unable to remove or bypass supraglottic or glottic FOB, needle cric / trach with jet ventilation as a bridge to surgical cricothyrotomy or tracheostomy
  • TTNV – can attach 3.0 ETT adapter for ventilation with BVM