Approach

Initial management for foreign body aspiration is airway support, which is dictated by the clinical presentation. Ensuring an airway takes precedence over any diagnostic or therapeutic intervention.

The most important component of a foreign body retrieval procedure is pre-procedural planning by the bronchoscopist in conjunction with the entire team, including nurses, respiratory therapists, technicians, and anaesthesiologists.[57]​ A team-based approach is likely to improve success rates.[58]

Initial interventions

Management should start with basic life support and confirmation of the diagnosis, where possible. People found face down, prone, or in neck- and torso-flexion positions associated with aspiration and positional asphyxia, should be moved into the supine position for reassessment.[32]

Patients who are experiencing an acute choking episode and who are conscious should be encouraged to cough.[32]​[59]​​​​​​​​​​​​ If the cough is effective and the foreign body expelled, no external manoeuvre is necessary. If coughing is ineffective, use back-slaps, abdominal thrusts (>1-year old), or chest thrusts (if unconscious) for children and adults.[32]​ Avoid abdominal thrusts in choking infants; there is increased risk of trauma to the upper abdominal viscera. Significant complications have been reported in adults following abdominal thrusts.[60][61][62]

Consider extracting visible items in the mouth, but avoid blind finger sweeps and the routine use of suction-based airway clearance devices; however, appropriately skilled healthcare providers can use Magill forceps.[26]​​[32]​​​​​ Often more than one of these techniques is needed, but there is insufficient evidence for one technique over another, or for the order in which they should be used.​[32]​​

Unconscious patients

In the unconscious patient, endotracheal intubation should be performed immediately, unless the foreign body can be seen in the upper airway and can be easily removed. Blind or repeated finger sweeps should be avoided because they may impact the object deeply into the pharynx and cause more injury. In cases of asphyxia from laryngeal foreign bodies that cannot be dislodged or are associated with severe oedema that precludes endotracheal intubation, cricothyroidotomy should be performed by the most experienced physician available. In small children aged under 10 years, use of a 12- to 14-gauge catheter over a needle may be a safer procedure to establish an airway.

Obtaining an airway urgently is vital, as irreversible anoxic brain injury can occur if airway patency is not restored within 3-5 minutes. Paralytic agents should be avoided, if possible, until the airway is secured.

Provide definitive treatment

Primary treatment should be provided once the airway is secured, and to non-asphyxiating patients.

Flexible or rigid bronchoscopy may be performed for removal of foreign bodies. Flexible bronchoscopy is an efficient initial method in both children and adults, with a success rate greater than 90%.[2][5]​​​

Rigid bronchoscopy and suspension microdirect laryngoscopy (SMDL) with jet ventilation should be considered prior to advancing to surgical intervention. Surgery is indicated if repeated bronchoscopic attempts fail. Thoracotomy with pulmonary resection is usually reserved for cases of destroyed segment, lobe, or lung.[24]​ Lung-sparing transverse bronchotomy through a transthoracic approach may also be considered.[63]

Timing

Most foreign bodies will not absorb or dissolve, with notable exceptions such as iron tablets.

Pro-inflammatory foreign bodies (e.g., iron tablets, potassium chloride tablets, disc batteries) may cause significant injury (stenosis, ulceration, trachea-esophageal fistula).[64][65][66][67] Prompt airway support and rapid removal of the foreign body is important.[67] Airway aspiration of an iron tablet should be considered a medical emergency.[64]

Foreign body aspiration in children

Children tend to present initially to a primary care physician. After the initial encouragement of cough, those in significant distress should be referred to the emergency department for rapid evaluation and management.[29] Foreign body aspiration can be a potentially life-threatening medical emergency.

Prediction models for the diagnosis of paediatric foreign body aspiration are at high risk of bias and have been inadequately validated.[31] There are currently no prediction models that can be recommended to guide clinical decision-making.[29]

Selecting the appropriate bronchoscopic technique

Rigid bronchoscopy should be performed in cases of stridor, asphyxia, radio-opaque object seen on chest x-ray, a history of foreign body aspiration associated with unilaterally decreased breath sounds, localised wheezing, obstructive hyper-inflation, or atelectasis.[14][45]

Rigid bronchoscopy functions as an endotracheal tube, securing the airway and providing a conduit through which the foreign body can be removed. SMDL, where available, allows jet ventilation and increased operating angle of instruments compared with rigid bronchoscopy, but it requires a collaborative approach to the foreign body retrieval.

In infants with very small airways, laryngeal suspension with 100% oxygen and the use of optical forceps has been recommended.[68]

In all other cases, flexible bronchoscopy should be performed initially to confirm the diagnosis, and attempt removal of the foreign body.[14][45]

Pre-procedural planning

If the nature of the foreign object is known, the bronchoscopist can obtain an identical object and practise removal in vitro, thus determining the best instrument to use during the actual procedure.[5] If the object is not small enough to fit through the endotracheal tube, the object should be removed en masse with the forceps or the basket that holds it, and the endotracheal tube (when used).

Typically, preparation for bronchoscopy in stable patients includes fasting from solids for 4-6 hours and from clear liquids for 2 hours, to prevent aspiration of gastric contents during the perioperative period. European guidance recommends reducing clear fluid fasting to 1 hour, reducing breast milk fasting to 3 hours, and allowing early post-operative feeding in paediatric patients.[69]

Removal of the foreign body

In stable children with suspected foreign body aspiration, flexible bronchoscopy has been shown to safely confirm the diagnosis and can be used for therapeutic purposes.[5][44][46][47]

Dislodgement, but unsuccessful retrieval of the object, is possible. If the foreign body is lost during retrieval, usually in the narrow subglottic space, the object should be pushed down into a main stem bronchus to allow sufficient ventilation and oxygenation before reattempting retrieval. If flexible bronchoscopy fails, rigid bronchoscopy and/or SMDL is the next step.[14] These procedures require general anaesthesia.

Repeated bronchoscopic examination may be necessary to remove a foreign body completely, especially if the foreign body is a peanut or other material that can easily break.[14][45]

Anaesthetic management

The anaesthetic management of foreign body aspiration can be challenging.[30] During induction, spontaneous ventilation must be maintained until it is evident that the child can be ventilated under anaesthesia.[49] Spontaneous assisted ventilation is favoured by some anaesthetists, because it allows continuous ventilation during removal of the foreign body. The depth of anaesthesia required for this, however, may decrease cardiac output and ventilation. Positive-pressure ventilation using muscle relaxants allows for a still airway, which facilitates retrieval of the foreign body. However, this technique may result in distal movement of the foreign body, which may make removal more difficult, and may lead to ball-valve obstruction of the airway.[49] The outcomes of the two techniques are similar, however.[70]

Foreign body aspiration in adults

In stable adults, flexible bronchoscopy should be used initially to confirm suspected cases of foreign body aspiration and to attempt removal of the foreign body.[4][51][52][53]​ Flexible bronchoscopy is the method of choice in adults with cervico-facial trauma and in those on mechanical ventilation. 

One selective literature review found that, in publicly reported cases, flexible bronchoscopy can be expected to be successful approximately 80% of the time.[71] Patient cooperation facilitates foreign body retrieval using flexible bronchoscopy.

Potential complications of attempting to remove large foreign bodies with a flexible bronchoscope include displacement or impaction of the foreign body in the lobar or mainstem bronchus, or shearing off of the foreign body in the narrow subglottic area, leading to acute asphyxia.[8] 

If flexible bronchoscopy fails, rigid bronchoscopy and/or SMDL is the next step. These procedures require general anaesthesia. Large foreign bodies that are round or smooth are probably best approached with the rigid bronchoscope or SMDL. SMDL, where available, allows jet ventilation and increased operating angle of instruments compared with rigid bronchoscopy, but it requires a collaborative approach to the foreign body retrieval.

Instruments available for foreign body extraction

These include smooth forceps, rat-tooth forceps, alligator forceps, snares, baskets, suction catheters, Fogarty balloons, biliary balloons, magnet catheters, and cryotherapy probes. (The author notes that many of the tools successfully used to remove a foreign body via a flexible bronchoscope are those commonly employed in urological cystoscopy. The tools are appropriately sized, and various options such as forceps, triple, and quadruple arm grabbers, and angled and straight baskets, are available.)

Balloons are useful for completely lodged objects. The balloon catheter is passed distal to the foreign body, and the balloon is inflated and gently withdrawn until the object is brought up into a larger proximal airway, from where it can be removed using forceps or a basket.

A magnet accessory can be used for ferromagnetic objects, such as some nails and pins. When cryotherapy is used, the probe is placed against the object, which adheres to the tip of the probe. The object, probe, and scope are then removed en masse.[72]

Laser and endobronchial electrosurgery may be used to free an embedded foreign body from the airway wall or to remove the associated granulation tissue.

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