Foreign Body Aspiration (FBA)

Don't agitate the child - A partially obstructed airway can be tipped to complete obstruction. Leave the child with the parent, no unnecessary exam, and move to the OR for a controlled airway examination under anesthesia rather than fighting it in the ED.

Rigid bronchoscopy is the definitive case - Rigid beats flexible here because you can ventilate through the scope, the rigid telescope sees better, and it accepts a range of suction catheters and optical forceps. It also gives the surgeon room to work the object past the glottis. Some centers take a child to rigid bronchoscopy on history alone, since up to 15% of aspirations have a normal exam and normal imaging.

Shared airway, shared plan - You and the bronchoscopist have the same tube. Talk out loud about when you are ventilating and when they are working, and keep ETCO2 and SpO2 in view the whole case.

Let them exhale - Passive chest and lung recoil may not push gas back out through a narrow scope, so hypercarbia and air trapping build fast. Allow a long expiratory time constant of 5 to 10 seconds during manual ventilation. Trapped gas hyperinflates the lung, drops venous return, and has produced PEA arrest on the table.

Read the right films - Inspiratory and expiratory PA and lateral chest x-rays: air trapping, unilateral hyperexpansion with a flattened hemidiaphragm and the mediastinum pushed away marks the obstructed side. Most aspirated objects are radiolucent, so a normal film does not clear the child.

Set up before induction - IV access with a CBC and electrolytes, and emergency tracheostomy supplies open in the room. If ventilation fails, intubating past the obstruction or deliberately advancing the object into one mainstem to ventilate the other lung is a legitimate rescue — and it goes far better in a fully equipped OR.

Watch the good lung after retrieval - Mucous plugging with later dislodgement can obstruct the contralateral side and desaturate a child who looked fixed. Suction and reassess both sides before you call it done.

Late presentations are worse - Objects found more than 3 days out most often present with obstructive emphysema. Tracheal foreign bodies carry the highest odds of needing mechanical ventilation, and delay brings airway stenosis, abscess, bronchial injury, and anoxic brain injury.

Afterward - Oral or inhaled corticosteroids are commonly given after retrieval for airway edema, and antibiotics are started if there are signs of post-obstructive infection. Bear in mind that a child already on bronchodilators and steroids for presumed asthma may have had their reactive symptoms masked.

Foreign body aspiration is an aerodigestive object lodged in the airway, and it is the fourth leading cause of death in preschool and younger children. Airway resistance rises with the inverse fourth power of the radius, so a small object in a small pediatric airway produces obstruction out of all proportion to its size.

Complete glottic or tracheal obstruction gives immediate choking, respiratory distress, cyanosis, and death if not treated. Partial obstruction behaves as a ball valve — air in, not out — producing air trapping, the most common radiographic abnormality at 53% of cases, along with atelectasis, mediastinal shift, and pneumothorax. Organic material swells and inflames the mucosa, so obstruction worsens with time. Children aspirate slightly more often into the right mainstem, and that preference grows with age.