Describe inhaled foreign body in the airway.

Foreign Body in the Airway

• An inhaled foreign body is a leading cause of accidental death in children under 3 years.
• Its danger lies in a brief, often unwitnessed episode followed by a silent interval, so that the diagnosis is missed and the child is treated for asthma or pneumonia for weeks.
• WHO and what — children aged 6 months to 3 years.
• The commonest objects are organic — peanuts and other nuts, seeds and pulses.
• Site — the right main bronchus is more often affected in adults and older children, being wider, shorter and more vertical; in young children the two sides are more nearly equal.
• The three clinical phases must be described.
• 1. The initial phase — sudden choking, violent coughing, gagging and possibly cyanosis, lasting minutes
• 2. The silent (asymptomatic) interval — the reflexes fatigue and the symptoms settle, lasting hours to weeks. This IS when the diagnosis IS missed.
• 3. The phase of complications — persistent cough, wheeze, recurrent or non-resolving pneumonia, bronchiectasis, lung abscess and atelectasis
• The most important diagnostic principle IS that A clear history OF choking outweighs everything else — a normal examination and a normal radiograph do not exclude an inhaled foreign body, and a convincing history is an indication for bronchoscopy
• Signs — unilateral wheeze or reduced air entry; a monophonic wheeze; and stridor if the object is laryngotracheal
• Any child with a unilateral wheeze, or with asthma that does not respond to treatment, or with pneumonia in the same lobe twice, should be considered for bronchoscopy
• Radiology — most inhaled foreign bodies are radiolucent.
• Obstructive emphysema (air trapping) is the commonest sign, from a ball-valve effect allowing air in but not out — giving a hyperlucent lung that does not deflate on expiration, with mediastinal shift away from the affected side on expiration
• An expiratory film, or a lateral decubitus film in a child too young to cooperate, is therefore essential — an inspiratory film alone will frequently look normal
• Later — collapse and consolidation
• CT is used where the diagnosis is uncertain, but should not delay bronchoscopy where the history is clear
• Management of the acutely choking patient — if coughing effectively, encourage the cough and do not intervene.