Define Foreign Body Aspiration. Describe its clinical features, investigations, management and complications.

Definition

• Foreign body (FB) aspiration is the inhalation of an object into the airway (larynx, trachea or bronchi).
• It is a paediatric emergency, most common in children aged 1–3 years, in whom curiosity, incomplete dentition and immature swallowing coordination increase the risk.

Common Foreign Bodies & Site

• Organic objects are commonest — groundnuts/peanuts, seeds, pulses; also small toy parts, beads, and pins.
• The right main bronchus is the commonest site of lodgement (it is wider, shorter and more vertical).
• Most FBs are radiolucent (organic), so they are not seen directly on X-ray.

Clinical Phases

• Initial phase — sudden choking, coughing, gagging and wheeze at the time of aspiration (a witnessed 'choking episode' is the key clue).
• Asymptomatic (latent) phase — symptoms settle as the FB lodges; this false reassurance often delays diagnosis.
• Complications phase — persistent cough, recurrent/non-resolving pneumonia, localised wheeze or lung collapse.

Clinical Features (BY Site)

• Laryngeal/tracheal FB: stridor, hoarseness, severe distress — can cause complete obstruction and asphyxia (an emergency).
• Bronchial FB: unilateral wheeze, reduced air entry and a hyper-resonant/dull hemithorax on the affected side.

Investigations

• Chest X-ray — an opaque FB is directly seen; a radiolucent FB shows indirect signs: unilateral obstructive emphysema (air trapping), mediastinal shift away from the affected side, atelectasis, or non-resolving consolidation.
• Inspiratory–expiratory (or lateral decubitus) films highlight air trapping.
• Bronchoscopy — both diagnostic and therapeutic; a normal X-ray does not exclude an FB, so a strong history warrants bronchoscopy.

Management — Acute Complete Obstruction (choking Child)

• Infant (< 1 yr): alternate 5 back blows + 5 chest thrusts (head down).
• Older child: abdominal thrusts (Heimlich manoeuvre).
• If the child becomes unconscious → start CPR and attempt to visualise/remove the FB.
• Do not perform blind finger sweeps (risk of pushing the FB deeper).

Management — Definitive

• Rigid bronchoscopy under general anaesthesia is the treatment of choice for removal.
• Antibiotics and physiotherapy for associated infection/atelectasis; treat complications.

Complications & Prevention

• Complications: asphyxia/death, recurrent pneumonia, lung abscess, bronchiectasis, atelectasis, pneumothorax.
• Prevention: avoid giving nuts, seeds and small hard foods to children under 3 years; keep small objects out of reach; supervise feeding; parental awareness.

WHY Children Are Prone

• The habit of putting objects in the mouth and running/playing while eating.
• Incomplete dentition (poor chewing of nuts) and immature airway-protective (swallowing) coordination.
• Peak age 1–3 years.

Differential Diagnosis

• Croup and asthma (wheeze/stridor without a choking history); recurrent pneumonia of other cause.
• The key discriminator is a witnessed choking/aspiration episode.

Post-removal Care

• Observe for airway oedema/laryngospasm; chest physiotherapy and antibiotics for associated infection/atelectasis.
• Repeat imaging to confirm re-expansion of the lung.

Prognosis

Excellent with early recognition and bronchoscopic removal. Delayed diagnosis leads to recurrent pneumonia, bronchiectasis and lung damage — hence a low threshold for bronchoscopy on a strong history.

Features BY Site of Lodgement

Radiological Signs (radiolucent FB)

• Obstructive emphysema (air trapping) of the affected side — hyperlucent lung.
• Mediastinal shift away from the affected side (more marked on expiration).
• Atelectasis/collapse or persistent, non-resolving consolidation distal to the obstruction.

A normal chest radiograph does not exclude it — bronchoscopy if suspected.