Pediatrics 2: Tracheal Foreign Body Portal
PEDS: Because this entire portal pertains only to pediatric patients, the convention of underlining has been omitted.
Diagnostic Considerations
Even if a parent or caregiver has not seen a child aspirate an object, foreign body airway obstruction is a strong possibility in infants and children who experience a sudden onset of respiratory distress. If the child is stable and ventilating well, rigid bronchoscopy is the diagnostic and therapeutic procedure of choice.
Treatment
After repositioning the head and neck, attempt to ventilate the patient. If this is unsuccessful, then attempt to dislodge the foreign body.
In infants up to 1 year, give 5 back blows followed by 5 chest thrusts, keeping the patient’s head held lower than the trunk. Remove the foreign body if it is visualized. Re-attempt ventilation.
In children > 1 year, deliver 5 abdominal thrusts. Evaluate the mouth and remove the foreign body if it is visualized. Re-attempt ventilation.
In adults, give 5 abdominal thrusts and then perform a finger sweep of the pharynx and remove the foreign body if it is visualized. Re-attempt ventilation.
Do not attempt tracheal foreign body removal unless the obstruction is complete, or the patient decompensates and the Heimlich maneuver has failed. Then try the following:
If unsuccessful in removing the foreign body and the patient still cannot be ventilated, use a laryngoscope to visualize the glottis. If the foreign body is visible, grasp and remove it with a Magill forceps.
Attempt to remove the foreign body with high vacuum suction or the use of the esophageal intubation detector (EID). (Vol III—AIR2 Airway Obstruction)
When the foreign body is a hard, non-compliant object such as a marble, a balloon catheter may be used. (Vol III—AIR2 Airway Obstruction)
If the foreign body cannot be seen or removed and ventilation is compromised, perform orotracheal intubation and attempt to force the foreign body into the right main stem bronchus with the ET tube so at least the left lung can be ventilated.
If the tracheal foreign body is pushed into the right main stem bronchus with an ET tube, ventilate the left lung. Attach a swivel connector to the ET tube and continue ventilations while passing a flexible bronchoscope through the connector into the ET tube. Visualize the foreign body.
If the foreign body is a friable mass—for instance, a piece of meat—insert a 3 to 5 French Fogarty catheter through or alongside the bronchoscope and past the piece of meat. Inflate the Fogarty balloon and pull the foreign body into or against the ET tube. Remove the ET tube, the foreign body, and the Fogarty catheter as a unit. Then, re-intubate the patient and continue ventilations.
If the foreign body is a piece of rubber balloon or a solid object that can be grasped, insert a flexible grasping forceps through or alongside the bronchoscope and the grasp the object. Pull it into or against the ET tube. Remove the ET tube, the foreign body, and the grasping forcep as a unit. Then, re-intubate the patient.
If foreign body removal has not been successful and ventilation is compromised, consider performing a tracheostomy and attempt to reach the foreign body with Magill forceps. A pediatric-size Magill forceps may be useful. Blind passage of a Fogarty catheter may be used to pull the object into the trachea.
Cricothyrotomy, emergency tracheostomy (in children < 8 years old), or transtracheal needle ventilation may also be considered as a means of establishing an airway.
If a patient has not been intubated, is having intermittent difficulty with a foreign body in the trachea, and is awake, consider performing RSI (Vol II—AIR SKILLS 4 Rapid Sequence Intubation) and use a flexible bronchoscope.
In infants and toddlers, use a rigid bronchoscope through which an optic forceps may be inserted. Optic forceps have peanut grasper and alligator jaw grasper attachments that can remove almost any kind of foreign body. In infants < about 2 years, use the optic forceps without the bronchoscope.
Pulmonary edema may follow foreign body removal as a result of the patient breathing against resistance. Oxygenate, monitor oxygen saturation, and measure blood gases for guidance. Intensive care monitoring is needed.
Wheezing is often heard in small children with a tracheal or bronchial foreign body. This may be intermittent. Thick bronchial secretions can behave like a foreign body. Inspiratory and expiratory chest x-rays may reveal asymmetrical lung filling or may be normal. If the child is stable, consultation with an otolaryngologist or pediatric pulmonologist is in order.