Chapter 4.7.3 Foreign body inhalation

Nuts, seeds or other small objects may be inhaled, most often by children < 4 years of age. The foreign body usually lodges in a bronchus (more often in the right) and can cause collapse or consolidation of the portion of lung distal to the site of blockage. Choking is a frequent initial symptom. This may be followed by a symptom-free interval of days or weeks before the child presents with persistent wheeze, chronic cough or pneumonia, which fails to respond to treatment. Small sharp objects can lodge in the larynx, causing stridor or wheeze. Rarely, a large object lodged in the larynx can cause sudden death from asphyxia, unless it can be dislodged or an emergency tracheostomy be done.

Diagnosis

Inhalation of a foreign body should be considered in a child with the following signs:

  • sudden onset of choking, coughing or wheezing; or
  • segmental or lobar pneumonia that fails to respond to antibiotic therapy

Examine the child for:

  • unilateral wheeze;
  • an area of decreased breath sounds that is either dull or hyper-resonant on percussion;
  • deviation of the trachea or apex beat.

Obtain a chest X-ray at full expiration to detect an area of hyperinflation or collapse, mediastinal shift (away from the affected side), or a foreign body if it is radio-opaque.

Treatment

Emergency first aid for the choking child: Attempt to dislodge and expel the foreign body. The management depends on the age of the child. For infants:

For infants:

  • Lay the infant in a head-down position on one of your arms or on your thigh.
  • Strike the middle of the infant’s back five times with the heel of your hand.
  • If the obstruction persists, turn the infant over and give five firm chest thrusts with two fingers on the lower half of the sternum.
  • If the obstruction persists, check the infant’s mouth for any obstruction that can be removed. 
  • If necessary, repeat this sequence with back slaps

For older children:

  • While the child is sitting, kneeling or lying, strike the child’s back five times with the heel of the hand.
  • If the obstruction persists, go behind the child and pass your arms around the child’s body; form a fist with one hand immediately below the sternum; place the other hand over the fist and thrust sharply upwards into the abdomen. Repeat this up to five times.
  • Then check the child's mouth for any obstruction that can be removed.
  • If necessary, repeat the sequence with back slaps again.

Once this has been done, it is important to check the patency of the airway by:

  • looking for chest movements
  • listening for breath sounds, and
  • feeling for breath.

If further management of the airway is required after the obstruction is removed, see Chart 4 describes actions which will keep the child’s airway open and prevent the tongue from falling back to obstruct the pharynx while the child recovers.

  • Later treatment of suspected foreign body aspiration. If a foreign body is suspected, refer the child to a hospital where diagnosis is possible and the object can be removed by bronchoscopy. If there is evidence of pneumonia, begin treatment with ampicillin (or benzylpenicillin) and gentamicin, as for very severe pneumonia before attempting to remove the foreign body.