What are the management steps for a patient showing the Foreign Body (FB) sign of aspiration?

Management of Foreign Body (FB) Sign of Aspiration

In patients showing the Foreign Body (FB) sign of aspiration, rigid bronchoscopy should be performed for extraction, as flexible bronchoscopy is generally contraindicated for the removal of endobronchial foreign bodies. 1

Initial Assessment and Management

• For severe airway obstruction (patient unable to make sounds):

  • In children: Perform subdiaphragmatic abdominal thrusts (Heimlich maneuver) until the object is expelled or the victim becomes unresponsive 1
  • In infants: Deliver repeated cycles of 5 back blows followed by 5 chest compressions until the object is expelled or the victim becomes unresponsive 1
  • If the victim becomes unresponsive, start CPR with chest compressions 1

• For mild airway obstruction (patient can cough and make sounds):

  • Allow the victim to clear the airway by coughing while observing for signs of severe obstruction 1

Diagnostic Approach

• Radiographic evaluation:

  • Look for localized hyperinflation, which may be the result of partial bronchial obstruction due to foreign body aspiration 1
  • Note that normal radiographic findings do not exclude FB aspiration, especially in infants where up to 48% may present with normal X-ray findings 2

• Clinical indicators that strongly suggest FB aspiration:

  • Witnessed choking (OR 2.1) 3
  • Noisy breathing, stridor, or dysphonia (OR 2.7) 3
  • New onset, recurrent, or persistent wheeze (OR 4.6) 3
  • Unilateral reduced air entry (OR 2.9) 3
  • Localized monophonic wheeze 1

Bronchoscopic Management

• Rigid bronchoscopy is the procedure of choice for foreign body extraction in children 1

  • Flexible bronchoscopy is generally contraindicated for removal of endobronchial foreign bodies 1
  • Flexible bronchoscopy can be used for diagnosis/exclusion of suspected FB aspiration, but not for extraction 1

• Timing of bronchoscopy:

  • Perform bronchoscopy promptly when FB aspiration is suspected, even with normal physical examination 4
  • Completion within 24 hours facilitates the examination and reduces the risk of complications 4

Special Considerations

• Age-related factors:

  • FB aspiration peaks at 1-2 years of age 4
  • In children under 3 years, organic foreign bodies (nuts, carrots, etc.) are significantly more common (86% of cases) 4
  • Infants present unique challenges due to small airways and the need for smaller bronchoscopes 2

• Risk stratification:

  • When three or more risk factors are present (witnessed choking, abnormal breathing sounds, wheeze, abnormal radiological findings, reduced air entry), the likelihood of proven FB increases significantly 3
  • Even with normal physical and radiological findings, 7.4% of suspected cases still have a foreign body 3

Post-Extraction Care

• Consider repeat bronchoscopy if there is concern for retained FB remnants (required in approximately 10% of cases) 2
• Evaluate for underlying conditions that may have contributed to aspiration 1
• Monitor for complications such as pneumonia, atelectasis, or bronchiectasis 1

Prevention Guidance

• Recommend increased awareness of hazards associated with small crunchy organic food items, especially nuts and carrots, for children under three years of age 4
• Educate caregivers about proper food preparation and supervision during meals 4