What is the appropriate management of foreign body aspiration and foreign bodies in the nose, mouth, eye, and ear?

Management of Foreign Bodies in Airway, Nose, Mouth, Eye, and Ear

Foreign Body Airway Obstruction (FBAO) - Immediate Life-Threatening Emergency

For severe airway obstruction with ineffective cough in conscious patients, immediately perform 5 back blows (back slaps) first, followed by 5 abdominal thrusts if back blows fail, alternating this sequence rapidly until the obstruction is relieved or the patient becomes unconscious. 1, 2

Critical Initial Assessment

• Severe FBAO requires immediate mechanical intervention—do NOT delay for diagnostic studies, examination, or imaging when the patient shows active respiratory distress. 2 Delaying intervention can result in complete obstruction, loss of consciousness, and death. 2

• Identify severe FBAO by: sudden onset of respiratory distress with witnessed choking, active wheezing indicating partial obstruction, and absence of fever or antecedent respiratory symptoms (distinguishing from infectious causes like croup). 2

Age-Specific Intervention Protocols

For children >1 year and adults:

• Begin with 5 back blows delivered between the shoulder blades with the patient leaning forward. 1, 2

• If back blows fail, immediately proceed to 5 abdominal thrusts (Heimlich maneuver—subdiaphragmatic thrusts). 1, 2

• Alternate rapidly between 5 back blows and 5 abdominal thrusts until the object is expelled or the patient becomes unresponsive. 2, 3

For infants <1 year:

• Perform 5 back blows followed by 5 chest compressions (NOT abdominal thrusts). 2, 3

• Never use abdominal thrusts in infants—this can cause liver injury. 2, 3

• Alternate cycles of 5 back blows and 5 chest compressions until obstruction is relieved. 2, 3

If Patient Becomes Unconscious

• Immediately begin CPR with chest compressions—do NOT check for pulse first. 2, 3

• After 30 compressions, look in the mouth and remove any visible foreign body with manual extraction. 1, 2

• Continue CPR cycles (30 compressions: 2 ventilations for adults; 5 compressions: 1 ventilation for infants). 3

Critical Pitfalls to Avoid

• Never perform blind finger sweeps—this can push the foreign body deeper into the pharynx and cause oropharyngeal damage. 1, 2, 3, 4

• Only remove objects that are clearly visible in the mouth. 1, 2

• Do not use suction-based airway clearance devices routinely—weak evidence and potential for harm. 1, 2

Healthcare Provider Advanced Interventions

• Appropriately skilled healthcare providers should use Magill forceps to remove visible foreign body airway obstructions, particularly in patients with out-of-hospital cardiac arrest from FBAO. 1, 2

• For unconscious patients, chest thrusts are recommended as an alternative intervention. 1, 2

Epidemiologic Context

• More than 90% of childhood deaths from foreign body aspiration occur in children <5 years of age, with nuts (especially peanuts and almonds) being the most common culprits. 2, 5 Immediate bystander intervention is critical for survival. 2

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Suspected Foreign Body Aspiration (Non-Acute Presentation)

Clinical Presentation Requiring Bronchoscopy

• Suspect foreign body aspiration in children presenting with: persistent harsh cough of abrupt onset, unilateral monophonic wheezing, recurrent pneumonia, persistent atelectasis, or localized hyperinflation on chest X-ray. 1, 6

• Key predictive factors for confirmed FBA include: exposure to nuts/seeds, unilateral wheezing or decreased breath sounds, stridor, and suggestive findings on chest X-ray. 6 However, choking episode, acute cough, and absence of fever do NOT reliably predict FBA. 6

Diagnostic Approach

• Obtain chest X-ray to identify radiopaque foreign bodies, atelectasis, hyperinflation, or pneumonia. 1, 6, 7 Sensitivity is only 66% and specificity 51%, so normal imaging does not exclude FBA. 7

• Asymmetric auscultation has 80% sensitivity and 72% specificity—more reliable than history or chest X-ray alone. 7

• Flexible bronchoscopy is the definitive diagnostic test and should be performed urgently (within 24 hours) when FBA is suspected. 1, 8 Rigid bronchoscopy is required for foreign body removal in children. 1, 7

Management Protocol

• Patients with suspected FBA should undergo bronchoscopy within 24 hours of hospital admission to avoid potentially dangerous delays. 8 In critical situations, intervention should occur on the day of admission. 8

• Rigid bronchoscopy successfully removes foreign bodies in 99% of cases with minimal complications (subglottic edema, bronchospasm in <2% of cases). 7

• The negative bronchoscopy rate is approximately 12-13%, which is acceptable given the life-threatening nature of missed FBA. 8, 7

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Ingested Foreign Bodies (Esophageal, Gastric, Intestinal)

Esophageal Foreign Bodies

• For complete esophageal obstruction with inability to handle secretions, perform emergent flexible endoscopy within 2-6 hours. 3

• For partial esophageal obstruction, endoscopy should be performed within 24 hours. 3

• The "push technique" is first-line for food bolus impaction with 90% success rate. 3

Gastric and Intestinal Foreign Bodies

• For asymptomatic children with foreign bodies in the stomach or beyond, maintain normal diet and hydration while monitoring stools for passage of the object. 3, 4

• Obtain abdominal X-ray to confirm presence, location, and number of objects. 4

• Do NOT give laxatives or induce vomiting—this does not accelerate passage and may cause complications. 3, 4

Red Flags Requiring Emergency Intervention

• Seek immediate care for: persistent vomiting, severe abdominal pain, signs of perforation (peritonitis), hematemesis, or development of respiratory symptoms. 3, 4

• Surgical consultation is indicated for: irretrievable foreign body by endoscopy, evidence of perforation, or complete bowel obstruction. 3

Follow-Up

• If the object has not passed within 3-4 weeks or symptoms develop, repeat imaging and gastroenterology consultation are warranted. 3

• Perform diagnostic evaluation for underlying esophageal disease (present in up to 25% of cases), including biopsies during index endoscopy to rule out eosinophilic esophagitis. 3

Critical Pitfall

• Avoid barium contrast studies—barium can coat the foreign body and increase aspiration risk. 3, 4

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Foreign Bodies in Nose, Eye, and Ear

Note: The provided evidence does not contain specific guidelines for nasal, ocular, or aural foreign bodies. These require specialized ENT or ophthalmology consultation for safe removal using appropriate instrumentation (nasal speculum, forceps, irrigation for ear; slit lamp examination and specialized removal techniques for eye). General principles include avoiding blind probing and ensuring adequate visualization during removal.