Foreign Body Inhalation

Question 1

A 2 year old boy was brought to the ED with severe coughing episodes after eating some grapes. Upon examination, you noticed that he is coughing and gagging, and his lips had a slight bluish tinge.

Answer 1

Impression
Given the signs of asphyxiation on top of recently having eaten grapes, I am concerned about forcing body inhalation in this child. This is an emergency demanding immediate management to prevent complications of hypoxia.

DDx
- anaphylaxis (allergies)
- airway burns
- Infective: croup, epiglottitis, Quincy, bacterial tracheitis

Goals
- immediate call for senior assistance and begin simultaneous assessment and resuscitation, call ENT/anaesthetics if available
- initiate emergency management including back blows and chest thrusts to remove the FB

Question 2

FBI - Assessment

Answer 2

Assessment
Want to keep child settled to avoid deterioration, so position comfortably in mothers lap etc and utilise minimal examination to avoid upsetting them.

A & B: rapidly assess degree of latency, and respiratory status to gauge severity of the obstruction.

Emergency management
- assess for coughin, if strong then encourage coughing
- 5 back blows (child lying face to floor)
- 5 chest thrusts
- if unresponsive: start APLS and chest compressions; utilise direct laryngoscopy to visualise FB, attempt to remove with forceps
- administer supportive 02 to improve sats
- ultimately, refer for bronchoscopy to remove FB completely

If there is no relief with these measures, then proceed to either
o cricothyroidotomy if FB is above vocal folds
o if FB is below folds, then use PPV to push the FB into L or R main bronchus then ventilate the other lung, before definitive removal in theatres

Question 3

FBI - History

Answer 3

History
- sx: timing and onset of symptoms; sudden/catastrophic or gradual onset. Sx of obstructing: coughing, wheezing/stridor, cyanosis, drooling, voice changes, haemoptysis (indicates impaction in the main bronchus)
- screen infective sx
- Paeds hx

Question 4

FBI - Examination

Answer 4

Examination
- General appearance + vitals (flat, non responsive, cyanotic, etc)
- Resp exam: reduced breath sounds increased RR, stridor, drooling, increased WOB, asymmetrical chest involvement

Question 5

FBI - Investigations

Answer 5

Key/Diagnostic
- video laryngoscopy
- Bronchoscopy
- CXR
- pre-op bloods if for theatres: G+H, coags, FBC, UEC, LFT

Question 6

FBI - Counselling/ Management

Answer 6

Management
- Parent education: children <5 are at increased risk of inhaled FBs, especially food
- should not be offered hard round small foods
- encourage safe eating habits (sit calmly, eat one thing at a time)
- avoid toys with small parts in children under 3