Airway Foreign Body

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The Pre-brief

Inhaled foreign bodies are ultimately rare presentations that occasionally have catastrophic consequences. Having the tools to quickly diagnose and manage the patient are key to a good outcome. We’ll review a case, some images and pearls.

Case: A 55-year old male presents from home in extremis. EMS is bagging a patient that appears agitated, encephalopathic and visibly cyanotic. No further history is available. The team is unable to get a good pleth on the patient’s pulse ox and states bagging has required a lot of pressure. You anticipate that this patient will need a definitive airway and adeptly perform RSI. After confirming the tube with end-tidal, you auscultate the chest and appreciate decreased breath sounds on the left. The case continues below.

Presentation:

The clinical presentation of an inhaled foreign body can range from mild irritation to stridor and respiratory distress to asphyxiation and cardiac arrest. Most patients are able to identify a specific incident of IFB prompting presentation, however in up to 8% of presentations, no history is available. While the majority of patients present acutely, the second most common presentation is with chronic cough, dyspnea or non-resolving pneumonia.

At Risk Populations or Characteristics

Chronically ill or debilitated

Prior cerebrovascular incident

Institutionalized

Poor dentition

Alcoholic

Elderly

Evaluation:

In the undifferentiated patient that requires endotracheal intubation, an IFB may still produce stridor audible on auscultation. However a significant obstruction will likely manifest as high peak pressures on your ventilation. As part of your investigation, you will likely perform suctioning, investigate your tube and perform an inspiratory hold on the ventilator. Suctioning may or may not identify a portion of the trachea and main bronchus that impede passage of the suction catheter.

In less severe cases, the patient may present for cough, dyspnea or recurrent pneumonia.

Back to the Case: After intubation, the peak pressure alarm won’t stop going off. The patient is still difficult to oxygenate despite 100%FiO2 and a PEEP of 10. You perform an inspiratory hold with plateau pressure measured at 42mmHg.

An inspiratory hold in a patient with isolated large airway obstruction will demonstrate a large difference between high peak pressures and normal plateau pressures, suggestive of high airway resistance. A caveat would be that in the incidence of an IFB with significant atelectasis, such as our case, compliance may be compromised leading to high peak pressure and high plateau pressures.

Partial Airway Obstruction	Air movement present, no lung collapse, high peak pressures, normal plateau pressures
Complete Airway Obstruction	No distal air movement, complete lung collapse, high peak pressures, high plateau pressures, high elastic pressure for given tidal volume

Back to the Case: Xray arrives and shoots this film, which you evaluate bedside:

Chest x-rays are abnormal in 86% of IFB presentations, non-resolving opacities and segmental or lobar collapse predominate the image findings. Alternatively and more common in children, the foreign body can act as a one way valve leading to post-obstructive emphysema. An inspiratory and expiratory film can increase sensitivity for a radiolucent obstruction by exaggerating the proportion of obstructed lung. Occasionally the chest imaging is definitive for the foreign body when the object is radiopaque, most commonly being metal objects and teeth.

For further characterization, a CT is often employed. CT imaging has the advantage of more accurately locating the foreign body, defining the lung involved and identifying any complications, such as granulation tissue.

Back to the Case: You quickly perform a bedside ultrasound with the findings below:

This demonstrates classic hepatization of the lung which correlates with significant atelectasis. Notable, no air bronchograms are seen in the lung parenchyma.

A patient on high ventilator settings is never the ideal bronchoscope candidate, but between the vent findings, chest x-ray and persistent hypoxia, you suspect an inhaled foreign body and grab your flexible bronchoscope.

Management:

Much of your management will depend on the clinical stability of your patient.

Rigid or flexible bronchoscopy is routinely used in management of IFB, however is ultimately an uncommon event, comprising < 1% of bronchs performed at large volume institutions. The majority (30.6%) of foreign bodies are found in the right lower lobe bronchus followed by the left main bronchus (20.4%).

Different techniques are employed for retrieval and may include using suction, forceps, baskets or balloon catheters. If the IFB was retained for a long duration, retrieval may be complicated by inflammation, edema, ulceration and granulation tissue. However, bronchoscopy is ultimately very successful with failure rates less than 5%.

Complications of Inhaled Foreign Bodies

Scarring

Carcinoma

Lung Abscess

Obstructive emphysema

Mediastinitis

Postobstructive pulmonary edema

Bronchial rupture

Pneumothorax

Bronchopleural fistula

Bronchial stricture

Chronic cough

The Debrief

Presentation of an inhaled foreign body can range from a mild cough to cardiac arrest.
Common radiographic findings include persistent areas of atelectasis or pneumonia
Removal is usually successful with rigid or flexible bronchoscopy.

References

Debeljak A, Sorli J, Music E, Kecelj P. Bronchoscopic removal of foreign bodies in adults: experience with 62 patients from 1974-1998. Eur Respir J. 1999 Oct;14(4):792-5. doi: 10.1034/j.1399-3003.1999.14d11.x. PMID: 10573222.
Tseng HJ, Hanna TN, Shuaib W, Aized M, Khosa F, Linnau KF. Imaging foreign bodies: ingested, aspirated, and inserted. Ann Emerg Med. 2015 Dec. 66(6):570-582.e5.
Sehgal IS, Dhooria S, Ram B, Singh N, Aggarwal AN, Gupta D, Behera D, Agarwal R. Foreign Body Inhalation in the Adult Population: Experience of 25,998 Bronchoscopies and Systematic Review of the Literature. Respir Care. 2015 Oct;60(10):1438-48. doi: 10.4187/respcare.03976. Epub 2015 May 12. PMID: 25969517.