Airway foreign bodies in adults
- Wes Shepherd, MD, FCCP
Wes Shepherd, MD, FCCP
- Associate Professor of Medicine
- Virginia Commonwealth University Medical Center
- Section Editors
- Polly E Parsons, MD
Polly E Parsons, MD
- Editor-in-Chief — Pulmonary and Critical Care Medicine
- Section Editor — Critical Care
- Professor of Medicine
- University of Vermont College of Medicine
- Praveen N Mathur, MB, BS
Praveen N Mathur, MB, BS
- Section Editor — Interventional Pulmonology
- Professor of Clinical Medicine
- Indiana University School of Medicine
Foreign body aspiration (FBA) is a potentially life-threatening event. Flexible and rigid bronchoscopy have become the cornerstone of both the diagnosis and treatment of patients with suspected FBA. Although FBA was traditionally managed by otolaryngologists and thoracic surgeons, the evolution of smaller diameter flexible bronchoscopes has expanded the role for pulmonary physicians in the diagnosis and management of patients who present with FBA.
The evaluation and treatment of FBA in adults will be reviewed here. FBA in children, central airway obstruction, and technical aspects of rigid bronchoscopy are discussed separately. (See "Airway foreign bodies in children" and "Clinical presentation, diagnostic evaluation, and management of central airway obstruction in adults" and "Rigid bronchoscopy: Intubation techniques".)
Foreign body aspiration (FBA) is more common in children than in adults. Data from the National Security Council reported that approximately 80 percent of cases occur in patients younger than 15 years of age, with the remaining 20 percent presenting over the age of 15 years . Overall, death from FBA is the fourth leading cause of accidental home and community deaths in the United States (table 1) with over 4600 fatal episodes of FBA reported during 2009 .
Death from FBA peaks in children <1 years old and in adults >75 years [1-6]. For children under the age of four years, FBA is the fourth leading cause of accidental death with several large case series reporting a peak incidence at one to two years [3-6]. Comparatively, tracheobronchial FBA is rare in older children and young adults [1,2,7]. However, in adults over the age of 75 years, the incidence rises again with deaths from FBA peaking at age 85 years .
Several observational case series report low rates of FBA in adults (0.66 per 100,000) [9-15]. One retrospective study from a single center reported the removal of 89 foreign bodies in adults over a 20 year period . Similarly, case series from the Mayo Clinic identified 60 adults diagnosed with FBA over a 33-year period and studies from a single center in Taiwan reported 43 cases over a 15-year period [11,13].
- National Safety Council. Report on injuries. Injury Facts. 2011 information online: www.nsc.org/library/report injury usa.htm (Accessed on January 23, 2014).
- Rafanan AL, Mehta AC. Adult airway foreign body removal. What's new? Clin Chest Med 2001; 22:319.
- Hsu Wc, Sheen Ts, Lin Cd, et al. Clinical experiences of removing foreign bodies in the airway and esophagus with a rigid endoscope: a series of 3217 cases from 1970 to 1996. Otolaryngol Head Neck Surg 2000; 122:450.
- Zhijun C, Fugao Z, Niankai Z, Jingjing C. Therapeutic experience from 1428 patients with pediatric tracheobronchial foreign body. J Pediatr Surg 2008; 43:718.
- Saki N, Nikakhlagh S, Rahim F, Abshirini H. Foreign body aspirations in infancy: a 20-year experience. Int J Med Sci 2009; 6:322.
- Tang LF, Xu YC, Wang YS, et al. Airway foreign body removal by flexible bronchoscopy: experience with 1027 children during 2000-2008. World J Pediatr 2009; 5:191.
- Baharloo F, Veyckemans F, Francis C, et al. Tracheobronchial foreign bodies: presentation and management in children and adults. Chest 1999; 115:1357.
- http://www.nsc.org/safety_home/HomeandRecreationalSafety/Pages/Choking.aspx (Accessed on September 23, 2013).
- McGuirt WF, Holmes KD, Feehs R, Browne JD. Tracheobronchial foreign bodies. Laryngoscope 1988; 98:615.
- Wolkove N, Kreisman H, Cohen C, Frank H. Occult foreign-body aspiration in adults. JAMA 1982; 248:1350.
- Limper AH, Prakash UB. Tracheobronchial foreign bodies in adults. Ann Intern Med 1990; 112:604.
- Lan RS. Non-asphyxiating tracheobronchial foreign bodies in adults. Eur Respir J 1994; 7:510.
- Chen CH, Lai CL, Tsai TT, et al. Foreign body aspiration into the lower airway in Chinese adults. Chest 1997; 112:129.
- Casalini AG, Majori M, Anghinolfi M, et al. Foreign body aspiration in adults and in children: advantages and consequences of a dedicated protocol in our 30-year experience. J Bronchology Interv Pulmonol 2013; 20:313.
- Mittleman RE, Wetli CV. The fatal cafe coronary. Foreign-body airway obstruction. JAMA 1982; 247:1285.
- Choroomi S, Curotta J. Foreign body aspiration and language spoken at home: 10-year review. J Laryngol Otol 2011; 125:719.
- Medidi S, Fountain A, Radwan M, Rumbak M. "Fishing in the trachea": a unique case of foreign body aspiration. J Bronchology Interv Pulmonol 2012; 19:168.
- Hamad AM, Elmistekawy EM, Ragab SM. Headscarf pin, a sharp foreign body aspiration with particular clinical characteristics. Eur Arch Otorhinolaryngol 2010; 267:1957.
- Weber SM, Chesnutt MS, Barton R, Cohen JI. Extraction of dental crowns from the airway: a multidisciplinary approach. Laryngoscope 2005; 115:687.
- Kovitz KL, Mayse ML. Foriegn body removal. In: Interventional Pulmonary Medicine, Beamis JF, Mathur P, Mehta AC (Eds), Marcel Dekker, New York 2004. p.259.
- Lund ME. Foreign body removal. In: Principles and Practice of Interventional Pulmonology, 2013. p.477-488.
- Elhassani NB. Tracheobronchial foreign bodies in the Middle East. A Baghdad study. J Thorac Cardiovasc Surg 1988; 96:621.
- HAUGEN RK. THE CAF'E CORONARY. SUDDEN DEATHS IN RESTAURANTS. JAMA 1963; 186:142.
- Eller WC, Haugen RK. Food asphyxiation--restaurant rescue. N Engl J Med 1973; 289:81.
- Wick R, Gilbert JD, Byard RW. Café coronary syndrome-fatal choking on food: an autopsy approach. J Clin Forensic Med 2006; 13:135.
- Holen S, Dickler EH. Missing teeth and dentures--killers of 2,500 annually. The dentists role in the prevention and treatment of food asphyxiation. J Dist Columbia Dent Soc 1973; 48:26.
- Feinberg MJ, Knebl J, Tully J, Segall L. Aspiration and the elderly. Dysphagia 1990; 5:61.
- Shaker R, Ren J, Zamir Z, et al. Effect of aging, position, and temperature on the threshold volume triggering pharyngeal swallows. Gastroenterology 1994; 107:396.
- Teramoto S, Matsuse T, Ouchi Y. Foreign body aspiration into the lower airways may not be unusual in older adults. Chest 1998; 113:1733.
- Mehta AC, Khemasuwan D. A foreign body of a different kind: Pill aspiration. Ann Thorac Med 2014; 9:1.
- Küpeli E, Khemasuwan D, Lee P, Mehta AC. "Pills" and the air passages. Chest 2013; 144:651.
- Kim ST, Kaisar OM, Clarke BE, et al. 'Iron lung': distinctive bronchoscopic features of acute iron tablet aspiration. Respirology 2003; 8:541.
- Boyd M, Chatterjee A, Chiles C, Chin R Jr. Tracheobronchial foreign body aspiration in adults. South Med J 2009; 102:171.
- Kiev J, Shepherd W, Moses L, Zhao X. Removal of an endobronchial bullet with flexible bronchoscopy nine years after injury. J Trauma 2008; 65:741.
- Mohamad I, Mohamad H, Ismail H. Bilateral pulmonary aspiration of teeth and the migration of a foreign body from one main bronchus to another. Med J Malaysia 2010; 65:309.
- Matsuse T, Oka T, Kida K, Fukuchi Y. Importance of diffuse aspiration bronchiolitis caused by chronic occult aspiration in the elderly. Chest 1996; 110:1289.
- Yilmaz A, Akkaya E, Damadoglu E, Gungor S. Occult bronchial foreign body aspiration in adults: analysis of four cases. Respirology 2004; 9:561.
- Mehta AC, Rafanan AL. Extraction of airway foreign body in adults. J Bronchol 2001; 8:123.
- Asadi Gharabaghi M, Asadi Gharabaghi M, Firoozbakhsh S. Empyema caused by foreign body aspiration. BMJ Case Rep 2012; 2012.
- Hu M, Green R, Gungor A. Pneumomediastinum and subcutaneous emphysema from bronchial foreign body aspiration. Am J Otolaryngol 2013; 34:85.
- Lee P, Culver DA, Farver C, Mehta AC. Syndrome of iron pill aspiration. Chest 2002; 121:1355.
- Johnson DR, Yew D. Aspiration of nortriptyline. Am J Emerg Med 1994; 12:337.
- Kinsey CM, Folch E, Majid A, Channick CL. Evaluation and management of pill aspiration: case discussion and review of the literature. Chest 2013; 143:1791.
- Saliba J, Mijovic T, Daniel S, et al. Asthma: the great imitator in foreign body aspiration? J Otolaryngol Head Neck Surg 2012; 41:200.
- Martinot A, Closset M, Marquette CH, et al. Indications for flexible versus rigid bronchoscopy in children with suspected foreign-body aspiration. Am J Respir Crit Care Med 1997; 155:1676.
- Tong B, Zhang L, Fang R, et al. 3D images based on MDCT in evaluation of patients with suspected foreign body aspiration. Eur Arch Otorhinolaryngol 2013; 270:1001.
- Cevizci N, Dokucu AI, Baskin D, et al. Virtual bronchoscopy as a dynamic modality in the diagnosis and treatment of suspected foreign body aspiration. Eur J Pediatr Surg 2008; 18:398.
- Zissin R, Shapiro-Feinberg M, Rozenman J, et al. CT findings of the chest in adults with aspirated foreign bodies. Eur Radiol 2001; 11:606.
- Heimlich HJ. A life-saving maneuver to prevent food-choking. JAMA 1975; 234:398.
- Ingalls TH. Heimlich versus a slap on the back. N Engl J Med 1979; 300:990.
- Skulberg A. Chest compression--an alternative to the Heimlich manoeuver? Resuscitation 1992; 24:91.
- Redding JS. The choking controversy: critique of evidence on the Heimlich maneuver. Crit Care Med 1979; 7:475.
- ECC Committee, Subcommittees and Task Forces of the American Heart Association. 2005 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation 2005; 112:IV1.
- Duan L, Chen X, Wang H, et al. Surgical treatment of late-diagnosed bronchial foreign body aspiration: a report of 23 cases. Clin Respir J 2014; 8:269.
- Walls, Ron M, Murphy, F. Foreign body in the adult airway. In: Manual of Emergency Airway Management, Fourth Ed., Wolters kluwer/Lippicott Williams and Wilkins, Philadelphia p.419-423.
- Mayr J, Dittrich S, Triebl K. A new method for removal of metallic-ferromagnetic foreign bodies from the tracheobronchial tree. Pediatr Surg Int 1997; 12:461.
- Saito H, Saka H, Sakai S, Shimokata K. Removal of broken fragment of biopsy forceps with magnetic extractor. Chest 1989; 95:700.
- Kim IG, Brummitt WM, Humphry A, et al. Foreign body in the airway: a review of 202 cases. Laryngoscope 1973; 83:347.
- Clinical manifestations
- Life-threatening asphyxiation
- Non-life-threatening foreign body
- Foreign body removal
- - Choice of procedure
- - Flexible bronchoscopy
- - Rigid bronchoscopy
- Anti-inflammatories and antibiotics
- INFORMATION FOR PATIENTS
- SUMMARY AND RECOMMENDATIONS