A 40 kg, 12-year-old boy with a history of cervical spine fusion due to syringomyelia presents to the hospital following the accidental inhalation of a pushpin during sneezing. There is no associated thoracic scoliosis or any neuromuscular deficits.
What Are the Initial Clinical Steps in Patient Management?
Initial management when presented with a definitive history of aspiration of a foreign body begins with the ABCs. An awake, alert patient without overt airway distress will permit a more complete workup, while a severely distressed patient with stridor and desaturation will mandate acute stabilization prior to rapid transfer to the operating room for surgical removal. All patients should have continuous pulse oximetry. Supplemental oxygen may be provided to maximize oxygenation. To optimize patient care and potentially minimize the need for emergency intervention, a member of the anesthesia or surgical team should accompany the patient during airway stabilization and transportation to the operating room.
Respiratory distress or the presence of stridor implies compromise of the airway and reduced airflow. Heliox (70% helium and 30% oxygen) will improve oxygenation by maximizing laminar airflow and reducing airflow resistance. The use of Heliox serves as a temporizing measure in the setting of foreign body aspiration in young children as it decreases the work of breathing and the associated anxiety.1 Intravenous dexamethasone at a dose of 0.5 mg·kg−1 may be beneficial in reducing the mucosal edema which partly contributes to the airway obstruction.2 Aerosolized epinephrine may be an additional means of reducing airway edema. The use of bronchodilators is considered to be relatively contraindicated until the foreign body is removed from the airway, as its use may predispose to dislodgement and distal migration of the foreign body due to an increase in airway caliber. Bronchodilators, however, are important adjuncts to pulmonary toilet following foreign body removal.3
What Are the Appropriate Investigations for a Foreign Body in the Trachea?
Radiologic studies are used as an adjunct to the physical examination in diagnosing suspected aerodigestive foreign bodies. Anteroposterior and lateral chest radiographs with inspiratory and expiratory views are helpful tools if the foreign body is opaque, or if bronchial obstruction is present. Lateral decubitus films are helpful when the patient is unable to cooperate for inspiratory/expiratory views. Typical radiologic findings often reveal a foreign body shadow, air trapping, segmental or lobar collapse, or consolidation. Unfortunately, the false negative rate (i.e., normal chest x-ray) ranges between 24% and 33% when compared to bronchoscopic findings.4
Spiral CT has shown some benefit when faced with persistent symptoms in a pediatric patient in the setting of an atypical history and normal chest x-ray. Fluoroscopy and cine CT are of little added benefit when a timely workup is of essence, especially if a plain radiograph or spiral CT has already ...