CHAPTER 47: Management of 2-Year-Old Child with an Airway Foreign Body

CASE PRESENTATION

A 14 kg, 2-year-old boy presents following an aspiration event. The child was playing by a pile of gravel in the backyard and had a significant coughing episode. His parents did some back blows; he then vomited and stabilized. They also did a finger sweep but found nothing. He now continues to cough and is somewhat labored in his breathing.

PATIENT ASSESSMENT

What Are the Initial Clinical Steps in Patient Management?

Initial management of a patient with suspected foreign body aspiration begins with assessment and initial stabilization of ABCs—Airway, Breathing, Circulation. An awake, alert patient without overt airway distress will permit a more complete work-up, while a severely distressed patient with stridor and desaturation will require acute stabilization for transfer to the operating room (OR) for surgical removal of the foreign body. Presenting symptoms following foreign body aspiration are inherently related to the type of object aspirated, the location of the object, and the overall duration of the obstructive event. Obtaining a timely history from the patient’s caregivers can provide most of these details, supplemented by a physical exam and investigations.

The practitioner can be lulled into a false sense of (airway) security when the patient is not imminently distressed. The patient must be constantly reassessed and re-evaluated for identification of respiratory change or deterioration. Timely collaborative care involving emergency room personnel, anesthesia practitioners, and the surgical airway management team is critical and should encompass investigations deemed safe based on patient stability, expedited supportive care, and transfer of the patient to the OR to ultimately resolve these tenuous situations.

All patients should be cared for in a high-acuity setting and have their vital signs continuously monitored. Supplemental oxygen may be provided to maximize pathophysiologic stabilization and optimization of the patient’s cardiorespiratory status.

What Pathophysiologic Changes Are Seen in a Child That Has Aspirated a Foreign Body?

The pathophysiology of aspiration events is determined mainly by the characteristics of the aspiration event. In particular, the severity and location of airway obstruction, the type, size, and shape of the aspirated object, and the timeline since aspiration are key factors in symptom evolution.

Airway obstruction following foreign body aspiration may be complete or partial, depending on the inherent characteristics of the foreign body relative to the patient’s airway diameter.

A complete airway obstruction is an emergency, usually associated with profound hypoxemia, subsequent cardiovascular compromise, and leading to cardiorespiratory arrest from asphyxia if left untreated. Mortality from foreign body aspiration has been estimated at 0.43%, with many patients presenting to emergency departments too late to rescue.¹ If a patient presents with vital signs and evidence of complete obstruction, the team is forced to act with their best efforts to gain control of the airway and facilitate ...