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any child with sudden onset of symptoms or when there is a history consistent
with ingestion or aspiration.
Triage
Children with a laryngeal or tracheal foreign body usually present in distress with
hoarseness, coughing, stridor, or wheezing. If the child is able to phonate, air is
moving through his or her larynx, indicating only partial obstruction. Efforts
should be made to allow the child to assume a position of comfort. Invasive
examination and interventions such as IV placement should be avoided when
possible, as crying may result in worsening of the airway obstruction. Complete
or near complete obstruction requires emergency airway management.
Initial Assessment
The history may include a witnessed ingestion or sudden onset of the above
symptoms with no other etiology noted. Examination findings may include stridor
with upper airway foreign bodies, and wheezing, persistent cough, focal
decreased aeration with lower airway foreign bodies. Asymmetric hyperinflation
or areas of lung collapse are rarely detectable without radiologic evaluation.
Management
Do not perform back blows or Heimlich maneuver to treat the child who is still
breathing as objects may become further lodged in the airway. Children in severe
distress should be taken to the OR for emergent removal under direct
laryngoscopy and bronchoscopy. For children who are not breathing, back blows
or the Heimlich maneuver should be done. If unsuccessful with resultant
progression to depressed mental status, laryngoscopy should be performed to
assess for glottic foreign material that can be removed with forceps.
For those in mild or moderate distress, plain films may help identify
radiopaque objects or show low lung volumes or hyperinflation in the setting of
radiolucent objects (see Fig. 106.3 ). A normal chest radiograph does not rule out
foreign body. In stable patients, fluoroscopy or CT can add diagnostic value
though this needs to be balanced against the higher doses of ionizing radiation for
these studies, and the likelihood that findings will influence subsequent
management. Alternatively, if there is high clinical concern for foreign body

despite negative radiographs, consideration should be given to urgent
bronchoscopy without further imaging. Those with low suspicion of foreign body
should have thorough follow-up and reevaluation. Development of symptoms in
the interim period should prompt appropriate further investigations as indicated.