EM ReSCu Peds 6: Foreign Body Aspiration

Brief Narrative Description of Case

Mother brings a 10-month-old child to the Emergency Department with a complaint of sudden onset of cough. She was in the kitchen and briefly left the infant with her 3-year-old sibling who was playing with her toys. She returned to find the child coughing along with “wheezing.” If asked, what mother is actually describing is stridor from the upper airway foreign body. Child will initially be stable with intermittent stridor but will develop increasing breathing difficulty leading to hypoxia. Foreign bodies may not be radio-opaque and x-rays will not reveal diagnosis. Participants will need to recognize the need for emergency airway intervention. Child will become increasingly hypoxic and distressed and require attempted intubation with an endotracheal tube. Team will not be able to remove the foreign body or advance an endotracheal tube. Once an advanced airway has been attempted, the child will improve clinically only briefly and will ultimately need a needle cricothyroidotomy to secure the airway because of a foreign body completely obstructing the airway. Participants are required to discuss diagnosis with family and why intubation is necessary. Mother will be upset and feel responsible for the child’s condition and will require reassurance. Final steps will be consultation with surgery, otolaryngology (ENT), or pulmonary service for foreign body removal and subsequent admission of the child to PICU.

Primary Learning Objectives

At the end of this simulation, participants should be able to:

  1. Describe the signs/symptoms of an upper airway foreign body (comprehension)
  2. Demonstrate early evaluation of a critically ill patient (application)
  3. Discuss the limitations of radiologic studies in the diagnosis of airway foreign bodies (comprehension)
  4. Demonstrate management upper airway obstructions including intubation and needle cricothyroidotomy (application)
  5. Demonstrate focused history taking from a caregiver (application)
  6. Explain diagnosis and management to caregivers (synthesis)
  7. Demonstrate teamwork and closed loop communication (application)

Critical Actions

  • Recognize stridor secondary to upper airway foreign body
  • Recognize impending airway compromise
  • Manage airway, including bag-mask ventilation and attempted intubation
  • Perform needle cricothyroidotomy
  • Prompt consultation with appropriate services for foreign body removal
  • Admit to Pediatric ICU or OR setting
  • Discuss diagnosis and management with parents

Case Creators

Author

  • Christopher Sampson, MD, FACEP

Editors

  • Muhammad Waseem, MD, MS, FACEP, FAAP, CHSE-A
  • Rebekah Burns, MD
  • Steven Lai, MD
  • Tiffany Moadel, MD
  • Heidi Baer, MD

Updated August 18, 2020

Setup

Chief complaint: Cough and wheezing
Patient age: 10 months old
Weight: 10 kg

Recommended Supplies

  • Manikin: Intubatable infant, ideally should have the ability to perform needle cricothyroidotomy, but task trainer may be used
  • Moulage: Small toy (e.g., Lego) for foreign body in airway lodged above vocal cords
  • Resources: Pediatric reference card such as PALS card and/or length-based tape (e.g., Broselow Tape)
  • Manikin set up: Dressed in infant clothing
  • Equipment: Pediatric Airway Equipment, McGill forceps, NRBM mask, bag-valve mask, needle cricothyroidotomy kit
  • Medications: Racemic epinephrine, albuterol, RSI medications, sedation medications, dexamethasone or methylprednisolone

Supporting Files

  • Normal infant chest x-ray
  • Photograph of airway foreign body

Participants/Roles

  • Team leader
    • Airway manager
    • Survey physician
    • Medication preparer
    • Medication giver
    • Family liaison/history taker
  • Standardized patient (actor or faculty) to play patient’s parent (only 1 parent needed)
  • Faculty or other embedded participants can play a nurse, respiratory therapist, or tech, if there are not enough learners to perform the above roles.

Team roles may need to be adjusted in order to suit local practices and norms

Prerequisite Knowledge

  • Faculty
    • PALS protocols
    • General knowledge of emergency medicine
    • Simulation implementation and debriefing experience
  • Emergency medicine residents
    • Any stage of training
    • Familiarity with needle cricothyroidotomy

Case Alternatives

  • If attempt intubation early on, have the child’s oxygen saturation improve, and the nurse can question why providers are wanting to intubate the patient.
  • If facilitators would like to increase the challenge of the case to target advanced learners, have the learners attempt foreign body removal.

Milestones

PC1. Emergency Stabilization
PC2. Performance of Focused History & Physical Exam
PC4. Differential Diagnoses and Management
PC7. Disposition
PC9. General Approach to Procedures
PC10. Airway Management
MK. Medical Knowledge
PROF1. Professional Values
ICS1. Patient Centered Communication
ICS2. Team Management

Resources

  1. Nickson C. Inhaled foreign body. https://litfl.com/inhaled-foreign-body/. Last update 2019.
  2. Passàli D, Lauriello M, Bellussi L, et al. Foreign body inhalation in children: an update. Acta Otorhinolaryngol Ital. 2010;30:27–32. PMID: 20559470
  3. Na’ara S, Vainer I, Amit M, et al. Foreign Body Aspiration in Infants and Older Children: A Comparative Study. Ear Nose Throat J. 2020;99:47-51. PMID: 30974996
  4. Rovin JD, Rodgers BM. Pediatric Foreign Body Aspiration. Pediatr Review. 2000;21:86-90. PMID: 10702322
  5. Needle cricothyrotomy. WikiEM. https://wikem.org/wiki/Needle_cricothyrotomy. Last update 2020.
ITEMFINDING
Overall AppearanceMother sitting in room, holding infant in her arms. Infant is having intermittent stridor.
HPIMother reports a story of her child having a sudden cough that resolved and now having “wheezing”.

She brought her daughter to the ED because she started coughing when she was in the other room and now has intermittent “wheezing” (actually stridor, but she thinks it is wheezing). She was fine when she first woke up, and this is very atypical for her. You are worried she is sick.

If asked, will describe events of the child playing with her sibling and developing a sudden onset of cough when she was out of room. She was in the kitchen and briefly left the infant with her 3-year-old sibling, who was playing with her toys. Mother will state child “wheezing” but when questioned will actually describe stridor.

Past Medical/Surgical HistoryNone, born at 38 weeks by spontaneous vaginal delivery
MedicationsNone
AllergiesNo known drug allergies
Family HistoryNone
Social HistoryAttends daycare

Initial Presentation

Start through end of primary survey (initial examination)

Critical Actions

  • Team leader assigns tasks
  • Obtain relevant history from parent
  • Perform primary survey
  • Place patient on continuous cardiac monitor
  • Perform focused physical exam
  • Recognize stridor

Physical Exam

ITEMFINDING
Vital SignsT: 37oC, HR: 110, BP: 90/52, RR: 26, SpO2: 96% on RA
GeneralAwake and alert infant held by parent or lying on stretcher
HEENTIntermittent stridor. Foreign body visualized at cords on initial inspection. Cannot be removed.
NeckSupple
LungsClear to auscultation bilaterally
CardiovascularRegular rate and rhythm, no murmurs
AbdomenSoft, non-tender, non-distended
NeurologicalNon-focal, moves all extremities
SkinWarm, dry, capillary refill < 2 sec

Instructor Notes: Changes and Case Branch Points

INTERVENTION / TIME POINTCHANGE IN CASEADDITIONAL INFORMATION
Following initial examIntermittent stridor. SpO2 will drop to 88%, but then return to normal range once stridor resolves.Mother will state “This is the wheezing I was talking about, are you going to give him any treatment?”
During intermittent stridorOxygen saturation decreases to 88%
Participants request chest x-rayImages provided to participants.
Participants request racemic epinephrineNo change in examMedications will be available.
After exam and imaging (if requested)Proceed to Stage 2.

Airway Compromise

After initial exam (and any imaging ordered) through preparation for intubation

Critical Actions

  • Recognize airway difficulty and need for intubation
  • Establish vascular access

Physical Exam

ITEMFINDING
Vital SignsT: 37oC, HR: 125, BP: 90/52, RR: 34, SpO2: 88%
Exam ChangesStridor is now constant and child having increasing respiratory difficulty and distress

Instructor Notes: Changes and Case Branch Points

INTERVENTION / TIME POINTCHANGE IN CASEADDITIONAL INFORMATION
Child returns from x-ray department or portable x-ray is completed.Stridor constant and SpO2 declinesNurse or mother will draw attention to patient, if team not recognizing
Racemic epinephrine nebulizer orderedNo effect
Albuterol MDI or nebulizer treatmentNo effect
Steroids given orally or intravenouslyNo effect
Order blood glucoseBlood glucose (point of care) 101 mg/dL
Order venous blood gas
  • pH 7.40
  • PO2 35 mmHg
  • PCO2 45 mmHg
Order arterial blood gasNo effectNurse questions why do we need to this painful procedure
Additional lab ordersPending when asked

Intubation

Teams calls for airway equipment

Critical Actions

  • Intubation must be attempted and once deemed unsuccessful, needle cricothyroidotomy must be attempted.

Physical Exam

ITEMFINDING
Vital SignsT: 37oC, HR: 130, BP: 90/52, RR: 42, SpO2: 84%
Exam ChangesCyanosis present with continuous stridor

Instructor Notes: Changes and Case Branch Points

INTERVENTION / TIME POINTCHANGE IN CASEADDITIONAL INFORMATION
Intubation attemptedWill be unable to place ET tube due to foreign body obstruction. Proceed to Stage 4.
Attempt to remove foreign bodyUnable to remove foreign body or removal causes trauma leading to significant edemaUse image provided, if foreign body unable to be placed in manikin

Cricothyroidotomy

Intubation attempt through cricothyroidotomy

Critical Actions

  • Perform needle cricothyroidotomy

Physical Exam

ITEMFINDING
Vital SignsT: 37oC, HR: 130, BP: 90/52, RR: 42, SpO2: 84%
Exam ChangesNo changes

Instructor Notes: Changes and Case Branch Points

INTERVENTION / TIME POINTCHANGE IN CASEADDITIONAL INFORMATION
Needle cricothyroidotomy attemptedHypoxia and cyanosis will improve following procedure. Proceed to Stage 5.Jet ventilation can be performed as a temporary measure.

Case Conclusion

Intubation attempt through cricothyroidotomy

Critical Actions

  • Surgical, ENT or pulmonary consultation (depending on local practices)

Physical Exam

ITEMFINDING
Vital SignsT: 37oC, HR: 130, BP: 90/52, RR: assisted, SpO2: 100% after needle cricothyroidotomy
Exam ChangesCyanosis and stridor resolve

Describe the signs/symptoms of an upper airway foreign body (comprehension)

In infants, several conditions can cause respiratory distress. Common causes include bronchiolitis, reactive airway disease, gastroesophageal reflux, congenital abnormalities, or foreign bodies. Unlike adults and older children, infants and young children are unable to provide a history of foreign body aspiration or manifest typical choking signs. Instead, caregivers and providers must rely on other non-specific presentations. Common complaints from parents may be non-specific, and what is described as wheezing may not actually be wheezing. Infants may have intermittent stridor or cyanosis. Partial obstruction makes the diagnosis difficult. The classic triad of new onset cough, wheezing and asymmetric breath sounds is not present in the majority of patients. The majority of aspirated foreign bodies in children are located in the bronchi. The most common presenting symptom is cough. In infants and young children, an increased respiratory rate may be present with respiratory distress.

Airway foreign bodies led to 17,000 emergency department visits in children <14 years old. Leading cause of accidental infantile deaths and 4th among preschool children. Peak occurrence is 1-2 years old with 80% <3 years old. In western nations, peanuts account for half of all organic ingestions. Classic triad of paroxysmal cough, wheezing and decreased air entry seen in only <40% of patients. Cough (72%) is the most frequent symptom. Expiratory stridor is a unique finding. Laryngotracheal foreign bodies are uncommon but likely life- threatening.

Demonstrate early evaluation of a critically ill patient (application)

Learners should approach a critically ill patient in a standardized fashion. Airway, breathing, and circulation should be assessed immediately. After A, B, C have been addressed, the patient should be evaluated for disability and exposed for a complete head to toe exam. If a child is found to have a complete obstruction, back blows and chest compressions should be started immediately in the infant in order to dislodge the foreign body.

Discuss the limitations of radiology in the diagnosis of airway foreign bodies (comprehension)

Radiographs may not be helpful in the diagnosis of an airway foreign body. Only about 10% of aspirated objects are radio-opaque. CT scan is another option. However, bronchoscopy may be more appropriate and should be performed if foreign body aspiration is suspected even if radiographic studies are normal.

Demonstrate management upper airway obstructions including intubation and needle cricothyroidotomy (application)

Removal of foreign bodies is often performed under rigid bronchoscopy. This helps to prevent mucosal damage and distal advancement of the object. If a child is unstable and requires airway management then progression to intubation is acceptable. Needle cricothyroidotomy involves placing a needle through the cricothyroid membrane followed by a catheter. This is only a temporary airway (<45 minutes) that should be performed in a can’t intubate, can’t ventilate situation. This procedure is recommended in children 5 years and under. This is not the same as a surgical cricothyroidotomy. The obstruction needs to be above the level of the cricothyroid membrane for it to be useful.

Relative contraindications are (1) inability to identify landmarks, (2) tracheal transection or severe trauma, and (3) underlying tumor, abscess/infection, or anatomical abnormality.

Equipments should include:

  • 12-14-gauge angiocatheter
  • 3 mL syringe x 2
  • Adapter to 7.0 ETT or 3.0 ETT
  • Pediatric bag valve mask

Procedure [YouTube video]:

  • Prep and drape for sterile technique as time permits
  • Locate cricothyroid membrane
  • Aiming caudally, pierce membrane with angiocatheter at an angle of 30-45 degrees
  • Attach 3 mL syringe filled with saline
  • Advance while aspirating; bubbles should indicate in airway
  • Advance catheter and remove needle; hub to skin
  • Attach 3-0 ETT adapter to angiocath or if not available attached 3 mL syringe with 7-0 ETT adapter
  • Attach bag valve mask and ventilate

Demonstrate focused history taking from a caregiver (application)

The history should be focused during the initial evaluation on possible etiologies of difficulty breathing. Inquiry about recent illnesses/infection symptoms, potential exposure to ingestions or toxins, potential trauma is pertinent. Especially in infants and young children, it is important to assess recent oral intake and potential losses as they are at high risk for hypovolemia and hypoglycemia. Past medical history assessment should include questioning about birth history and any prenatal complications. Medications and allergies should be inquired about, just like for all patients. If the patient is breast fed, the mother’s medications should also be reviewed.

Explain diagnosis and management to caregivers (synthesis)

If personnel are available, one member of the team may stay with the family to gather history and explain interventions. Information should be relayed to the family using layperson’s terms. The rationale for invasive interventions such as IV placement, BMV, intubation, and needle cricothyroidotomy should be explained preceding or at the time of occurrence, when possible.

Demonstrate teamwork and closed loop communication (application)

Teams may use different frameworks to improve team dynamics and communication. Below are a few definitions that may be helpful to discuss, adapted from the AHRQ TeamSTEPPS Pocket Guide.

  • Brief: Short session prior to start of encounter to share the plan, discuss team formation, assign roles and responsibilities, establish expectations and climate, anticipate outcomes and likely contingencies
  • Huddle: Ad hoc team discussion to re-establish Situation Awareness; designed to reinforce plans already in place and assess the need to adjust the plan
  • Callout: A strategy used to communicate critical information during an emergent event. Helps the team prepare for vital next steps in patient care. (Example: Leader- “Airway status?”; Surveying provider- “Airway clear”; Leader- “Breath sounds?”; Surveying provider- “Breath sounds decreased on right”)
  • Check-back: A closed-loop communication strategy that requires a verification of information ensuring that information conveyed by the sender is understood by the receiver as intended. The sender initiates the message; the receiver accepts it and restates the message. In return, the sender verifies that the re-statement of the original message is correct or amends if not. (Example: Leader- “Give diphenhydramine 25 mg IV push”; Med Prep- “Diphenhydramine 25 mg IV push”; Leader- “That’s correct”)
  • SBAR: A framework for team members to structure information when communicating to one another.
    • S = Situation (What is going on with the patient?)
    • B = Background (What is the clinical background or context?)
    • A = Assessment (What do I think the problem is?)
    • R = Recommendation (What would I do to correct it?)
  • Situation monitoring: The process of continually scanning and assessing a situation to gain and maintain an understanding of what is going on around you.
  • Situation awareness: The state of “knowing what’s going on around you.”
  • Shared mental model: Result of each team member maintaining situation awareness and ensures that all team members are “on the same page.” An organizing knowledge structure of relevant facts and relationships about a task or situation that are commonly held by team members.
  • STEP: A tool for monitoring situations during complex situations. A systematic method to review Status of patient, Team members’ performance and status, Environment, and Progress towards goal.
  • Cross-monitoring: A harm error reduction strategy that involves 1. Monitoring actions of other team members 2. Providing a safety net within the team. 3. Ensuring that mistakes or oversights are caught quickly and easily. 4. “Watching each other’s back.”
  • CUS: Signal phrases that denote “I am Concerned,” “I am Uncomfortable,” and “This is a Safety Issue.” When spoken, all team members should understand clearly not only the issue but also the magnitude of the issue.

Chest X-ray (AP view)

Chest X-ray (Lateral view)

Airway Visualization

Download Case 6 supporting files

Notes:

  • CXR interpretation: Normal chest x-ray. Images by author Dr. Rebekah Burns.
  • Airway visualization: Image of foreign body that can be used, if unable to actually place object in manikin. Image by author Dr. C Sampson.

For the embedded participant playing the patient’s parent

Case Background Information

Your daughter has choked on a small toy that is stuck in her airway. This is causing her to have stridor, which is a noise made when the upper airway is obstructed. This can quickly lead to difficulty breathing or cause her to stop breathing.

You are bringing your daughter to the Emergency Department because she has been “wheezing” intermittently since the coughing episode started and you are very concerned. You were not in the room when she choked on the toy so you are unsure of what happened.

Who are the Learners?

Emergency medicine residents

This case is specifically aimed at interns who are in their first year of specialty training and may have experience in gathering information from patients and families, and standard medical treatments and procedures. They may be less familiar with escalating medical therapies when first measures are not successful.

Standardized Patient Information

You brought your daughter to the Emergency Department because she started coughing when you were in the other room and now has intermittent “wheezing” (actually stridor, but you think it is wheezing). She was fine when she first woke up, and this is very atypical for her. You are worried she is sick.

Your demeanor is concerned but relatively calm. You do not want to obstruct care but want to know what is happening. Do not interrupt them if they are thinking out loud or discussing care with one another but ask questions when possible if they don’t explain what they are doing.

Patient Information

(Please remember not to offer any of this information, but when asked please respond while remaining in character.)

  • CHIEF COMPLAINT (your response to open-ended questions such as “what’s going on?” or “what can we do for you? Or “what happened?”): “She has been coughing and wheezing this morning.”
  • AGE: 10 months old
  • ADDITIONAL HISTORY:You first noticed the coughing around 9 AM this morning. She woke up at 7:00 AM normally and had a normal breakfast. At 9 AM, she was playing with her 3-year- old brother. You went briefly to the kitchen to prepare milk for the child. You heard loud coughing and choking. At first, you didn’t think much of it because she occasionally coughs. The coughing stopped but now the child has intermittent stridor that you describe as “wheezing”. She has not had fever, congestion, emesis, or recent illness. She has not received any medications. There are no medications other than acetaminophen and ibuprofen at home. She has not had any falls or injuries at home.
  • PAST MEDICAL HISTORY: Lives with both parents. 1 cat. No smoke exposure. Mother watches child at home with sibling. No travel.
  • SOCIAL HISTORY: Lives with 2 parents, first baby
  • FAMILY HISTORY: Brother was admitted for RSV at 12 months of age
  • PAST SURGICAL HISTORY: None
  • MEDICATIONS: None
  • ALLERGIES: No known drug allergies
  • IMMUNIZATIONS: Up-to-date
  • BIRTH HISTORY: Born by spontaneous vaginal delivery at 38 weeks to a 34-year-old G2P2 woman. Normal prenatal care, no complications during pregnancy or delivery. Discharged home from hospital on day 2 of life with mom and dad.

Potential Dialogue

IMPORTANT: Do not offer unsolicited information. Please allow the learners to ask questions. Do not offer information unless they ask you.

Things mom could say without being asked:

  • “I have never seen her cough like this before. Why is she wheezing? Does she have RSV?”
  • “She is usually healthy and never gets sick.”

Things you might say triggered by events in the scenario:

EVENTYOUR POTENTIAL RESPONSE
When the stridor sounds start“Why is she wheezing again?”
When she becomes hypoxic (turns blue and O2 saturation begins to decline)“Is she getting sicker?”
If they start using a bag mask to help your child breath without telling you what they are doing“Is she not breathing?!”
If they start to intubate“Is she going to die?!”

The learners enter the room to find a child is coughing. During the initial exam, the child will have intermittent stridor. They immediately place the patient on bedside monitors. Learners will recognize that the patient is hypoxic and having increased respiratory difficulty. Supplemental oxygen is provided. The child’s respiratory distress improves slightly but does not resolve. After completing a physical examination, obtaining an appropriate history, and ordering imaging, the providers note that the child’s respiratory status has continued to worsen and ultimately endotracheal intubation is required. Learners will not be able to remove the foreign body despite efforts. Intubation will not be successful due to the foreign body obstructing the airway. Needle cricothyroidotomy will need to be performed which will provide adequate ventilation. The child will then require an appropriate surgical consultation and admission to PICU.doses of PGE1 infusion. The team should discuss intubation and mechanical ventilation early when ordering and administering PGE1.

Anticipated Management Mistakes

  1. Failure to recognize the need for intubation: Some of our learners do not immediately recognize that the patient requires prompt airway management, leading to delay in diagnosis. We found it helpful to allow the pulse oxygenation to continue to drop despite supplemental oxygen to prompt the need for attempted intubation. Also have the nurse or mother express the need for an additional step: “Are you going to do something?”
  2. Team attempts removal of foreign body: Use image of foreign body provided instead of placing in manikin. When team visualizes foreign body, tell them it cannot be moved. If the team removes foreign body, the case may need to pause to replace or option of upper airway edema from trauma during removal could be added to make the team have to progress to needle cricothyroidotomy
  3. Apprehension to perform needle cricothyroidotomy: Have nurse show team equipment is available once intubation fails.

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