Algorithm for suspected foreign body aspiration in children

CT: computed tomography; FBA: foreign body aspiration.

* For emergency management of total or near-total airway obstruction, refer to UpToDate algorithm and topics on complete airway obstruction in children.

¶ A moderate or high suspicion of FBA includes all children with a witnessed FBA (regardless of symptoms) and those with suggestive respiratory symptoms or suspicious characteristics on imaging, especially if there is a history of choking within the preceding hours or weeks. Symptoms suggestive of FBA include cyanotic spells, stridor, sudden onset of cough or wheezing (often focal and monophonic), and/or unilaterally diminished breast sounds.

Δ For stable patients with a high clinical suspicion of aspiration, it is reasonable to proceed directly to bronchoscopy, even if the plain radiographs are normal or inconclusive. Alternatively, CT can be performed first to help clarify the diagnosis (dashed arrow). In pediatric specialty centers, airway CT is often performed using low-dose, high-speed protocols that do not require sedation. Where such protocols are available, early use of this modality may be appropriate for many patients. CT has high sensitivity for all types of foreign bodies and may thus reduce the need for bronchoscopy^[1-2].

◊ Rigid bronchoscopy is the procedure of choice to remove a foreign body. In cases where the diagnosis or location of the foreign body is unclear, it is usually preferable to perform flexible bronchoscopy first and then proceed to rigid bronchoscopy for foreign body removal.