Airway foreign bodies in adults

INTRODUCTION — Foreign bodies in the airways can be a potentially life-threatening event. Flexible and rigid bronchoscopy have become the cornerstone of both the diagnosis and treatment of patients with suspected airway foreign bodies, which are most commonly seen in patients with foreign body aspiration (FBA). Although FBA was traditionally managed by otolaryngologists and thoracic surgeons, the evolution of smaller diameter flexible bronchoscopes has expanded the role for pulmonary physicians in the diagnosis and management of patients who present with FBA.

The evaluation and treatment of FBA in adults will be reviewed here. FBA in children, central airway obstruction, and technical aspects of rigid bronchoscopy are discussed separately. (See "Airway foreign bodies in children" and "Clinical presentation, diagnostic evaluation, and management of malignant central airway obstruction in adults" and "Rigid bronchoscopy: Intubation techniques".)

EPIDEMIOLOGY — Foreign body aspiration (FBA) is more common in children than in adults. Data from the National Security Council reported that approximately 80 percent of cases occur in patients younger than 15 years of age, with the remaining 20 percent presenting over the age of 15 years [1]. Overall, death from FBA is the fourth leading cause of accidental home and community deaths in the United States (table 1) with over 5000 fatal episodes of FBA reported during 2015 [1].

Death from FBA peaks in children <1 years old and in adults >75 years [1-6]. For children under the age of four years, FBA is the fourth leading cause of accidental death and the leading cause of infantile death [7], with several large case series reporting a peak incidence at one to two years of age [3-6]. Children under two years of age account for more than 75 percent of FBA [8]. Comparatively, tracheobronchial FBA is rare in older children and young adults [1,2,9]. However, in adults over the age of 75 years, the incidence rises again with deaths from FBA peaking at age 85 [10].

Several observational case series report low rates of FBA in adults (0.66 per 100,000) [11-17]. One retrospective study from a single center reported the removal of 89 foreign bodies in adults over a 20-year period [16]. Similarly, case series from the Mayo Clinic identified 60 adults diagnosed with FBA over a 33-year period and studies from a single center in Taiwan reported 43 cases over a 15-year period [13,15].

The incidence of FBA appears to be without sex predominance [1].

PATHOGENESIS — In children, nuts, seeds, and other organic material account for the majority of foreign bodies. However, in adults the nature of the inhaled objects is highly variable ranging from organic to inorganic material (picture 1A-B).

●Inorganic – Nail or pin aspiration occurs primarily in young or middle-aged adults during "do-it-yourself" activities or those with psychiatric illness [18]. Headscarf pin aspiration can occur in women who hold pins in their mouth to fix their scarf [19]. Aspiration of dental debris, appliances, or prostheses can complicate facial trauma or dental procedures (image 1A-B) [20]. Tracheostomy tube devices and cleaning tools may be aspirated. Though not aspirated, diagnostic and therapeutic tools for bronchoscopic procedures such as transbronchial needles, brushes, and airway stents that have become fractured or migrated are also sources of foreign body that may require removal. The spectrum of inorganic materials includes both metallic and plastic which require a strategic approach to removal [21,22].

●Organic – Food is frequently aspirated due to incomplete chewing or to poor swallowing function. The type of food aspirated varies with local customs or ethnic background [1,23]. For example, in Western, Chinese, and Middle Eastern populations, vegetable matter, bones, and watermelon seeds are the most frequently aspirated food particles, respectively [13-15,24].

One syndrome, referred to as the cafe coronary, consists of fatal or near fatal food asphyxiation caused by incompletely chewed meat (movie 1) [25-27]. This generally occurs in older patients with dentition problems, swallowing disorders, or Parkinsonism [17,28-31]. One observational study has also suggested that a higher incidence of food aspiration (particularly nuts) occurred in children of non-English-speaking families [23]. However, the highest incidence of unintentional death from choking occurs in those of Hispanic ethnicity and is lowest in African Americans [1]. Often unrecognized in adults is the aspiration of a wide variety of pills with potential for both very exuberant inflammatory reactions and systemic effects [32,33]. (See "Approach to the evaluation of dysphagia in adults" and "Oropharyngeal dysphagia: Clinical features, diagnosis, and management".)

A review of live airway foreign bodies was published including live fish, leeches, and roundworms. These may present with symptoms similar to inorganic foreign bodies and may require a unique approach to removal [34].

The type of foreign body will significantly impact the degree of tissue reaction in the airway. For example, some inorganic materials such as metal or glass items may cause little tissue inflammation but can result in direct airway injury if they are sharp. In contrast, some organic materials, such as nuts and a variety of pills, can cause significant inflammation, granulation tissue formation, and airway stenosis. Aspirated organic material can also expand from airway moisture and worsen obstruction. Aspiration of medications in pill form, such as iron tablets (image 2), aspirin, and potassium chloride, can also cause severe airway inflammation and ulceration [32,35].

It is also possible for airway foreign bodies to enter the airway directly through the bronchial wall rather than being aspirated as seen in trauma such as a penetrating gunshot injury. This has been described with mediastinal foreign bodies that migrate through the airway wall over a long period of time such as a broncholith from a systemic mycosis [36]. Similarly, foreign bodies can migrate via the airway to a different lobe or from one bronchus to another bronchus on the opposite side (image 3) [37].

PRESENTATION — The clinical and radiographic presentation of foreign body aspiration (FBA) in adults is largely described in retrospective case series of confirmed FBA. Compared to children, FBA in adults usually has a subtle presentation (eg, chronic cough) with a paucity of image findings. Consequently, a high index of clinical suspicion is necessary for diagnosis, which is often delayed. Direct visualization of the foreign body, usually on bronchoscopy, is required for definitive diagnosis.

Risk factors — Risk factors in adults include loss of consciousness from trauma, drug or alcohol intoxication, or anesthesia. Additional risk factors in older adults include age-related slowing in the swallowing mechanism, medication use (impairing cough and swallowing), stroke related dysphagia, and numerous degenerative neurologic diseases such as Alzheimer's or Parkinson's disease [38].

Clinical manifestations — Presenting symptoms of FBA depend on the degree of obstruction caused by the foreign body, as well as the location and length of time that the foreign body has been in the airway. In contrast to acute presentation in children, in adults, the clinical presentation of FBA can be acute or chronic and is often subtle or silent. Thus, chronic cough due to distal obstruction of the lower airways is the most common symptom followed by symptoms that mimic pneumonia including fever, chest pain, and hemoptysis. Rarely, adults present with acute asphyxiation due to large obstructing upper airway foreign bodies (glottis, subglottis, or trachea) (algorithm 1).

Acute or chronic cough is seen in up to 80 percent of all cases; other associated symptoms include fever, hemoptysis, foul-smelling sputum, chest pain, or wheeze [2,16,38]. Dyspnea is uncommon and reported by only 25 percent of patients in one series of confirmed FBA [14]. Most patients do not volunteer or recall a history of choking (possibly due to the underlying alteration in mental status at the time of aspiration) which frequently results in a delay in diagnosis [12,14,26,31,39,40].

Foreign bodies that have been present for some time may also present with the signs and symptoms of complications mimicking both benign or malignant diseases (eg, unexplained dyspnea or unilateral wheeze mimicking atypical asthma). Bronchial obstruction by a foreign body can result in potentially serious long term complications, including recurrent pneumonia, atelectasis, bronchial stenosis, bronchiectasis, hemoptysis, postobstructive infection, lung abscess, empyema, pneumothorax, and pneumomediastinum [13-15,39,41-43]. For example, some organic foreign bodies, particularly those with a high oil content (such as peanuts), cause severe mucosal inflammation and accumulation of bulky granulation tissue within a few hours (picture 2). Such patients may or may not recall a history of choking and present weeks to months later with recurrent pneumonia from bronchial stenosis, or years later with the signs and symptoms of bronchiectasis (algorithm 1). This pattern also can be seen with chronically impacted sharp or rusty foreign bodies, and following iron or other types of pill aspiration [35,44-46].

The size and location of the foreign body also impacts the type of presentation. Aspiration of large foreign bodies that obstruct major airways (oropharynx and trachea) are more likely to present with acute asphyxiation with approximately a third located in the supraglottic position [17]. However, more commonly, foreign bodies are aspirated to the lower lobes and result in distal bronchial obstruction. The most common site of aspiration in adults is the right bronchus, specifically the mainstem or divisions of right lower lobe bronchus which is thought to be due to the more vertical angle and sometimes slightly larger diameter of the right main bronchus relative to the left [41].

Physical examination in the early stages may be unrevealing unless there is a monophasic wheeze from a tracheal FBA or unilateral wheeze from mainstem or lobar location. The presence of a monophasic wheeze is not pathognomonic. Later on in the course of foreign body obstruction, patients may present with signs of a lobar pneumonia (eg, dullness, bronchial breathing, egophony, increased vocal fremitus) or a pleural effusion (stony dullness, decreased breath sounds).

A foreign body may also be discovered incidentally during flexible bronchoscopy performed for symptoms of endobronchial disease, such as chronic cough, hemoptysis, asthma not responding to therapy, or recurrent/nonresolving pneumonia (figure 1 and picture 3) [47]. Thus, a high index of clinical suspicion is necessary, particularly in those with atypical asthma or chronic obstructive pulmonary disease unresponsive to therapy. (See "Evaluation of wheezing illnesses other than asthma in adults".)

Imaging — Imaging should not delay intervention in cases of suspected acute asphyxiation but is indicated in those who are stable.

Findings on imaging depend upon the type and location of the material aspirated and the time elapsed. In practice, plain film of the neck and chest are often performed simultaneously and can be followed by site-specific CT if suspicion remains. The majority of foreign bodies are radiolucent and not easily identified on plain film [22]. As such, further investigation with computed tomography (CT) may be considered if there is a high index of suspicion in the setting of negative radiographs. Due to the subtle and chronic presentation of FBA in adults, imaging may be more likely to demonstrate the complications of FBA including post obstructive pneumonia, atelectasis, and, rarely, pneumothorax and unilateral hyperinflation (image 4A-B).

●If obstruction of the upper airway (oropharynx and upper trachea) is suspected, initial imaging should include anterior-posterior and lateral soft tissue views of the neck. If these tests are negative and the suspicion for FBA remains, further imaging with CT may be indicated.

●When FBA of the lower airways (below the vocal cords) is suspected, a chest radiograph should be the initial radiographic test performed to look for an obvious radiopaque airway lesion. Negative scans may prompt further evaluation with CT.

Although, foreign bodies can be located in any airway, due to the predilection of foreign bodies to travel to the right side, image findings may reflect a right-sided predominance of abnormalities [41].

The reported sensitivity of chest radiography is approximately 70 to 80 percent in children, and clinical experience suggests similar poor sensitivity in adults [22,48]. Due to better resolution, CT may be more sensitive than chest radiography at detecting FBA. However, it is also limited by the slice thickness relative to the size of the foreign body and cannot easily distinguish organic material in an airway from significant inflammation and post obstructive changes or malignancy. Although not proven or routine, three-dimensional imaging on a multi-detector multi-slice CT (referred to as virtual bronchoscopy) has been used to enhance the detection of foreign bodies within the airway [49,50].

The variability of imaging findings in adults was illustrated in a series of 19 adults who presented to the hospital with FBA [51]. Chest radiographs showed areas of consolidation, atelectasis and pleural effusion, and rarely evidence of the foreign body in the right main bronchus. Compared with chest radiograph, chest CT more frequently showed a radiopaque foreign body (16 versus 3). Other findings included atelectasis, hyperlucency consistent with air trapping, bronchiectasis, lobar consolidation, pleural effusion, hilar adenopathy, and a thickened bronchial wall adjacent to the foreign body.

If clinical suspicion remains high for a foreign body aspiration, irrespective of radiographic imaging, visual airway inspection is recommended as many organic foreign bodies are radiolucent [32].

Diagnosis — FBA is suspected in adults who present with acute symptoms of upper airway obstruction (eg, stridor or choking) or in those with chronic symptoms such as cough and recurrent pneumonia, especially when in the same anatomic segment. Due to the subtle presentation, a delay in diagnosis is not uncommon for several weeks, or in some cases, for many years. The diagnosis of FBA is dependent upon visualization of the foreign body. In general, laryngoscopy (direct or oropharyngeal) or bronchoscopy is used to identify a foreign body in the upper airway (above the vocal cords), and bronchoscopy (flexible or rigid) is used for the identification of foreign bodies located in the lower airway (below the vocal cords). (See 'Flexible bronchoscopy' below and 'Rigid bronchoscopy' below.)

Given its widespread availability, flexible bronchoscopy is often the diagnostic procedure of choice for non-life-threatening FBA in adults, particularly those with smaller foreign bodies of the lower airway. Flexible bronchoscopy allows precise identification and localization of foreign bodies and facilitates the choice of instruments necessary for retrieval. Additionally, flexible bronchoscopy allows for removal of the foreign body during the diagnostic procedure if the operator is skilled in these techniques. Standard diagnostic or therapeutic flexible bronchoscopes are usually adequate for the management of FBA in adults. (picture 4). (See "Clinical presentation, diagnostic evaluation, and management of malignant central airway obstruction in adults" and "Flexible bronchoscopy in adults: Indications and contraindications" and "Airway foreign bodies in children", section on 'Foreign body removal'.)

MANAGEMENT

Overview — In a conscious adult, there are data supporting the efficacy of chest thrusts, back blows or slaps, blind finger sweeps and abdominal thrusts in relieving complete foreign body airway obstruction [52-56]. However, while effective they may be associated with potential harm [57]. Data supporting early removal of foreign bodies from the airway suggest improved neurologic survival (odds ratio 6.0, 95% CI 1.5-23.4) [57].

●In cases of life-threatening asphyxiation, initial support should be focused on treating airway obstruction and respiratory failure. Once the airway is secured, a laryngoscopic evaluation of the oropharynx should be performed immediately to diagnose and retrieve a supraglottic/glottic foreign body. If a foreign body is not seen, rigid bronchoscopy is generally the procedure of choice in cases of asphyxiating foreign body suspected to be in the trachea or major bronchi. (See 'Life-threatening asphyxiation' below.)

●In patients with non-life-threatening foreign body aspiration (FBA), our practice is to perform flexible bronchoscopy. (See 'Non-life-threatening foreign body' below.)

In most cases the foreign body should be retrieved at the time of diagnosis when feasible. Occasionally, more than one instrument will be necessary for diagnosis and safe retrieval. Rarely, thoracotomy will be required for recalcitrant cases [58]. (See "Basic airway management in adults".)

The diagnosis and management of children with airway FBA is discussed separately. (See "Airway foreign bodies in children".)

Life-threatening asphyxiation — When large foreign bodies completely or almost completely obstruct major upper airways (glottis, supraglottis, trachea), it is critical that patients be oxygenated and their airway secured (figure 2). Support may include bag valve mask ventilation and endotracheal intubation. If ventilation is unsuccessful then an emergent cricothyrotomy or tracheotomy may be required if the foreign body is suspected to be above the vocal cords. Once the airway is secured, immediate inspection of the oropharynx (glottis, supraglottis) is indicated because one-third of FBA cases presenting as acute asphyxiation are located in the supraglottis. Retrieval of the foreign body with a Magill forceps can be safely performed using direct laryngoscopy (glottis, supraglottis), or with smooth or alligator forceps during rigid or flexible bronchoscopy (large central foreign body of the tracheal or major bronchus). (See "Direct laryngoscopy and endotracheal intubation in adults" and "Clinical presentation, diagnostic evaluation, and management of malignant central airway obstruction in adults" and "Basic airway management in adults".)

In rare cases of cardiac or near-cardiac arrest thought to be due to complete obstruction of the trachea (eg, resistance during bag-mask ventilation in the absence of a supraglottic foreign body on laryngoscopy), there may be insufficient time to intubate using a rigid bronchoscope and routine endotracheal tube (ETT) placement or cricothyrotomy may not result in adequate ventilation. In such cases, some experts perform intubation using a standard ETT and, with the cuff deflated and stylet in place, attempt to distally displace a suspected foreign body into a major bronchus (usually the right) by passing the ETT as far as it can go [59]; the ETT is then pulled back proximally into the trachea until it is 3 to 5 cm above the carina and the cuff inflated ("down-then-up-maneuver"). This maneuver, although unstudied, may be life-saving by converting an obstructing tracheal foreign body to an obstructing bronchial foreign body, thereby allowing single lung ventilation of the unobstructed side.

Non-life-threatening foreign body — Early diagnostic flexible bronchoscopy is indicated in patients with nonemergent presentations who are without symptoms or signs of acute asphyxiation. The operator must be aware that, even in patients with stable respiratory status, clinical decompensation may occur during the diagnostic procedure due to accidental dislodgement of the foreign body (figure 3). Thus, when FBA is suspected, flexible bronchoscopy should be performed in a room equipped for resuscitation and definitive airway management. In addition, it is preferred that the bronchoscopist have advanced airway tools and rigid bronchoscopy immediately available in the event of a more serious airway obstruction. (See "Flexible bronchoscopy in adults: Indications and contraindications" and "Flexible scope intubation for anesthesia".)

Foreign body removal

Chest and abdominal thrusts — Chest blows and abdominal thrusts are first-aid maneuvers that can be attempted on site after the operator has called for help. It involves the operator standing behind the patient (with the patient preferably in the upright standing position). The patient should lean slightly forward and five blows given to the upper back with the heel of the hand. If the FB is not expectorated, the operator’s arms should then be placed around the waist of the patient. A fist should be made with one hand and placed just above the umbilicus. The fist is grabbed with the other hand and a thrust is delivered by the simultaneous push inward and upward. The maneuver may be repeated several times until the object is expectorated or until help arrives. If the patient is supine, then a similar upward and inward thrust may be attempted while facing the patient. In a patient who is pregnant or obese, the fist may be placed slightly higher in the abdomen, just below the xiphoid bone.

Choice of procedure — Once the diagnosis of FBA has been established, the foreign body should be removed as quickly as possible. If possible, foreign body extraction should be performed even in the setting of pneumonia or sepsis as this may help control the infection. Although bronchoscopic retrieval is usually required, occasionally, young and healthy adults with a small, movable foreign body (fruit pit or bead) are successfully managed with positional maneuvers (lateral decubitus and Trendelenburg). This may result in spontaneous expectoration of the foreign body, or bring it into a more proximal position prior to definitive management.

The choice of procedure for foreign body removal depends on the type of presentation, characteristics of the foreign body inhaled, location of the foreign body, duration of the foreign body in the airway, if known, and local expertise. In general, the following applies:

●In cases of life-threatening asphyxiation, once the airway is secured, a laryngoscopic evaluation of the oropharynx should be performed to diagnose and retrieve a supraglottic/glottic foreign body. If a foreign body is not seen or the location is suspected to be central airways (trachea or major bronchi), rigid or flexible bronchoscopy is generally the procedure of choice. Rigid bronchoscopy is preferred for the extraction of large, more complex, foreign bodies in the central airways and for foreign bodies that cannot be removed by flexible bronchoscopy. Many centers with experience in rigid bronchoscopy prefer this technique as the initial modality as it can be combined easily with flexible bronchoscopy. (See 'Rigid bronchoscopy' below.)

●In patients with non-life threatening FBA, flexible bronchoscopy is often the initial procedure of choice. Flexible bronchoscopy is the diagnostic procedure of choice for non-life-threatening FBA in adults, especially those with smaller foreign bodies of the lower airway (below the vocal cords). Flexible bronchoscopy is ideal for cases of distally wedged foreign bodies beyond the reach of rigid instruments [13]. Although rigid bronchoscopy is preferred for large, central foreign bodies, flexible bronchoscopy has also been successfully used for this indication [13-15,41]. In addition, foreign body retrieval using a flexible bronchoscope is preferred for intubated patients and those with cervical instability or facial trauma which limit the use of rigid bronchoscopy. In most cases, the foreign body can be retrieved during flexible bronchoscopy. However, occasionally, some cases will need rigid bronchoscopy or a combination of devices. (See 'Flexible bronchoscopy' below.)

●In rare circumstances, thoracotomy is required for recalcitrant cases [58]. (See "Overview of minimally invasive thoracic surgery".)

Flexible bronchoscopy — The success rates of flexible bronchoscopic extraction in adults range from 60 to 90 percent [13-15]. However, rigid bronchoscopy may still be required for foreign body removal in a minority of cases or in more complex cases.

The oral approach is preferred as the foreign body is more easily removed through the mouth than being pulled through the nasal passage.

The advantage of flexible bronchoscopy compared to rigid bronchoscopy is that it can be performed under moderate sedation as opposed to general anesthesia. However, should general anesthesia and ventilation be necessary, a flexible bronchoscope can be passed through a laryngeal mask airway (LMA) allowing easy access to the central airways (picture 5). Although not all LMAs have an aperture, for those that have an epiglottic aperture, it is important to cut the aperture bars of the mask to allow for easier passage of the flexible bronchoscope and avoid foreign body dislodgement in the supraglottic space during extraction. On the other hand, unlike rigid bronchoscopy, airway blood or mucous cannot be suctioned during extraction when a retrieval instrument is in the working channel of a flexible bronchoscope, which can obstruct the visual field. Correcting coagulopathies prior to foreign body extraction may also reduce bleeding.

Many types of ancillary equipment, which include forceps (some with rubber-tip), grasping claws, fish net baskets, snares, balloon-tipped catheters, magnet-tipped probes, and cryoprobes are available to allow foreign body extraction using flexible bronchoscopes (picture 4) [2,60,61]. The choice of retrieval equipment varies with the size, shape, weight, and nature of the foreign body aspirated:

●Retrieval baskets and snares are best used for small organic and more friable foreign bodies that can easily fit inside the dimensions of the retrieval device (eg, vegetable matter, popcorn kernels, peanuts) (picture 6). Their use in this setting may avoid maceration from repeated vigorous forceps grasping. Forceps may increase the likelihood of foreign body fragmentation and further distal wedging which are less accessible to extraction (picture 7). For basket retrieval, the basket is advanced through the working channel of the bronchoscope to the foreign body. The foreign body can be gently wedged into the basket chamber and, once secured inside the chamber, the basket is closed over it, and the foreign body extracted.

●Grasping forceps or rubber-tip forceps may be preferred for firm, less friable foreign bodies (eg, bones, plastic, and metallic objects). A magnet-tip probe may also be utilized for ferrometallic objects. For smooth and rounded foreign bodies, smooth forceps or rubber-tip forceps are preferred as compared to alligator forceps which are typically used for grasping sharp or irregular foreign bodies (figure 4). For successful foreign body removal, the key is to grip it in its widest diameter. Forceps are typically advanced to a few millimeters proximal to the foreign body. The forcep cups are opened maximally and advanced toward the foreign body under direct vision. The foreign body is gently but securely gripped and then extracted en bloc with the bronchoscope keeping the forcep and foreign body just outside the working channel of the bronchoscope (movie 2).

●Occasionally, small embolectomy-type balloons are used to mobilize impacted foreign bodies. The device is advanced gently past the foreign body, inflated, and then retracted slowly to loosen the foreign body into a larger airway or more favorable position for grasping with a forcep or basket.

●Contact cryotherapy probes can be used in conjunction with flexible bronchoscopy in patients with organic FBA. The cryoprobe freezes the target material, causing the foreign body to adhere to the probe for safe removal. Sterile saline can first be utilized through the working channel to saturate the organic foreign body to further enhance freezing the foreign body with the cryoprobe. This technique can also be used for inorganic foreign bodies. (See "Bronchoscopic cryotechniques in adults".)

●Often a foreign body may have granulation tissue surrounding it, which anchors it firmly to the airway wall and makes extraction more difficult. This tissue can be carefully treated with application of laser, argon plasma coagulation, cryotherapy, or electrocautery to release the foreign body. Precautions must be taken to avoid contacting the normal airway mucosa or the foreign body itself. (See "Bronchoscopic laser in the management of airway disease in adults" and "Bronchoscopic argon plasma coagulation in the management of airway disease in adults" and "Endobronchial electrocautery".)

During the extraction procedure, it is crucial not to push the foreign body distally with the bronchoscope, grasping device, or suction catheter (figure 5). If blood and secretions are present proximal to the foreign body, the visual field should be cleared by careful suctioning. Ice-saline or topical epinephrine may be instilled for hemostasis and to reduce mucosal edema encasing the foreign body.

When the foreign body is secured, the foreign body, grasping device, and bronchoscope are all removed as one unit with careful attention to stay in the center of the airway and to maintain visualization of the foreign body throughout extraction. During the last step of extraction, the foreign body can be lost accidentally, either because it is blocked in the narrow glottic area, or due to inappropriate coaxial movement between the bronchoscope and the forceps (figure 6). If this occurs, the operator should first carefully inspect the oral cavity and the larynx with a laryngoscope or bronchoscope and regrasp the object if possible before reexamining the trachea and bronchi. Availability and skill using a Magill forceps can be helpful in retrieving a foreign body in the oropharynx. When removing a sharp object, if possible, grasp the sharp end for removal to protect against it becoming embedded in the mucosa. Once the foreign body is removed, the entire tracheobronchial tree should be checked for another foreign body or residual fragments. If doubt regarding the completeness of removal persists, a repeat flexible bronchoscopic examination a few days later should be considered.

Rigid bronchoscopy — The rigid bronchoscope provides excellent access to the central airways, allowing gas exchange and passage of multiple instruments, including grasping forceps, suction catheter, and even the flexible bronchoscope. General anesthesia with short-acting intravenous agents, including propofol, is safe in this setting as procedure time for foreign body removal is usually brief. However, deeper sedation with general anesthesia can also be provided if necessary (eg, large, sharp movable objects). Optical forceps allow direct visualization of the foreign body and optically guided grasping for removal (movie 3). Alternatively, a rigid telescope and forceps can be used through the bronchoscope (picture 8). (See "Rigid bronchoscopy: Instrumentation" and "Rigid bronchoscopy: Intubation techniques".)

Rigid forceps are typically used to grasp large, central foreign bodies during rigid bronchoscopy. The same principles of grasping technique that are used for flexible bronchoscopy are used for rigid bronchoscopy. In patients with large, hard foreign bodies, such as pistachio shells, breaking the foreign body into two or three fragments may help extraction. Heavy foreign bodies such as metallic objects tend to move distally due to gravity; in this setting, it may be helpful to place the patient in the Trendelenburg position to facilitate spontaneous movement of the object into a more proximal airway. Similar to flexible bronchoscopy, embolectomy-type balloons and cryoprobes can also be used to facilitate extraction. (See 'Flexible bronchoscopy' above.)

The same principles of foreign body extraction that apply to flexible bronchoscopy also apply to rigid bronchoscopy, including clearing the visual field and avoiding distal dislodgement and fragmentation of foreign body. Once the foreign body is removed, the rigid bronchoscope is reintroduced and the airways are carefully reexamined, ideally with a flexible bronchoscope passed through the rigid tube, to rule out another foreign body or residual fragments [62]. (See 'Flexible bronchoscopy' above.)

Anti-inflammatories and antibiotics — Anti-inflammatories and antibiotics are not routinely administered to patients with suspected or documented FBA. However, they can be administered under the following select circumstances:

●Glucocorticoids are occasionally used when a foreign body is completely encased in bulky and bleeding granulation tissue and the extraction is difficult or impossible (figure 7). In such cases, it may be useful to postpone extraction and initiate a short course (12 to 24 hours) of intravenous glucocorticoids (1 to 2 mg/kg prednisolone or equivalent), provided the patient is clinically stable. Although this practice and dosing has not been validated in prospective trials, it may result in significant improvement of the inflammatory reaction and facilitates subsequent extraction. Glucocorticoid therapy may result in dislodgement of the foreign body followed by unwitnessed expectoration and swallowing. Therefore, these patients should remain under observation in the hospital until the extraction procedure confirms the absence of the foreign body. If there is a significant delay between diagnosis and attempted removal, it is reasonable to perform a repeat flexible bronchoscopy to verify that the foreign body is still present.

●Antibiotics are indicated only in cases of clinically, radiologically, or microbiologically documented respiratory tract infection. However, their use should not delay extraction even if pneumonia or sepsis is suspected. Foreign body removal under these circumstances may improve infection control by treating the source of infection (akin to draining an abscess). Cultures taken during bronchoscopy may help guide antibiotic choice.

●Parenteral glucocorticoids, aerosolized epinephrine, or helium-oxygen therapy may be considered when postoperative subglottic edema or stridor occurs following removal, or as a “bridge” to removal. (See "Clinical presentation, diagnostic evaluation, and management of malignant central airway obstruction in adults" and "Physiology and clinical use of heliox".)

Follow-up — Most patients improve clinically following FBA removal. Those with imaging abnormalities should have follow-up imaging six weeks to three months after extraction to confirm resolution. Treatment of the complications and prevention of further aspiration events are indicated and are discussed in the followings sections:

●Pneumonia (see "Treatment of community-acquired pneumonia in adults who require hospitalization")

●Bronchial stenosis (see "Flexible bronchoscopy balloon dilation for nonmalignant airway strictures (bronchoplasty)" and "Airway stents")

●Bronchiectasis (see "Bronchiectasis in adults: Treatment of acute and recurrent exacerbations")

●Dysphagia (see "Oropharyngeal dysphagia: Clinical features, diagnosis, and management" and "Approach to the evaluation of dysphagia in adults")

●Hemoptysis (see "Evaluation and management of life-threatening hemoptysis")

●Empyema (see "Epidemiology, clinical presentation, and diagnostic evaluation of parapneumonic effusion and empyema in adults")

●Pneumothorax (see "Treatment of secondary spontaneous pneumothorax in adults")

INFORMATION FOR PATIENTS — UpToDate offers two types of patient education materials, "The Basics" and "Beyond the Basics." The Basics patient education pieces are written in plain language, at the 5^th to 6^th grade reading level, and they answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are written at the 10^th to 12^th grade reading level and are best for patients who want in-depth information and are comfortable with some medical jargon.

Here are the patient education articles that are relevant to this topic. We encourage you to print or e-mail these topics to your patients. (You can also locate patient education articles on a variety of subjects by searching on "patient info" and the keyword(s) of interest.)

●Basics topic (see "Patient education: Aspiration pneumonia (The Basics)")

SUMMARY AND RECOMMENDATIONS

●Epidemiology and pathogenesis – Foreign body aspiration (FBA) is more common in children than in adults with only 20 percent of cases occurring over the age of 15 years. Risk factors for FBA in adults include age over 75 years, neurologic disorders, loss of consciousness, and alcohol or sedative use. (See 'Epidemiology' above and 'Pathogenesis' above.)

●Clinical presentation – In adults, FBA presenting as acute asphyxiation due to large obstructing foreign bodies of the upper airway is rare. More commonly, the clinical presentation of FBA is subtle or silent and due to distal wedging of the foreign body in lower lobe bronchi. Cough is the most common symptom followed by symptoms due to complications of FBA (eg, pneumonia, bronchial stenosis, bronchiectasis) including fever, hemoptysis, chest pain, or wheeze. Most foreign bodies are radiolucent on imaging and require direct visualization, usually bronchoscopy for diagnosis (algorithm 1). (See 'Presentation' above.)

●Evaluation of life-threatening asphyxiation – In patients with life-threatening asphyxiation, initial support should be focused on treating airway obstruction and respiratory failure. Once the airway is secured, a laryngoscopic evaluation of the oropharynx should be performed immediately to diagnose and retrieve a supraglottic/glottic foreign body. If a foreign body is not seen, rigid bronchoscopy is generally the procedure of choice when the foreign body is suspected to be in the trachea or major bronchi. (See 'Life-threatening asphyxiation' above.)

●Initial diagnostic evaluation of non-life-threatening asphyxiation – In patients with non-life-threatening FBA, diagnostic and therapeutic flexible bronchoscopy is preferred. Flexible bronchoscopy should be performed in a room equipped for resuscitation and definitive airway management because clinical decompensation may occur due to accidental dislodgement of the foreign body. Thus, the bronchoscopist may consult with a thoracic surgeon and should have advanced airway tools and rigid bronchoscopy immediately available in the event of a more serious airway obstruction or bleeding. (See 'Non-life-threatening foreign body' above.)

●Management – Once the diagnosis of FBA has been established, the foreign body should be removed as quickly as possible to prevent mucosal inflammation and accumulation of granulation tissue. Typically, laryngoscopy is used for foreign bodies in the oropharynx (above the vocal cords) and bronchoscopy is used to extract foreign bodies from the lower airway (below the vocal cords). (See 'Foreign body removal' above.)

•Flexible bronchoscopy is preferred over rigid bronchoscopy in most patients, and especially in those with non-life-threatening, distally wedged, foreign bodies, as well as in those who are mechanically ventilated, and in those with spine, craniofacial, or skull fractures that prevent the manipulation required for rigid bronchoscopy. Many types of ancillary equipment are available including a variety of forceps including rubber-tip, baskets, grasping claws, snares, balloon-tipped catheters, and magnet-tip probes. Cryotherapy can be used in conjunction with flexible bronchoscopy to extract organic foreign bodies. Removal of granulation tissue, when present, with electrocautery, argon plasma coagulation, or laser may be required to ease extraction of the foreign body. (See 'Flexible bronchoscopy' above.)

•Rigid bronchoscopy is preferred for the extraction of large obstructing foreign bodies in the central airways, and for complex foreign bodies that cannot be removed by flexible bronchoscopy. Extraction is typically achieved with forceps. Many centers with experience in rigid bronchoscopy prefer this technique as the initial modality as it can be combined easily with flexible bronchoscopy. (See 'Rigid bronchoscopy' above.)

•Careful attention should be paid to avoiding distal dislodgement and fragmentation of the foreign body. Once the foreign body is removed, the airways should be carefully reinspected, preferably with a flexible bronchoscope, to rule out another foreign body or residual fragments.

●Supplemental therapies – Anti-inflammatories and antibiotics are not routinely administered to patients with suspected or documented FBA. However, occasionally, short courses of glucocorticoids can be administered for foreign bodies that are difficult to extract due to complete encasement by bulky granulation tissue. Antibiotics are indicated only in cases of documented respiratory tract infection. (See 'Anti-inflammatories and antibiotics' above.)