Foreign Body Aspiration

Foreign body aspiration, also known as pulmonary aspiration, occurs when an object is accidentally inhaled into a person’s airways. This usually results in an obstruction of a specific area of the respiratory tract, such as: 1

• The larynx. Also known as the voice box, the larynx is part of the throat and located in the neck
• The trachea. Also known as the windpipe, the trachea connects the larynx to the bronchi
• The bronchi. Two passageways, each individually known as a bronchus, which carry air from the trachea into the lungs

Foreign bodies that are commonly aspirated are usually small in size and can be either an edible item, such as a nut or raisin, or a non-edible item such as a coin or marble. Children under the age of three are most likely to experience a foreign body aspiration, although it can happen at any age. 2

Typically, a foreign body aspiration causes respiratory symptoms such as: 1 2 3

• Choking
• Coughing
• Difficulty breathing and/or abnormal breathing sounds

The precise symptoms experienced and severity of the condition depend on how large the blockage is, as well as precisely where in the airways it has settled. Often, an affected person shows initial signs of choking and coughing and will then subsequently begin to display other respiratory symptoms, such as wheezing or recurrent coughing. 2 3 However, in the most severe cases, foreign body aspiration can become life-threatening. For this reason, all cases of a foreign body in the airways should be treated as a medical emergency. ref3

Initial treatment usually focuses on managing the person’s ability to breathe properly, before moving onto removal of the foreign body. If the object is not removed, later complications can include swelling and infection to the area of the airways surrounding the object. 4

The symptoms experienced during a foreign body aspiration are variable and usually depend on three main factors: 1 2

• Where in the airways the object has settled. Most foreign bodies settle in the bronchi, which is considered a lower airway obstruction. Obstructions higher up in the airways, such as in the larynx or trachea, are typically more severe
• The size and nature of the foreign body inhaled. Whether it is big or small, sharp or blunt, hard or soft
• The time since the object was inhaled. Whether the aspiration has only just taken place, if it occurred within the last few days or weeks, or further in the past

Immediate symptoms to look out for that may indicate a foreign body aspiration include: 1 2 5 6

• Choking
• Coughing
• Difficulty breathing and shortness of breath
• Difficulty speaking
• Wheezing or stridor. Stridor is a particular kind of wheeze that often produces a loud, single-pitch noise, usually during inhalation. A wheeze is a high-pitched, continuous sound, usually heard during exhalation
• Bluish tinge to the skin

Any symptoms experienced will typically occur immediately after the foreign body has been inhaled. If the blockage to the airways is significant enough, symptoms may occur in quick succession, become severe and can eventually lead to loss of consciousness and even death, unless the object is dislodged. 7

In milder cases, where the obstruction is less significant, the symptoms experienced may be less severe. 7 However, anyone who is displaying immediate symptoms of having inhaled a foreign body should still seek emergency help.

If the affected person is displaying immediate choking symptoms, it can be useful to distinguish between the signs of a mild or significant obstruction.

If the person is experiencing a mild obstruction, they are often able to: 5

• Breathe
• Talk
• Cough
• Be responsive and answer questions

More severe obstructions in the airways may be indicated by:

• An inability to breathe
• An inability to speak or properly vocalise
• Coughs that are particularly quiet or silent
• Blushing tinge to the skin
• Loss of consciousness

In general, upper airway obstructions in the larynx and trachea tend to be more severe than obstructions in the bronchi or lower airway. 2 5 8 If abnormal breathing sounds such as wheezing or stridor are present, this may help to indicate whether the person has an upper or lower airway obstruction. Stridor is a loud, single-pitch noise, usually heard during inhalation. It is typically a sign of an upper airway obstruction. A wheeze is a high-pitched, continuous sound, usually heard during exhalation and is more often a sign of a lower airway obstruction. ref2 6

People who have a mild obstruction in the airways may initially exhibit some of the immediate symptoms above, but can then move into an asymptomatic phase. During this time, the foreign body is still lodged in the airways, but the reflexes have relaxed, and symptoms such as difficulty breathing or coughing have reduced. This phase can last from a few hours up to a number of weeks. 1

However, after a period of time, other symptoms might become apparent. This is because even a mild case of foreign body aspiration is likely to cause health complications in the future. As most complications occur as a result of delayed diagnosis, it is recommended that a person with suspected foreign body aspiration seeks medical attention immediately, even if they are in an asymptomatic phase. 9

After the asymptomatic phase, further indications that an object has been inhaled may include: 1 2 5

• Recurrent cough
• Wheezing or stridor
• Fever
• Persistent difficulty swallowing

A foreign body aspiration is caused when a person inhales a foreign object into their airways. This is most often done by accident, usually while eating or when a non-edible object is placed in the mouth.

Food is the most frequently aspirated type of object, with nuts and seeds being particularly common. 7 Raisins, grapes and sweets are other food items which are often seen aspirated. Liquids, such as water, can also be inhaled into the airways. In addition to edible objects, other non-edible items which are commonly retrieved from the airways include: 2 10 ref6

• Balloons can be particularly dangerous when inhaled and account for roughly 29 percent of aspiration deaths in children 11
• Other small toys, such as marbles
• Coins
• Pins
• Dental appliances, such as crowns, fillings and orthodontic retainers 12

Age is a primary risk factor for foreign body aspiration, and approximately 80 percent of instances occur in young children under the age of three years old. 2 This is due to a number of reasons, including: 4 7 13

• Children are much more likely to place foreign objects in their mouth
• Young children may not yet have their molar teeth, which can result in a reduced ability to chew their food down sufficiently
• Young children usually have slightly smaller airways than adults, making them more prone to obstruction

However, foreign body aspiration can occur at any age. According to one study, the median age for foreign body aspiration in adults is 60 years old. 7 In adults, foreign body aspiration usually occurs while eating. 2

Other risk factors for foreign body aspiration include: 5 7

• Wearing oral appliances, such as an orthodontic retainer or mouthpiece
• Intoxication
• Sedation
• Neurological disorders, such as dementia or Parkinson’s disease
• Psychiatric disorders, such as schizophrenia or bipolar disorder. In these cases, foreign body aspiration may be a deliberate act, although the motivation behind it is often unclear 14
• Eating high-risk foods, such as nuts, seeds, sweets and small fruits
• Medical conditions or procedures that may impair the swallowing reflex, such as throat surgery 7

Rapid diagnosis is extremely important for foreign body aspiration, because a significant obstruction in the airways that is restricting breathing can quickly become life-threatening. After assessing the symptoms, if a doctor suspects a significant airway obstruction, emergency treatment will likely be sought to remove the object, without any further need for imaging tests. 2

However, if the affected person is stable and displaying symptoms of a mild or historic foreign body aspiration, further tests may be recommended before treatment.

A doctor might choose to perform a physical examination first, which can include: 2 7

• Checking breathing function
• Checking speech and voice function
• Checking physical appearance, including for signs of any bluish tinge to the skin
• Vital signs tests, such as pulse, blood pressure and temperature readings
• Pulse oximetry, a non-invasive test which monitors the levels of oxygen in the blood

If foreign body aspiration is still suspected, a doctor may recommend an imaging test in order to gain an internal view of the body. An X-ray is usually the first imaging test suggested. 2 This non-invasive method uses electromagnetic radiation and can often detect the presence of foreign bodies in the airways. However, not all objects are visible on radiograph tests such as X-rays.

If an X-ray is inconclusive, a CT scan may then be recommended. 2 This test is also non-invasive and uses powerful X-rays to generate a more detailed image of the inside of the body.

As well as detecting the presence of a foreign body in the airways, imaging tests may also be able to identify certain possible complications of the aspiration, such as any collapse of a lung. 15

If imaging tests are inconclusive, a bronchoscopy might be suggested to help diagnose a foreign body aspiration. During a bronchoscopy, a long, thin tube called a bronchoscope is typically inserted through the mouth to gain an internal view of the airways. The bronchoscope has a light source and camera on one end, which allows the doctor to see areas such as the larynx, trachea and bronchi up close. 16

In the case of foreign body aspiration, a bronchoscopy can either be used diagnostically, to confirm the presence and location of a foreign body in the airways, or as a treatment method to physically remove the item.

Treatment of foreign body aspiration involves managing the person's ability to breathe and removing the foreign body. It is extremely important to respond quickly if the affected person has a significant obstruction that is affecting their ability to breathe, as this can quickly become life-threatening.

If an airway obstruction is suspected, it is important to deliver first aid quickly. Both mild and severe choking can be successfully treated at the scene, and this should take precedence over immediately calling for emergency medical care. 17 18

When someone is displaying signs of choking, the following steps can be used to help remove the object: 18 19 20

• Encourage the person to keep coughing. If the obstruction is mild, they are usually able to cough and clear the blockage themselves.
• Back blows. If the person is unable to cough, or coughing is unsuccessful, lean the person slightly forward and give up to five sharps blows to their back, between the shoulder blades. Deliver these blows with the heel of one hand, while supporting the person’s chest with the other hand.
• Abdominal thrusts/Heimlich Maneuver. If back blows are unsuccessful, give up to five abdominal thrusts. Stand behind and slightly to the side of the person and wrap both arms around their waist. Clench a fist with one hand, cover it with the other hand, and pull sharply inwards and upwards just above their navel.

If the above measures are unsuccessful, call for emergency medical help and then continue alternating between back blows and abdominal thrusts until assistance arrives. If the person becomes unconscious, lay them on a flat surface and begin to deliver cardiopulmonary resuscitation (CPR), even if a pulse is present.

Good to know: The above advice is appropriate for adults and children over the age of one year. For information about what to do if a baby is choking, see this resource on first aid for a baby who is choking.

If further attempts at first aid are unsuccessful and once medical help arrives, an emergency endotracheal intubation may be attempted. This process involves passing a flexible tube, known as an endotracheal tube, through the person’s mouth and into the airways. The tube can assist in opening the airways to provide oxygen and can also be used to remove blockages. 2 21

In the most severe cases of choking, an emergency tracheotomy may be performed. A tracheotomy involves creating a small opening at the front of the neck. A tube is then inserted through this opening into the trachea, helping the person to breathe. 2 22

People who have milder cases of foreign body aspiration may not require emergency medical treatment. However, prompt treatment is usually still necessary, because a foreign body in the airways can quickly cause other health complications, such as a respiratory infection like pneumonia.

Removal of the foreign body during a bronchoscopy is a common, and usually successful, treatment method for inhaled objects located in the trachea or bronchi. 2

A bronchoscope is a long, thin tube with a camera and light source on one end. This tube can be flexible or rigid and is inserted into a person’s airways to access and look into the respiratory tract. A bronchoscopy is typically performed under general anesthesia, although local anesthesia and/or sedatives may be used for more simple procedures. 23

As well as helping to locate the foreign body, certain surgical instruments, such as forceps or a suction pad can be attached to the bronchoscope to enable removal of the object. Once the item is removed, the doctor will usually return the bronchoscope to the airway to ensure no fragments of the foreign body remain. 9

If the object is located in the larynx, a similar treatment method known as a laryngoscopy may be used instead. 9

Surgical removal is rarely necessary for foreign body aspiration. 2 However, if the inhaled item is particularly large, sharp or difficult to remove, surgery may be required. 9

A tracheotomy is a surgical procedure that involves making a small opening in the front of a person’s neck, known as a tracheostomy, in order to access the trachea. Removal of an aspirated foreign body located in this region can then be attempted through the surgical opening. Tracheotomies are usually performed under general anesthetic, meaning the patient is unconscious. 24 25

A thoracotomy is a surgical procedure that involves making an incision between a person’s ribs, in order to open the chest and access the lungs. This is also performed under general anesthesia and is usually only suggested if the foreign body is located in the bronchi, and bronchoscopic attempts to remove the foreign body have been unsuccessful. 9 26 27

Medication is typically not prescribed to treat foreign body aspirations. However, antibiotics may be prescribed to target any bacterial infections that arise as a result of the condition. 9

Because foreign body aspiration occurs most commonly in children under the age of three, it is important to educate caregivers about the condition, so they can help prevent the children in their care inhaling small objects. Preventive suggestions include: 10 4 28 29

• Keep small objects that may be a choking hazard, such as coins, buttons and marbles, away from children
• Teach children not to place foreign objects in their mouth, nose or other body openings
• Avoid giving children under three years of age high-risk foods, such as nuts, seeds, small fruits and sweets
• Avoid talking, laughing or playing while eating
• Avoid running or exercising while eating

Although common in children, foreign body inhalation can occur to anyone at any age. Avoid putting non-edible objects into the mouth, and always take care to eat slowly.

In the most severe cases of foreign body aspiration, the inhaled object can cause choking, and impaired breathing function. Unless the object is urgently removed, the condition may become fatal. If a person is suspected to be choking, urgent treatment such as back blows and abdominal thrusts are required to help remove the foreign body and prevent any further complications.

Good to know: If the foreign body is successfully ejected during a choking episode, further medical treatment is usually not necessary. However, it is important to continue monitoring the person for signs of any further infection or irritation. If symptoms appear, such as persistent coughing, pain or discomfort, it is recommended to seek medical attention as it may indicate that a complication has arisen. 4 28

For foreign bodies that remain in the airways, urgent removal is usually necessary as most complications arise as a result of delayed diagnosis. Approximately 67 percent of people with a foreign body obstruction in the larynx or trachea, who do not undergo removal within 24 hours, experience complications. 9

The appearance and severity of any complications depend on the size, nature and location of the foreign object inhaled.

Pneumonia is a potentially severe infection that causes swelling to the tissue in one or both of the lungs. There are various types of pneumonia, and the term <em>aspiration pneumonia</em> specifically relates to bacterial pneumonia caused by breathing food or stomach contents into the lungs. 30

The most common symptom of pneumonia is a wet cough that often produces mucus. Other symptoms can include shortness of breath, chest pain and a fever. Aspiration pneumonia is usually treated with antibiotics. 31

Aspiration pneumonitis is a chemical injury to the lungs that occurs when food, stomach contents or a foreign body is breathed all the way into the lungs. Various substances, including gastric acid, can cause a chemical burn to the airways and/or lungs, resulting in swelling and symptoms such as sudden shortness of breath and coughing. A fever may also be present. 31 If severe, aspiration pneumonitis can potentially lead to acute respiratory distress syndrome. 32

Because the injury is chemical rather than bacterial, antibiotics are usually not effective at treating aspiration pneumonitis. Instead, doctors may suggest oxygen therapy, assistance from a breathing machine or clearing the foreign body from the airways using a bronchoscope. 31

Other potential complications that can occur as a result of foreign body aspiration include: 2 10 28 33 34

• Atelectasis, where the air sacs in the lung, also known as alveoli, collapse and cannot expand properly
• Pneumothorax, where air accumulates in the area between the lung and chest wall, causing a partial or full collapse of the lung. This condition is sometimes known as a collapsed lung
• Pneumomediastinum, which is the abnormal presence of air in the mediastinum, the space between the two lungs
• Bronchiectasis, a long-term condition that leads to excess mucus in the lungs
• Lung abscess, a pus-filled cavity in the lungs surrounded by inflamed tissue, often caused by a bacterial infection
• Emphysema, a lung condition that can cause shortness of breath
• Brain damage, resulting from lack of oxygen to the brain

Injury to the abdomen and ribs is sometimes caused by the delivery of abdominal thrusts. People who receive abdominal thrusts may require further examination by a doctor to rule out any internal injuries, such as rib fractures or tears to the stomach. 35

• Foreign body inhalation
• Foreign body in the airway
• Pulmonary aspiration
• FBA

Q: What are the main symptoms of foreign body aspiration?
A: When a person experiences an obstructed airway due to inhaling a foreign object, they may experience some or all of the following symptoms:

• Choking
• Coughing
• Difficulty breathing and/or abnormal breath sounds such as wheezing
• Difficulty speaking
• Bluish tinge to the skin

The severity of the symptoms depends on the size, nature and location of the inhaled object. In mild cases, the affected person may move into an asymptomatic phase, where no symptoms are present despite the object still being settled in the airways. However, this stage is usually temporary, and symptoms that may arise after a period of time include recurrent coughing, fever and difficulty swallowing.

Q: Can a foreign body be aspirated into the lungs?
A: Yes. An object inhaled into the airways can cause an obstruction in the bronchi, which are the two passageways that deliver air into the lungs. Foreign bodies can also become lodged in the larynx/voice box and the trachea/windpipe.

Q: What treatment options are there for removal of a foreign body?
A: The treatment method used to remove a foreign body depends on the object’s size, nature and exact location in the respiratory tract. First aid can often be administered during a choking episode, by encouraging the affected person to cough or by delivering back blows and abdominal thrusts.

If medical help is required to remove the foreign body, the most common treatment method is a bronchoscopy. This is usually performed under general anesthetic and entails a long, thin tube called a bronchoscope, being inserted into the airways to access the respiratory tract and remove the foreign body. In rare cases, surgery may be necessary.

Q: What are the after effects of choking?
A: Choking is a serious and potentially life-threatening condition that requires immediate intervention. However, if the foreign object is successfully removed from the airways, usually no further medical attention is needed. If any signs of further irritation do occur, such as persistent coughing, pain or discomfort, medical attention should be sought.

Q: Does foreign body aspiration happen to both children and adults?
A: Yes, anyone at any age can accidentally inhale a foreign body into the airways. However, the condition is most common in children under the age of three years old.

Q: What is the difference between foreign body aspiration and foreign body ingestion?
A: Foreign body aspiration occurs when a foreign body is inhaled into the airways, whereas a foreign body ingestion occurs when a foreign body is swallowed into the digestive tract. The two conditions have completely different symptoms, treatments and complications. Read more about Foreign Body Ingestion »