Airway foreign body aspiration is a medical emergency where an object lodges in the airway and obstructing normal airflow and causing respiratory distress. It is common in children and adults especially those with swallowing difficulties, neurological impairments or reduced consciousness. Identifying and managing foreign bodies is crucial to prevent life-threatening complications like suffocation, pneumonia or permanent lung damage. Imaging plays a critical role in diagnosing foreign bodies, guiding treatment decisions and assessing for potential complications. Foreign body aspiration is common in children under 5 especially those between 1 and 3 years old and can occur during eating or under the influence of alcohol or sedatives. If the object completely obstructs the airway and it can lead to respiratory failure and suffocation. Partial obstruction can cause persistent symptoms like coughing, wheezing or recurrent pneumonia.
Airway foreign bodies can enter the respiratory system through various mechanisms, such as inhaling objects during activities like talking, laughing, eating or playing. Common objects aspirated include food particles, toys and non-food items. Adults may also experience foreign body aspiration because of larger objects or compromised swallowing mechanisms which may be because of neurological disorders or impaired consciousness. Foreign bodies may lodge at different levels of the respiratory tract with trachea, mainstem bronchi or smaller bronchioles being the most common. Objects lodged in the trachea or larger bronchi can cause more obstruction while those in smaller bronchi may go undetected for longer periods but still pose risks of infection or chronic respiratory problems.
Airway foreign body aspiration can cause a range of symptoms from mild coughing to severe respiratory distress. Acute symptoms include difficulty breathing, severe coughing, wheezing, dyspnea and decreased breath sounds. Chronic symptoms can develop if the foreign body is not removed promptly and leading to recurrent pneumonia or respiratory infections because of bacterial colonization, chronic cough, hemoptysis and worsening wheezing or respiratory distress. In some cases, foreign body aspiration may go unnoticed, especially in young children or individuals who struggle with communication. In such cases, the foreign body may go unnoticed until complications like pneumonia or persistent coughing occur.
Imaging is essential for diagnosing and managing airway foreign bodies. It confirms the presence of a foreign body, identifying its location, size and nature which is crucial for planning removal. Imaging can help identify radiolucent foreign bodies like food particles or metal objects which may not be visible on standard X-rays. It also helps assess potential complications like atelectasis, pneumonia or pneumothorax which may occur if a foreign body causes prolonged obstruction or airway injury. Once a foreign body is located and characterized and imaging results guide management decisions like bronchoscopy which may be necessary for removal. In some cases, imaging helps determine the most appropriate approach based on the object’s location and size.
Several imaging modalities are used to evaluate suspected airway foreign bodies each with its strengths and limitations. Radiography (X-ray) is the first imaging modality used when a foreign body aspiration is suspected as it can identify radio-opaque foreign bodies and reveal signs of airway obstruction. X-rays cannot reliably detect radiolucent foreign bodies and may not be easily detected on standard images.
Computed Tomography (CT) is more sensitive than X-rays for detecting foreign bodies particularly radiolucent objects. CT scans provide high-resolution cross-sectional images of the airway and lungs and allowing for precise localization and characterization of the foreign body. They can detect associated complications like pneumonia, abscess formation or bronchial rupture.
Flexible bronchoscopy is an essential diagnostic and therapeutic tool for foreign body aspiration and allowing direct visualization of the trachea, bronchi and bronchioles. It is the most effective way to locate and remove a foreign body and assess for signs of injury or inflammation in the airway. It is an invasive procedure that requires local anesthesia or sedation and there is a risk of complications such as bleeding, infection or perforation of the airway.
Ultrasound may be used in specific case particularly when evaluating the upper airway or assessing for pneumothorax or other complications. It is non-invasive does not involve radiation and can be used in conjunction with other imaging techniques to assess complications. It is not typically used for lower airway foreign bodies or deep objects in the trachea or bronchi.
Diagnosing airway foreign bodies can be challenging due to radiolucent objects, location and delayed presentation. X-rays may not detect radiolucent objects which may require CT scans. The foreign body’s location can also complicate diagnosis, as objects lodged in different bronchis may produce different symptoms. Delayed presentation can lead to recurrent respiratory issues so high suspicion and appropriate imaging follow-up are crucial. Objects lodged in the right bronchus may produce subtle symptoms.
Indications
Acute respiratory distress or choking: Imaging is necessary when a patient experiences sudden choking, difficulty breathing or cyanosis after eating, playing or engaging in activities that may involve the aspiration of a foreign body.
Coughing and wheezing: Imaging is required when a patient presents with persistent coughing, wheezing or stridor after a choking episode.
Unilateral wheezing or breath sounds: Imaging is necessary when wheezing or breath sounds are heard more prominently on one side of the chest.
Suspicion of foreign body aspiration in children: Imaging is necessary when a child presents with sudden coughing, choking or dyspnea particularly after eating or playing.
Inability to visualize foreign bodies via physical examination: Imaging is essential for confirming the presence and localization of a foreign body that cannot be visualized through physical examination.
Recurrent respiratory infections or pneumonia: Imaging is necessary if a patient presents with recurrent episodes of pneumonia or other respiratory infections that do not resolve with appropriate antibiotic treatment.
History of aspiration with no clear clinical diagnosis: Imaging is indicated for patients with a known risk of aspiration like those with impaired swallowing because of neurological conditions, altered consciousness or those who are under sedation.
Difficulty with swallowing or inability to clear airway obstruction: Imaging is necessary if there is a sudden decrease or absence of breath sounds on one side of the chest or if the patient demonstrates signs of partial airway obstruction.
Trauma or accident history with possible foreign body aspiration: Imaging is required for patients who have been involved in an accident and present with symptoms like choking, difficulty breathing or a change in respiratory pattern.
Acute change in respiratory status after ingestion or: Imaging should be performed if there is a history of a patient accidentally inhaling or swallowing an object and presenting with respiratory distress.
Diagnostic evaluation for foreign body in the upper airways (larynx, trachea): Imaging is used to evaluate foreign bodies in the upper airways particularly in the larynx or trachea where they can cause significant obstruction.
Invasive procedures: Imaging is required for patients who have undergone endotracheal intubation, bronchoscopy or other invasive procedures that may have led to inadvertent aspiration of foreign objects or secretions into the airway.
Difficulty or delayed removal of foreign body: Imaging may be used to plan the best approach for removal of a foreign body.
Contraindications
Exposure to radiation
Pregnancy
Severe claustrophobia
Presence of metallic bodies
Inability to stay still
Severe allergy
Outcomes
Equipment
Radiography: X-ray machine
Computed Tomography (CT): CT scanner
Magnetic Resonance Imaging (MRI): MRI machine
Patient preparation
Radiography: Minimal preparation is required. The patient should remove any metal objects and wear a hospital gown.
Computed Tomography (CT): Patients may need to fast for 4 to 6 hours if contrast agents are used and adequate hydration is encouraged. Allergy history and kidney function must be evaluated before the procedure especially if iodine-based contrast agents are used.
Magnetic Resonance Imaging (MRI): The patient must remove all metal objects and disclose any implants or devices that may be affected by the MRI’s magnetic field. Fasting may be necessary if gadolinium contrast is used.
Patient position
Radiography (X-ray): Patients may need to stand or lie down on the basis of the area being imaged. For chest X-rays, they might be asked to hold their breath.
Computed Tomography (CT): The patient lies on a motorized table and may need to hold their breath for better image quality.
Magnetic Resonance Imaging (MRI): The patient lies on a table that slides into the MRI machine, and they must remain still to ensure accurate imaging.
Technique
Radiography:
Step 1: Patient Preparation:
The patient is asked to remove any metal objects like jewelry, belts or glasses that may interfere with the imaging. The patient is provided with a hospital gown to wear ensuring no metal buttons or zippers.
Pregnant women may be screened for pregnancy as radiographs can pose risks to a developing fetus.
Step 2: Patient Position:
The patient is asked to either stand or lie down depending on the area being imaged (chest X-ray or abdominal X-ray).
The technologist positions the X-ray tube and detector at the appropriate angles. For a chest X-ray, the patient is typically asked to take a deep breath and hold it to ensure clear visualization of the airway structures.
Step 3: Image Acquisition:
The X-ray machine emits radiation that passes through the body. The detector captures the transmitted X-rays and creating a 2D image of the body’s internal structures.
The technologist may take multiple images from different angles (front and side views) to visualize the foreign body in the airway.
Step 4: Post-Procedure:
Once the images are acquired, the patient is asked to change back into their clothes.
A radiologist interprets the X-ray images to identify foreign bodies, airway obstruction or signs of injury.
Computed Tomography (CT):
Step 1: Patient Preparation:
Patients are typically asked to fast for 4 to 6 hours if contrast agents are being used to enhance the imaging.
Allergies to iodine-based contrast agents are checked, and kidney function is assessed as certain patients (those with renal impairment) are at risk for contrast-related complications.
The patient removes any metal objects and wears a hospital gown.
Step 2: Patient position:
The patient is asked to lie on the motorized CT table which is designed to move the patient through the scanner.
The head or chest is positioned inside the CT scanner with the suspected area of the airway aligned with the machine’s scanning field.
The patient may need to hold their breath briefly to reduce motion artifacts during the scan.
Step 3: Image Acquisition:
The CT scanner uses an X-ray tube and detector array that rotate around the patient capturing multiple images from different angles.
The data is processed by the CT machine to produce cross-sectional images of the airway and surrounding structures.
If contrast is used, it is typically injected intravenously enhancing the contrast between tissues, blood vessels and foreign bodies.
Step 4: Post-Procedure:
After the scan, the patient is monitored for any reactions to the contrast agent if used.
Once the images are ready, the radiologist examines the CT scans for detailed 3D reconstructions of the airway and detecting both radio-opaque and non-radio-opaque foreign bodies.
Magnetic Resonance Imaging (MRI)
Step 1: Patient Preparation:
The patient is thoroughly screened for any metal implants, such as pacemakers, metal stents or surgical clips as these could interfere with the MRI’s magnetic field.
Any jewellery or metal objects are removed and the patient is given a hospital gown to wear.
If a contrast agent (gadolinium-based) is required the patient may be instructed to fast for several hours before the scan.
Step 2: Patient position:
The patient is asked to lie on the MRI table which will slide them into the MRI machine.
The area of interest (the chest or airway) is positioned at the center of the scanner to optimize imaging.
MRI is non-invasive and often requires the patient to remain still during the scan to obtain clear and detailed images.
Step 4: Image Acquisition:
The MRI machine generates a strong magnetic field and uses radiofrequency pulses to interact with hydrogen atoms in the body causing them to emit signals.
These signals are captured by the MRI machine’s detectors, and the data is processed to generate high-resolution cross-sectional images of the airway and nearby tissues.
If contrast agents are used they may be injected intravenously to improve the contrast of tissues and blood vessels.
Step 5: Post-Procedure:
The patient is observed for any reactions if a gadolinium contrast agent was used.
The MRI images are reviewed by the radiologist who analyzes them for any abnormalities or foreign bodies in the airway.
Airway foreign body aspiration is a medical emergency where an object lodges in the airway and obstructing normal airflow and causing respiratory distress. It is common in children and adults especially those with swallowing difficulties, neurological impairments or reduced consciousness. Identifying and managing foreign bodies is crucial to prevent life-threatening complications like suffocation, pneumonia or permanent lung damage. Imaging plays a critical role in diagnosing foreign bodies, guiding treatment decisions and assessing for potential complications. Foreign body aspiration is common in children under 5 especially those between 1 and 3 years old and can occur during eating or under the influence of alcohol or sedatives. If the object completely obstructs the airway and it can lead to respiratory failure and suffocation. Partial obstruction can cause persistent symptoms like coughing, wheezing or recurrent pneumonia.
Airway foreign bodies can enter the respiratory system through various mechanisms, such as inhaling objects during activities like talking, laughing, eating or playing. Common objects aspirated include food particles, toys and non-food items. Adults may also experience foreign body aspiration because of larger objects or compromised swallowing mechanisms which may be because of neurological disorders or impaired consciousness. Foreign bodies may lodge at different levels of the respiratory tract with trachea, mainstem bronchi or smaller bronchioles being the most common. Objects lodged in the trachea or larger bronchi can cause more obstruction while those in smaller bronchi may go undetected for longer periods but still pose risks of infection or chronic respiratory problems.
Airway foreign body aspiration can cause a range of symptoms from mild coughing to severe respiratory distress. Acute symptoms include difficulty breathing, severe coughing, wheezing, dyspnea and decreased breath sounds. Chronic symptoms can develop if the foreign body is not removed promptly and leading to recurrent pneumonia or respiratory infections because of bacterial colonization, chronic cough, hemoptysis and worsening wheezing or respiratory distress. In some cases, foreign body aspiration may go unnoticed, especially in young children or individuals who struggle with communication. In such cases, the foreign body may go unnoticed until complications like pneumonia or persistent coughing occur.
Imaging is essential for diagnosing and managing airway foreign bodies. It confirms the presence of a foreign body, identifying its location, size and nature which is crucial for planning removal. Imaging can help identify radiolucent foreign bodies like food particles or metal objects which may not be visible on standard X-rays. It also helps assess potential complications like atelectasis, pneumonia or pneumothorax which may occur if a foreign body causes prolonged obstruction or airway injury. Once a foreign body is located and characterized and imaging results guide management decisions like bronchoscopy which may be necessary for removal. In some cases, imaging helps determine the most appropriate approach based on the object’s location and size.
Several imaging modalities are used to evaluate suspected airway foreign bodies each with its strengths and limitations. Radiography (X-ray) is the first imaging modality used when a foreign body aspiration is suspected as it can identify radio-opaque foreign bodies and reveal signs of airway obstruction. X-rays cannot reliably detect radiolucent foreign bodies and may not be easily detected on standard images.
Computed Tomography (CT) is more sensitive than X-rays for detecting foreign bodies particularly radiolucent objects. CT scans provide high-resolution cross-sectional images of the airway and lungs and allowing for precise localization and characterization of the foreign body. They can detect associated complications like pneumonia, abscess formation or bronchial rupture.
Flexible bronchoscopy is an essential diagnostic and therapeutic tool for foreign body aspiration and allowing direct visualization of the trachea, bronchi and bronchioles. It is the most effective way to locate and remove a foreign body and assess for signs of injury or inflammation in the airway. It is an invasive procedure that requires local anesthesia or sedation and there is a risk of complications such as bleeding, infection or perforation of the airway.
Ultrasound may be used in specific case particularly when evaluating the upper airway or assessing for pneumothorax or other complications. It is non-invasive does not involve radiation and can be used in conjunction with other imaging techniques to assess complications. It is not typically used for lower airway foreign bodies or deep objects in the trachea or bronchi.
Diagnosing airway foreign bodies can be challenging due to radiolucent objects, location and delayed presentation. X-rays may not detect radiolucent objects which may require CT scans. The foreign body’s location can also complicate diagnosis, as objects lodged in different bronchis may produce different symptoms. Delayed presentation can lead to recurrent respiratory issues so high suspicion and appropriate imaging follow-up are crucial. Objects lodged in the right bronchus may produce subtle symptoms.
Acute respiratory distress or choking: Imaging is necessary when a patient experiences sudden choking, difficulty breathing or cyanosis after eating, playing or engaging in activities that may involve the aspiration of a foreign body.
Coughing and wheezing: Imaging is required when a patient presents with persistent coughing, wheezing or stridor after a choking episode.
Unilateral wheezing or breath sounds: Imaging is necessary when wheezing or breath sounds are heard more prominently on one side of the chest.
Suspicion of foreign body aspiration in children: Imaging is necessary when a child presents with sudden coughing, choking or dyspnea particularly after eating or playing.
Inability to visualize foreign bodies via physical examination: Imaging is essential for confirming the presence and localization of a foreign body that cannot be visualized through physical examination.
Recurrent respiratory infections or pneumonia: Imaging is necessary if a patient presents with recurrent episodes of pneumonia or other respiratory infections that do not resolve with appropriate antibiotic treatment.
History of aspiration with no clear clinical diagnosis: Imaging is indicated for patients with a known risk of aspiration like those with impaired swallowing because of neurological conditions, altered consciousness or those who are under sedation.
Difficulty with swallowing or inability to clear airway obstruction: Imaging is necessary if there is a sudden decrease or absence of breath sounds on one side of the chest or if the patient demonstrates signs of partial airway obstruction.
Trauma or accident history with possible foreign body aspiration: Imaging is required for patients who have been involved in an accident and present with symptoms like choking, difficulty breathing or a change in respiratory pattern.
Acute change in respiratory status after ingestion or: Imaging should be performed if there is a history of a patient accidentally inhaling or swallowing an object and presenting with respiratory distress.
Diagnostic evaluation for foreign body in the upper airways (larynx, trachea): Imaging is used to evaluate foreign bodies in the upper airways particularly in the larynx or trachea where they can cause significant obstruction.
Invasive procedures: Imaging is required for patients who have undergone endotracheal intubation, bronchoscopy or other invasive procedures that may have led to inadvertent aspiration of foreign objects or secretions into the airway.
Difficulty or delayed removal of foreign body: Imaging may be used to plan the best approach for removal of a foreign body.
Exposure to radiation
Pregnancy
Severe claustrophobia
Presence of metallic bodies
Inability to stay still
Severe allergy
Radiography: X-ray machine
Computed Tomography (CT): CT scanner
Magnetic Resonance Imaging (MRI): MRI machine
Radiography: Minimal preparation is required. The patient should remove any metal objects and wear a hospital gown.
Computed Tomography (CT): Patients may need to fast for 4 to 6 hours if contrast agents are used and adequate hydration is encouraged. Allergy history and kidney function must be evaluated before the procedure especially if iodine-based contrast agents are used.
Magnetic Resonance Imaging (MRI): The patient must remove all metal objects and disclose any implants or devices that may be affected by the MRI’s magnetic field. Fasting may be necessary if gadolinium contrast is used.
Radiography (X-ray): Patients may need to stand or lie down on the basis of the area being imaged. For chest X-rays, they might be asked to hold their breath.
Computed Tomography (CT): The patient lies on a motorized table and may need to hold their breath for better image quality.
Magnetic Resonance Imaging (MRI): The patient lies on a table that slides into the MRI machine, and they must remain still to ensure accurate imaging.
Radiography:
Step 1: Patient Preparation:
The patient is asked to remove any metal objects like jewelry, belts or glasses that may interfere with the imaging. The patient is provided with a hospital gown to wear ensuring no metal buttons or zippers.
Pregnant women may be screened for pregnancy as radiographs can pose risks to a developing fetus.
Step 2: Patient Position:
The patient is asked to either stand or lie down depending on the area being imaged (chest X-ray or abdominal X-ray).
The technologist positions the X-ray tube and detector at the appropriate angles. For a chest X-ray, the patient is typically asked to take a deep breath and hold it to ensure clear visualization of the airway structures.
Step 3: Image Acquisition:
The X-ray machine emits radiation that passes through the body. The detector captures the transmitted X-rays and creating a 2D image of the body’s internal structures.
The technologist may take multiple images from different angles (front and side views) to visualize the foreign body in the airway.
Step 4: Post-Procedure:
Once the images are acquired, the patient is asked to change back into their clothes.
A radiologist interprets the X-ray images to identify foreign bodies, airway obstruction or signs of injury.
Computed Tomography (CT):
Step 1: Patient Preparation:
Patients are typically asked to fast for 4 to 6 hours if contrast agents are being used to enhance the imaging.
Allergies to iodine-based contrast agents are checked, and kidney function is assessed as certain patients (those with renal impairment) are at risk for contrast-related complications.
The patient removes any metal objects and wears a hospital gown.
Step 2: Patient position:
The patient is asked to lie on the motorized CT table which is designed to move the patient through the scanner.
The head or chest is positioned inside the CT scanner with the suspected area of the airway aligned with the machine’s scanning field.
The patient may need to hold their breath briefly to reduce motion artifacts during the scan.
Step 3: Image Acquisition:
The CT scanner uses an X-ray tube and detector array that rotate around the patient capturing multiple images from different angles.
The data is processed by the CT machine to produce cross-sectional images of the airway and surrounding structures.
If contrast is used, it is typically injected intravenously enhancing the contrast between tissues, blood vessels and foreign bodies.
Step 4: Post-Procedure:
After the scan, the patient is monitored for any reactions to the contrast agent if used.
Once the images are ready, the radiologist examines the CT scans for detailed 3D reconstructions of the airway and detecting both radio-opaque and non-radio-opaque foreign bodies.
Magnetic Resonance Imaging (MRI)
Step 1: Patient Preparation:
The patient is thoroughly screened for any metal implants, such as pacemakers, metal stents or surgical clips as these could interfere with the MRI’s magnetic field.
Any jewellery or metal objects are removed and the patient is given a hospital gown to wear.
If a contrast agent (gadolinium-based) is required the patient may be instructed to fast for several hours before the scan.
Step 2: Patient position:
The patient is asked to lie on the MRI table which will slide them into the MRI machine.
The area of interest (the chest or airway) is positioned at the center of the scanner to optimize imaging.
MRI is non-invasive and often requires the patient to remain still during the scan to obtain clear and detailed images.
Step 4: Image Acquisition:
The MRI machine generates a strong magnetic field and uses radiofrequency pulses to interact with hydrogen atoms in the body causing them to emit signals.
These signals are captured by the MRI machine’s detectors, and the data is processed to generate high-resolution cross-sectional images of the airway and nearby tissues.
If contrast agents are used they may be injected intravenously to improve the contrast of tissues and blood vessels.
Step 5: Post-Procedure:
The patient is observed for any reactions if a gadolinium contrast agent was used.
The MRI images are reviewed by the radiologist who analyzes them for any abnormalities or foreign bodies in the airway.
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