sharp objects (e.g., bones, needles, pins) may perforate the bowel wall, resulting in peritonitis, abscess formation, or hemorrhage Respiratory Foreign Body Upper Airway Foreign bodies that lodge in the upper airway can be immediately life threatening According to the National Safety Council, choking was the fourth leading cause of unintentional injury death in the United States in 2017, and a leading cause in children under years of age, resulting in 1,124 deaths in this age group Most children with aspirated foreign bodies are younger than years of age The most common foods responsible for fatalities in the United States include hot dogs, candy, meat, and grapes Childhood fatality from aspiration of man-made objects is less common Frequently aspirated objects include balloons, small balls, and beads Children with foreign bodies in the upper airway may present with acute respiratory distress, stridor, or complete obstruction of the upper airway In patients with complete airway obstruction, emergency treatment begins with basic life support skills Back blows and chest compressions are used in infants, and the Heimlich maneuver is used in toddlers, children, and adolescents, if the patient is conscious Cardiopulmonary resuscitation should be initiated if the patient becomes unresponsive If these methods fail to dislodge the foreign body, rapid progression to direct visualization and manual extraction or an emergency airway is necessary (see Chapters Airway and Cardiopulmonary Resuscitation ) FIGURE 32.1 Two-view chest radiograph demonstrating esophageal coin located at level of the thoracic inlet Lower Respiratory Tract Foreign bodies lodged in the lower tracheobronchial tree present a diagnostic challenge due to the ubiquitous nature of the presenting symptoms (e.g., cough, wheezing, respiratory distress), the frequency of the asymptomatic presentation, and the potential for false-negative and false-positive screening radiographs Foreign bodies of the lower respiratory tract are more common in young children, with a slight increased propensity for the object to lodge on the right side (52%) Organic matter accounts for 81% of aspirations, with nuts and seeds being the most common, followed by other food products (apples, carrots, popcorn), plants, and grasses Plastics and metals make up a minority of aspirated objects ( Fig 32.2 ), and coin aspiration is rare The diagnosis of lower airway foreign-body aspiration is often delayed due to nonspecific symptoms, and these patients may be incorrectly diagnosed with an asthma exacerbation, pneumonia, or bronchiolitis The classic clinical triad for an aspirated foreign body (cough, focal wheeze, and decreased breath sounds) is seen in only 14% to 39% of patients The most common symptoms reported are persistent cough (72% to 87%), difficulty breathing (60% to 64%), and wheezing (52% to 60%) A history of a witnessed choking event is highly suggestive of acute aspiration with a sensitivity of up to 93% It is important to inquire about a choking history since parents may not initially offer it A significant proportion of patients may not have a witnessed choking event, making the diagnosis more difficult EVALUATION AND DECISION Unknown Location Generally, the symptom complex and history surrounding the event provide a clue as to the likely location of the object within the respiratory or GI tract Foreign bodies in either location may present with airway symptoms, gagging, or vomiting Symptoms of cough and respiratory distress with tachypnea, retractions, stridor, wheezing, or asymmetric aeration suggest a foreign body in the upper or lower airway Symptoms of gagging, vomiting, drooling, dysphagia, or pain suggest esophageal impaction Diagnosis can be challenging since foreign bodies in either location may cause minimal symptoms If the history and physical examination not provide the necessary clues, initial evaluation should include a chest radiograph (including the neck and upper abdomen) to evaluate for a radiopaque foreign body Additional views, including an expiratory chest radiograph or lateral decubitus films (discussed below) may help diagnose an aspirated foreign body ( Fig 32.3 ) Gastrointestinal Foreign Body Esophageal Foreign Body: Diagnosis Children with esophageal foreign bodies often have a history of swallowing the object (either witnessed by parents or reported by the child) Symptoms associated with esophageal impaction include dysphagia, refusal to eat, foreignbody sensation, localizing pain, drooling, gagging and vomiting In the absence of an ingestion history, the diagnosis may be challenging because these same symptoms occur with common childhood ailments such as acute gastroenteritis, pharyngitis, or gingivostomatitis Any patient with swallowing difficulty requires a thorough examination of the mouth, oropharynx, neck, chest, and abdomen Radiographic evaluation may be needed in some cases (see Chapter 56 Pain: Dysphagia ) The approach to a child with an ingested foreign body is outlined in Figure 32.4 FIGURE 32.2 Two-view chest radiograph demonstrating aspirated radiopaque foreign body (an earring) located in the left bronchus Children with an esophageal foreign body may be asymptomatic (40% of children with coins in the esophagus) Radiographic evaluation is therefore recommended for most children with a history of an ingested foreign body In the asymptomatic patient, this evaluation is generally urgent but not emergent; however, button battery ingestions and multiple magnet ingestions are exceptions, as discussed below If the patient’s symptoms suggest esophageal impaction, endoscopy is recommended for visualization and removal of the object In most cases, oral contrast studies should be avoided due to the risk of aspiration and contrast material obscuring visualization on endoscopy Computed tomography (CT) scan may be considered in special circumstances Children with a predisposing condition (e.g., tracheoesophageal fistula repair, esophageal stricture, eosinophilic esophagitis) are more likely to have esophageal food or foreign-body impaction Handheld metal detectors have been used as an initial screen when coin ingestion is suspected, as an alternative to radiographs Though these devices compare favorably with radiography in determining the presence or absence of a coin and its location, they are less reliable in detecting other metallic objects and detecting objects in obese patients Users would need to gain experience with the device using x-ray confirmation before abandoning radiography, and ensure patient follow-up as some objects may be missed with this method FIGURE 32.3 Inspiratory and expiratory chest radiographs demonstrating air trapping in the right lung during expiration, indicating likely right-sided foreign body A peanut was removed at bronchoscopy