NATIONAL HARBOR, MD. – You may think that child’s cough is due to a respiratory infection. But it could be due to a peanut.
Peanuts, little plastic toys, apples, and especially pieces of hot dog: These are the things of which emergency department nightmares are made.
"Close to a million children visit emergency departments every year due to concerns over foreign bodies" in the airway or esophagus, Dr. Patrick C. Barth said at a meeting sponsored by the American College of Emergency Physicians. "And about 100 of those kids die from airway obstruction."
It’s not surprising that most of the choking incidents occur in young children – those between 3 and 4 years old. Learning how to chew, swallow, and breathe at the same time is a complicated physiologic task that takes a while to master, said Dr. Barth, an otolaryngologist at the Nemours/Alfred I. duPont Hospital for Children in Wilmington, Del.
Toddlers also explore all kinds of objects with their mouths as well as their hands, increasing the likelihood that they will swallow or inhale an object.
"If there is a history of a prior airway obstruction, you need to have a high level of suspicion."
"Seeds, popcorn, chunks of apple, or any foods with two different consistencies are hard for kids to manage. The slippery surface causes the food to quickly pass out of the mouth and they don’t have molars yet, so [they] can’t masticate well."
Peanuts, even though they are not large enough to block the trachea, can be really problematic, he added. "The oils set up a significant inflammatory reaction in the airways, so these kids can look really sick. And the inflammation makes endoscopy really difficult."
Children don’t always present in acute respiratory distress; they could just have a nagging wheeze or cough with no obvious illness. But if you think there might be a choking problem, look for one. "If there is a history of a prior airway obstruction, you need to have a high level of suspicion," he said.
A plain radiograph is usually the first diagnostic tool, although an x-ray won’t show radiolucent items, such as those made of plastic. But inspiratory and expiratory films might increase suspicion if there is asymmetric collapse when the child exhales.
CT may also be helpful, but the need should be balanced against the risks, since young children need to be sedated to acquire quality images.
The rigid bronchoscope is a good tool for both diagnosis and extraction of a foreign body, Dr. Barth said. The rigid type allows for simultaneous ventilation and the passage of instruments to remove the object. A flexible scope lacks this ability, and adequate ventilation is critically important in a child whose breathing may already be compromised. "If there’s a sharp object in the airway, the rigid bronchoscope also lets you sheathe it, so you don’t cause airway injury as you’re extracting it," he said.
In 30% of suspected cases, the bronchoscopy turns out to be negative. But in the case of airway obstruction, it’s better to be safe than sorry.
"This is a reasonable rate, because you really do not want to miss one of these. If you have a high level of suspicion, it’s not wrong to do a bronchoscopy."
Dr. Barth had no financial disclosures.