Definition

A foreign body in the trachea is a condition where an inhaled foreign object enters the trachea. The trachea is a respiratory passage shaped like a pipe that connects the throat and the bronchi (smaller airways that lead into the lungs).

A foreign body refers to an object that is not normally present in a particular organ, and this object usually enters through the nose or mouth. Foreign bodies can be solid, liquid, or gas, whether organic (nuts, bones, etc.) or inorganic (nails, needles, pins, etc.). The most commonly inhaled foreign bodies are usually small and appear edible, such as nuts or raisins, or non-edible objects like coins or marbles.

Children under the age of three are most likely to experience aspiration (inhalation) of foreign bodies, although cases can occur at any age. Foreign bodies in the trachea are most commonly caused by aspiration. They can result in various symptoms, ranging from minor symptoms that are often overlooked to respiratory distress, respiratory failure, and even death.

Causes

The most common cause of this condition is usually the inadvertent inhalation of an object. Foreign bodies entering the airway typically occur during eating or when inserting an inedible object into the mouth, especially in children.

Food, such as nuts, grains, raisins, grapes, and candy, is the most common type of foreign body to enter the airway. Liquids, like water, can also be accidentally inhaled into the airway.

In adults, the most common causes of foreign bodies in the trachea are fish bones, meat, and dentures. Meanwhile, in children, non-edible items can be accidentally inhaled into the trachea, such as marbles, coins, pins, buttons, beads, button-shaped batteries, etc.

These foreign objects can partially or completely block the airway. This can be particularly dangerous, especially for young children, because their airways are smaller than those of adults, making it difficult for them to effectively cough out the object.

Risk factor

Children in the age group of 1-3 years are at risk of choking due to inserting various foods and objects less than 1.5 cm in diameter into their mouths. Additionally, other factors that play a role in children include:

• Increased mobility and curiosity
• Decreased intensity of parental supervision
• Tendency of young children to explore their environment with their hands and mouths

Not only children, but older adults are also at risk of swallowing foreign objects, especially those with primary neurological disorders such as stroke, Parkinson's disease, and dementia. People who have decreased gag reflex due to alcohol influence, drug overdose, seizures, or trauma are also at risk of experiencing this incident.

Some other factors that can also increase the risk of foreign objects in the trachea are:

• History of using mouth appliances, such as braces or dentures
• Sedation effects (sleeping pills)
• Mental disorders, such as schizophrenia or bipolar disorder. In these cases, aspiration of foreign objects may be intentional, although the motivation behind it is often unclear
• Frequent consumption of foods like nuts, seeds, candy, and small fruits
• Medical conditions or procedures that can disrupt swallowing reflexes, such as throat surgery
• Being male

Symptoms

The symptoms experienced due to a foreign object in the trachea can vary and usually depend on several factors, such as the location where the object lodges, the size and nature of the foreign object (large or small, sharp or blunt, hard or soft), and the time elapsed since the object was inhaled. Common symptoms that typically occur when there is a foreign object in the trachea include:

• Choking
• Coughing
• Difficulty breathing and wheezing
• Difficulty speaking
• Feeling choked and obstructed in the throat
• Audible wheezing or high-pitched squeaking sounds when exhaling, as well as stridor, a loud single-pitched sound when inhaling
• Bluish discoloration of the skin may be apparent

Any symptoms experienced usually occur immediately after the foreign object is inhaled. If the obstruction in the airway almost completely closes the airway, the symptoms can worsen and ultimately lead to loss of consciousness and even death.

Diagnosis

Interview and physical examination

In diagnosing a foreign object in the trachea, the doctor will inquire about the chronological events surrounding the inhalation of the foreign object and the initial symptoms experienced, such as choking. In children, sometimes the initial symptoms may not be well articulated by the child themselves, and the incident of inhalation may not have been directly witnessed by parents or caregivers, making diagnosis challenging.

The doctor will suspect the presence of a foreign object in the trachea if there are symptoms of choking, coughing, or a sensation of something stuck in the throat felt suddenly, especially when the child is eating or playing with toys or small objects without parental supervision. The doctor will also perform a physical examination, particularly focusing on the respiratory system, such as assessing the respiratory rate, oxygen saturation, movement of the chest wall during breathing, and listening to breath sounds using a stethoscope.

Imaging studies

To further confirm the diagnosis, the doctor may suggest additional tests, such as X-rays. However, not all foreign objects may be visible on X-ray images; only certain objects such as coins, needles, or batteries can be seen. For other foreign objects like seeds or nuts, a CT scan may be necessary.

If the foreign object still cannot be identified, a bronchoscopy examination may be performed. Bronchoscopy involves the use of a tube-like instrument equipped with a camera at the tip. This tube is inserted into the airways to directly visualize the foreign object inside. Bronchoscopy is often chosen as a therapeutic option if initial attempts to remove the foreign object are unsuccessful.

Management

A foreign body in the trachea is considered a medical emergency because it can lead to respiratory failure, hence immediate on-site management is crucial. The primary goal of management is to ensure the patient can breathe and remove the foreign object. First aid for choking due to inhalation of a foreign body in the airway includes:

• Encourage the individual to continue coughing. If the obstruction is mild, they may still be able to cough and expel the foreign object on their own.
• Back blows. If the individual cannot cough, slightly tilt them forward and deliver up to five blows to their back, between the shoulder blades. Administer the blows with the heel of one hand while supporting the person's chest with the other hand. This method is typically preferred for infants or young children.
• Abdominal thrusts or Heimlich Maneuver. If the above steps fail, administer up to five abdominal thrusts. The rescuer stands behind and slightly to the side of the individual, then wraps both hands around their waist. Make a fist with one hand and cover it with the other hand, then forcefully pull the hands inward and upward, just above their navel.

If the above steps are unsuccessful, call for emergency medical assistance and then continue alternating between back blows and abdominal thrusts until help arrives. If first aid is unsuccessful, the doctor will remove the foreign object through surgery or bronchoscopy.

Complications

Complications of a foreign body in the trachea that is not promptly removed can lead to several serious consequences:

• Aspiration pneumonia: This is a lung infection caused by the presence of a foreign body in the lower airway.
• Aspiration pneumonitis: Swelling of the lower airway due to a foreign body.
• Atelectasis: This is the collapse of all or part of the lung.
• Pneumothorax: This refers to air outside the lungs, which can cause the lung to collapse.
• Pneumomediastinum: This is the presence of air in the chest cavity between the two lungs.
• Bronchiectasis: This is the accumulation of mucus due to the widening of the lower airway.
• Abscess: Formation of pus-filled pockets in the lung.
• Emphysema: This refers to damage to lung tissue.
• Respiratory failure: The inability to breathe adequately to maintain oxygen levels in the blood.
• Death: In severe cases, a foreign body in the trachea can lead to fatal consequences.

Prevention

Since cases of foreign bodies in the trachea commonly occur in children under the age of three, it is important to educate caregivers about this condition so they can help prevent children from inhaling small objects. Some ways to prevent it include:

• Keep small objects that can cause choking hazards, such as coins, buttons, and marbles, away from children
• Teach children not to put foreign objects into their mouths, noses, or other body openings
• Avoid giving high-risk foods to children under the age of three, such as nuts, seeds, small fruits, and candy
• Avoid talking, laughing, or playing while eating
• Avoid running or exercising while eating

When to see a doctor?

A foreign body in the trachea is a medical emergency and requires immediate assistance. If you or your child experience symptoms of a foreign body in the trachea or accidentally inhale an object into the airway, administer first aid at the scene immediately. If first aid fails to remove the foreign body, promptly visit the Emergency Department.