Foreign Body Aspiration (Inhaled Object)

What to do right now: choking first aid

If the airway is completely blocked, the person cannot cough effectively, speak or breathe. Act immediately and have someone call 911 or your local emergency number.

• Adults and children over 1 year: give 5 firm back blows between the shoulder blades, then 5 abdominal thrusts (Heimlich maneuver). Alternate until the object comes out or the person becomes unresponsive.
• Babies under 1 year: hold the baby face down along your forearm, head lower than the body, and give 5 back blows, then turn the baby over and give 5 chest thrusts with two fingers on the center of the chest. Do not use abdominal thrusts on infants.
• If the person becomes unresponsive: start CPR. Look in the mouth before rescue breaths and remove an object only if you can see it.
• If the person is coughing forcefully and can speak or cry, encourage them to keep coughing. Do not slap the back or reach into the mouth, which can push the object deeper.
• Never do a blind finger sweep.

Even when the object seems to have come out, get a medical check if there is any ongoing cough, wheeze or breathing change. More on objects stuck in the swallowing passage is on the foreign body in the throat page.

Where inhaled objects end up

• Larynx (voice box): large or sharp objects. Causes hoarseness, stridor and severe distress. Most dangerous.
• Trachea (windpipe): may move with each breath, causing a "slap" sound and wheeze on both sides.
• Bronchi (lung airways): about 80% to 90% of cases. In adults the right main bronchus is more common because it is wider and straighter. In young children the two sides are affected more equally.

Symptoms

Symptoms usually come in three phases, which is why aspiration is often missed:

1. Initial episode: sudden choking, gagging, coughing and sometimes blue color. It can last seconds to minutes.
2. Quiet phase: the object settles in an airway and the cough reflex tires. The child may seem completely well for hours to weeks.
3. Complications: a persistent cough, wheeze on one side, fever, pneumonia that keeps returning in the same spot, a collapsed lung segment (atelectasis), or coughing up blood.

The classic trio of cough, wheeze and reduced breath sounds on one side is present in only a minority of children. A history of a witnessed choking episode is the single most useful clue, and many cases occur unwitnessed.

In children

Toddlers explore with their mouths, have no back molars to grind food, and often run, laugh or cry while eating. Nuts are a particular problem: they swell with moisture and their oils inflame the airway. Aspiration is often mistaken for croup, bronchiolitis or asthma.

In adults

Adults usually inhale food (meat, bones), teeth, dental crowns, pills or pins held in the mouth. Risk rises with stroke, Parkinson's disease, dementia, heavy drinking, sedatives, seizures and dental procedures. Older adults may not recall the event and present with chronic cough or a lung "mass" on a scan.

How it is diagnosed

• History: any choking episode, a missing object, the timing of the cough.
• Examination: listening for wheeze or reduced air entry on one side.
• Chest X-ray: shows metal and other radiopaque objects, but most inhaled objects (food, plastic) do not show up. Indirect signs include an over-inflated lung on one side (air trapping), collapse or pneumonia. X-rays taken while breathing in and out, or lying on each side in small children, show trapping better. A normal X-ray does not rule aspiration out.
• CT scan: low-dose CT can show the object and airway in adults and some children.
• Bronchoscopy: a camera passed into the airways is both the definitive test and the treatment. When the history is convincing, doctors proceed straight to it.

Treatment

Rigid bronchoscopy under general anesthesia is the standard in children and for difficult objects. The surgeon passes a hollow metal tube into the airway and grasps the object with forceps. Flexible bronchoscopy is often used in adults and can remove many objects through a thin scope, sometimes with sedation only.

After removal:

• Most people go home within a day.
• Antibiotics are given if pneumonia is present.
• Steroids or nebulized treatments may reduce airway swelling.
• A repeat bronchoscopy is occasionally needed for fragments, especially with peanuts.

Surgery to open the chest is rarely needed, only when an object cannot be reached or the lung beyond it is permanently damaged.

Complications of a missed object

The longer an object stays, the more complications develop:

• recurrent pneumonia and lung abscess
• scarring and permanent widening of the airway (bronchiectasis)
• granulation tissue that bleeds or traps the object
• airway perforation or a collapsed lung, rarely

Objects removed within 24 hours have the lowest complication rate.

Preventing aspiration in children

• Do not give whole nuts, popcorn, hard candy or chewing gum to children under 4 to 5 years.
• Cut grapes, cherry tomatoes and blueberries into quarters lengthwise; cut hot dogs lengthwise and into small pieces.
• Children should sit to eat and should not run, play or lie down with food in their mouth.
• Keep coins, beads, balloons (uninflated and burst), button batteries, magnets and small toy parts out of reach. Follow age labels on toys.
• Learn infant and child choking first aid and CPR.

In adults, eat slowly, cut food small, limit alcohol with meals, and ask for a swallowing assessment if you cough often while eating.

Frequently asked questions

What are the signs of foreign body aspiration in a child?

The main sign is a sudden coughing, choking or gagging fit while eating or playing. Afterward there may be wheezing, noisy breathing, a persistent cough or breathing faster. Some children seem fine for days, then develop fever and pneumonia. Any witnessed choking episode with ongoing symptoms needs medical assessment.

Can an inhaled object come out on its own?

Sometimes a strong cough expels it at the time. Once an object has lodged in a lung airway, it rarely comes out by itself, and waiting risks pneumonia and lung damage. If a child had a choking episode and still coughs or wheezes, they need assessment even if they seem well.

Will a chest X-ray show an inhaled peanut?

No. Food, nuts and most plastics do not show on X-rays. Doctors look for indirect signs such as trapped air or a collapsed area. A normal X-ray cannot exclude aspiration, so bronchoscopy is done when the story is suggestive.

How do doctors remove an object from the lungs?

They use a bronchoscope, a tube or thin scope passed through the mouth into the airways under anesthesia. Small forceps, baskets or balloons grip the object and pull it out. Most children and adults go home the same day or the next day.

What happens if food goes into your lungs?

A small amount of liquid or food crumbs is usually coughed out and causes no harm. A larger piece can block an airway, causing persistent cough, wheeze and pneumonia. Repeated small aspirations of food or drink, common after a stroke, are covered on the aspiration page.