Patient Presentation
A 34 month-old male came to the emergency room with a history of acute choking/coughing and the mother was worried he has swallowed a coin. She had left him unattended for a couple of minutes and found him playing with her purse. She used both choking and coughing to describe him seeming to have an acute problem with something in his mouth. He was breathing and turned red, but never stopped breathing and didn’t turn other colors. She tried a couple of back blows and he did not cough up any specific object nor could she see anything in his mouth. He had some increased saliva after the back blows and was crying normally and appeared scared to the mother, but was not coughing/choking after this time. She also found some tissues, a dime and some gum in his hands. She was able to calm him down and he continued to breath normally. His speech was also normal for his age. She brought him to the emergency room as she was worried that he had swallowed a coin or other object.
The past medical history showed that he was a former 27 week premature infant who had required significant respiratory support, gastric tube feedings and had chronic pulmonary aspiration in the past. He had a history of more recent bronchospasm, but the aspiration had resolved and he was eating normally.
The pertinent physical exam showed a weary male clinging to his mother. His vital signs were normal with a respiratory rate of 28 and saturation of 98%. His examination was normal including HEENT, lungs and abdomen.
The diagnosis of of a possible acute aspiration of an unknown object was made in a normally appearing male. The radiologic evaluation of chest and abdominal radiographs revealed a round radioopaque object that was likely a coin. The patient’s clinical course over his time in the emergency room found him to have no respiratory distress, was able to speak normally and drink some fluids without difficulty. His mother was very certain that her purse had not had any other round objects such as a button battery or a magnet. After again commending his mother that she did a great job doing the emergency procedures for choking, he was sent home to monitor his patient’s stools and to followup with his regular doctor if the object was not found within a week, or if he had any abdominal problems.
Figure 143 – CXR shows a round radiopaque foreign body in the antrum of the stomach.
Discussion
Chronic pulmonary aspiration is the entry of a material into the lower airways that recurrently occurs. The material is often upper airway secretions, food/fluid or gastric contents. Patients are unable to protect their airway because of anatomic problems (e.g. laryngomalacia, craniofacial abnormalities), swallowing dysfunction (e.g. esophageal dysmotility), or neuromuscular problems (e.g. muscular dystrophy, cerebral palsy), or other problems (e.g. prematurity, viral bronchiolitis, bottle propping).
The lung damage severity from the aspiration is felt to be mainly due to the volume of the aspirate and the pH. Acid pH causes more problems as does higher volumes. A study of dogs found that 2 ml/kg could cause severe damage. Note that this volume relative to body size can be a small amount in a small patient. Aspiration can cause epithelial damage, edema, hemorrhage, atelectasis, and pulmonary fibrosis and chronic changes. These can occur quickly with epithelium potentially being involved within seconds, atelectasis within 3 minutes, acute pneumonia changes within hours and granulomatous changes within 48 hours.
Caregivers can describe symptoms as choking with feeds or increased secretions, wheezing that isn’t responsive to bronchodiliators, cough, and recurrent respiratory illnesses. Some patients, especially infants and young children may present with apnea or bradycardia or unresponsive events. Some children, especially those with neuromuscular problems, may have silent aspiration as they are not able to protect their airway effectively by choking, coughing, wheezing, etc.
Physical examination may show problems during feeding such as problems sucking, swallowing, choking, drooling or coughing. There may be wet sounds in the lungs or wheezing after feeding which may predominate in the dependent lung fields (i.e. upper lobes and posterior lower lobes). Chest radiograph is usually the first imaging study which may show hyperinflation, bronchial wall thickening, and/or diffuse/localized infiltrates. The chest radiograph could also be normal. Dysphagia (the transfer of the food bolus from the mouth to the esophagus) is a common reason for chronic aspiration. Fluoroscopic swallow studies of the patient swallowing different liquids and textured foods are done with a radiologist and speech pathologist to discern if aspiration is occurring during, and what material viscosity may be tolerated. The material viscosity (sometimes called thickness or texture) can help clarify a potential treatment plan for a patient.
Treatment depends on many factors but includes proper positioning, use of viscous materials that do not cause aspiration, non-oral feedings bypassing the upper airway through use of a temporary or permanent feeding tube, and oral rehabilitation. Surgical treatments are sometime used such as stomach fundoplication. Oral secretions can be a big problem for some patients and treatment options include medications, botulinum toxin, or surgical treatment. Prompt evaluation and treatment of pneumonia is also important.
Learning Point
Acute choking is usually more easily identifiable than chronic problems but the materials are often similar which are upper airway secretions, gastric contents, and food. Acute choking also includes foreign bodies.
In 1994 in the US, the Child Safety Protection Act required choking hazard labels on small toys and other items, and banned production of toys that pose choking, aspiration or ingestion hazards for children < 3 years of age. Additional regulations have been made since including requiring batteries to be inaccessible in products intended for children < 3 years old. Regulations have made many of these products safer.
A 15 year review of the Consumer Product Safety Commission’s National Electronic Injury Surveillance System was conducted in 2016 of consumer products that children ingested or aspirated and were reported. This did not include organic items such as food.
During 2000-2014 there were an estimated 73,000 cases/year of acute aspiration/ingestion, with about 84% of these for ingestions. During 2010-14 there were an estimated 85,500 cases/year, with about 87% of these for ingestions. Children < 5 years accounted for the highest number of cases with 2-3 year olds being the most common ages during both time frames. Most children during 2000-2014 were treated and released with about 11% requiring admission. Almost all of the cases had occurred in a home environment.
From the table below it is obvious that children will put just about anything into their mouths as they explore the world. Between the two time periods the percentage of coins decreased for both aspiration and ingestion, while jewelry increased for aspiration and remained steady for ingestion. The authors hypothesize that this may be due to increased use of cashless payment methods and therefore decreased need for coinage. Coins overall still remained a common item.
Batteries also doubled for ingestion, and again the authors hypothesize that there are more battery operated items in the home, therefore increased exposure. While the table below notes 0% for batteries being aspirated, there were a few cases reported.
The authors also compare their data to another study from 1988-90 before the regulation of balloons, and during that time period the reported mortality from balloons was 0.3%. In the current study the authors specifically note that their data does not show “no balloon related aspiration” but state that it is clear that there is a dramatic decline after regulation in 1994.
| 2000-2004 Aspirated |
2010-2014 Aspirated |
2000-2004 Ingested |
2010-2014 Ingested |
|
|---|---|---|---|---|
| Other | 36 | 42 | 25 | 32 |
| Coins | 38 | 11 | 54 | 44 |
| Jewelry | 14 | 29 | 7 | 6 |
| Paper | 6 | 8 | 0 | 0 |
| Batteries | 0 | 0 | 4 | 8 |
| Bobby Pins | 3 | 2 | 0 | 0 |
| Baby Bottle Tops | 2 | 2 | 0 | 0 |
| Building sets | 1 | 4 | 0 | 0 |
| Nails, Screws, Bolts | 0 | 0 | 6 | 5 |
| Kitchen Items | 0 | 0 | 1 | 3 |
| Marbles | 0 | 0 | 3 | 2 |
| Action Figures | 0 | 2 | 0 | 0 |
The “Other” category above includes additional miscellaneous items such as chalk/crayons, Christmas decorations, cleaning materials, floor materials, pens/pencils/erasers, needles/pins, and other consumer products.
Questions for Further Discussion
1. What are the emergency procedures for someone who is choking?
2. What common foods do people choke on?
3. How do you counsel parents regarding choking and other toddler safety issues?
Related Cases
- Disease: Choking
- Symptom/Presentation: Cough
- Specialty: Emergency Medicine | Gastroenterology | Otolaryngology
- Age: Toddler
To Learn More
To view pediatric review articles on this topic from the past year check PubMed.
Evidence-based medicine information on this topic can be found at SearchingPediatrics.com and the Cochrane Database of Systematic Reviews.
Information prescriptions for patients can be found at MedlinePlus for these topics: Choking and Lung Diseases.
To view current news articles on this topic check Google News.
To view images related to this topic check Google Images.
To view videos related to this topic check YouTube Videos.
Hanba C, Cox S, Bobian M, et al. Consumer product ingestion and aspiration in children: A 15-year review. Laryngoscope. 2017;127(5):1202-1207. doi:10.1002/lary.26216
Torres-Silva CA. Chronic Pulmonary Aspiration in Children: Diagnosis and Management. Curr Probl Pediatr Adolesc Health Care. 2018;48(3):74-81. doi:10.1016/j.cppeds.2018.01.004
Tutor JD. Dysphagia and Chronic Pulmonary Aspiration in Children. Pediatrics In Review. 2020;41(5):236-244. doi:10.1542/pir.2018-0124
Author
Donna M. D’Alessandro, MD
Professor of Pediatrics, University of Iowa