Foreign Body Airway Obstruction - Paediatric

Quick Answer

Immediate Action: If conscious with ineffective cough → Call for help, 5 back blows, 5 chest thrusts (infants: chest thrusts only, no abdominal thrusts). If unconscious → Start CPR, check mouth for visible object before breaths. All suspected FBAO with penetration syndrome require urgent specialist review for diagnostic bronchoscopy, even with normal imaging.

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ACEM Exam Focus

Primary Written: Expect questions on anatomy of paediatric airway, penetration syndrome significance, differential between effective/ineffective cough, and ANZCOR choking algorithm.

Primary Viva: Prepare for applied anatomy of airway (cricoid ring, narrowest point), pathophysiology of ball-valve obstruction, and mechanism of chemical pneumonitis from organic materials.

Fellowship Written: SAQs on initial ED management, interpreting CXR findings (obstructive emphysema, mediastinal shift), bronchoscopy indications, and complications of delayed diagnosis.

Fellowship OSCE: Resuscitation station for choking child, communication station for breaking bad news about bronchoscopy, or history station for penetrating syndrome identification.

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Key Points

• Penetration syndrome (sudden choking, cyanosis, coughing episode) is the most sensitive predictor of foreign body aspiration, with sensitivity 75-91% - even with normal CXR, requires bronchoscopy
• Peak incidence: 1-3 years, particularly 18-24 months - developmental stage with oral exploration, lack of molars, immature swallowing coordination, male predominance 1.5:1 to 2.4:1
• Organic materials (nuts, seeds) cause 30-40% of cases and trigger chemical pneumonitis from lipid oils leading to rapid granulation tissue formation
• ANZCOR Guideline 4.2: Distinguishes effective cough (encourage, monitor) from ineffective cough (back blows, chest thrusts) - abdominal thrusts contraindicated in children
• CXR limitations: Sensitivity only 66-73%, specificity 67-75% - up to 25-30% have normal imaging; look for indirect signs (obstructive emphysema, mediastinal shift, atelectasis)
• Bronchoscopy timing: Within 24 hours significantly reduces complications (pneumonia, granulation tissue); delayed diagnosis greater than 48 hours increases morbidity
• High-risk objects: Peanuts (most common and dangerous), balloons (leading cause of fatal choking), hot dogs/grapes (complete seal), button batteries (rapid esophageal necrosis)
• Indigenous children: Higher incidence, later presentation due to geographic barriers, more complications from delayed diagnosis - lower threshold for bronchoscopy

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Clinical Overview

Epidemiology

Foreign body airway obstruction (FBAO) is a leading cause of accidental injury and death in children worldwide:

• Incidence: 17-20 per 100,000 children annually, with higher rates in low-to-middle income countries
• Mortality: 0.4-1.8% overall, but significantly higher (up to 10-15%) for laryngotracheal obstructions causing immediate asphyxiation
• Age distribution: 75-80% occur in children under 3 years, peak at 18-24 months
• Gender: Male predominance 1.5:1 to 2.4:1 across all studies
• Setting: greater than 90% occur at home under caregiver supervision
• Seasonal variation: Slightly higher during holiday periods (increased access to nuts, toys)

Pathophysiology

Three Clinical Phases

Phase 1: Acute Penetration (Penetration Syndrome)

• Immediate onset of choking, coughing, gagging, cyanosis
• Foreign body lodges in airway triggering protective reflexes
• May progress to complete obstruction if object large enough (larynx, trachea)
• Duration: seconds to minutes

Phase 2: Asymptomatic Interval (Lucid Interval)

• Foreign body settles, reflexes fatigue, child may appear normal
• Object may migrate distally into bronchial tree
• Can last hours to days - "danger zone" for delayed diagnosis
• Parents may dismiss initial event or seek delayed medical attention

Phase 3: Complication Phase

• Signs return due to inflammation, obstruction, or infection
• Localized wheeze, decreased breath sounds, respiratory distress
• Secondary pneumonia, atelectasis, lung abscess, bronchiectasis
• Granulation tissue formation (especially with organic materials)

Mechanisms of Airway Obstruction

Complete Obstruction

• Object seals airway completely (larynx, trachea, main bronchus)
• Immediate asphyxiation if not relieved
• No air movement, ineffective cough, silent chest
• High mortality without immediate intervention

Partial Obstruction - Ball-Valve Mechanism

• Most common in bronchial foreign bodies
• Object allows air entry during inspiration but traps it during expiration
• Results in obstructive emphysema (hyperinflation distal to FB)
• Progressive hyperinflation, mediastinal shift away from affected side
• Can lead to pneumothorax if rupture occurs

Partial Obstruction - Stop-Valve Mechanism

• Object completely blocks air movement in and out
• Results in atelectasis (collapse distal to FB)
• Mediastinal shift TOWARD affected side
• Usually develops after 24-48 hours as mucus accumulates

Organic vs Inorganic Materials

Foreign Body Types

Food-Related (60-70% of cases)

⚠️ Warning: High-Risk Foods: Peanuts, whole grapes, hot dogs, raw carrots, popcorn, hard candy - avoid in children under 4 years. AAP recommends cutting into small pieces (less than 1 cm diameter).

Non-Food (30-40% of cases)

Button Battery Emergency

• Causes liquefactive necrosis from electrical current discharge
• Can cause aortoesophageal fistula if in esophagus
• Rapid tissue damage within 2 hours
• Emergency removal within 2 hours of ingestion
• Mortality up to 15% if delayed greater than 8 hours

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Age-Specific Considerations

Infants (0-12 months)

Developmental Factors

• Exclusively oral exploration
• Lack of protective airway reflexes
• Small airway diameter (trachea ~4 mm)
• Supramontanal airway narrower than glottic opening
• Inability to communicate choking event

Common Objects

• Formula/milk (aspiration)
• Small toys, batteries
• Clothing buttons, beads

Anatomical Considerations

• Large occiput causes neck flexion when supine
• Tongue relatively large
• Epiglottis omega-shaped, flops posteriorly
• Narrowest point: cricoid ring (not vocal cords)

Management Differences

• Chest thrusts only (no abdominal thrusts - risk of liver injury)
• Back blows with infant head-down position
• Two-finger chest thrust technique (same position as CPR)
• Lower threshold for intubation - airway loss rapid

Critical Alert: Infant Airway Emergency: Laryngospasm and complete obstruction can occur with small objects. Maintain high index of suspicion, early airway intervention, and have appropriate sized equipment (size 1 LMA, size 3.0-3.5 ETT) immediately available.

Toddlers (12-36 months)

Peak Risk Period (18-24 months)

• Increased mobility and exploration
• Transition from liquids to solid foods
• Lack of molars for proper chewing
• Immature swallowing coordination
• Running while eating

Common Objects

• Peanuts (most common)
• Small toy parts
• Coins, buttons
• Food items (grapes, hot dogs)

Developmental Ability

• May indicate choking event with gestures or limited words
• Can cooperate with some examination
• May resist interventions

Management Approach

• Use age-appropriate communication
• Involve parents for history and support
• Play-based examination techniques
• Consider sedation for imaging if cooperative

Preschool (3-6 years)

Lower Risk

• Improved chewing and swallowing
• Better understanding of danger
• Less oral exploration
• Airway larger (trachea ~6-7 mm)

Common Objects

• Toy parts
• Marbles, small balls
• Small food items
• School supplies (erasers, pen caps)

Management Differences

• Can give clear history
• May cooperate with procedures
• Less risk of rapid decompensation
• Better communication about symptoms

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Clinical Approach

Recognition in the Prehospital Setting

Penetration Syndrome Assessment

Critical Questions for Caregivers

1. Was there a sudden episode of choking, coughing, or gagging?
2. What was the child doing at the time? (eating, playing with toys)
3. Was there cyanosis or change in breathing immediately after?
4. Has there been any respiratory symptoms since the episode?
5. How long ago did this occur?

Penetration Syndrome Definition Sudden onset of choking, gagging, coughing, and often cyanosis occurring while eating or playing. This is the most sensitive clinical indicator of foreign body aspiration (sensitivity 75-91%).

Effective vs Ineffective Cough (ANZCOR 4.2)

Effective Cough (Mild Obstruction)

• Child is able to speak, cry, or make sounds
• Strong cough present
• Good breathing effort
• Normal skin colour
• May be able to answer questions

Management: Encourage coughing, stay with child, monitor for deterioration. Do not perform back blows or chest thrusts.

Ineffective Cough (Severe Obstruction)

• Weak or absent cough
• Inability to speak or make sounds
• Stridor or silent chest
• Cyanosis present or impending
• Decreasing level of consciousness
• Ineffective breathing effort

Management: Immediate intervention required - back blows, chest thrusts, call for help (000/111).

ED Assessment

Primary Survey

A - Airway

• Assess patency, look for visible foreign body in mouth
• Listen for stridor (inspiratory = supraglottic, biphasic = glottic/subglottic, expiratory = intrathoracic)
• Assess for drooling (suggests upper airway obstruction)
• Assess voice quality (hoarseness, aphonia)

B - Breathing

• Respiratory rate (age-specific norms)
• Work of breathing (retractions, accessory muscle use, nasal flaring)
• Auscultation (unilateral wheeze, decreased breath sounds)
• Oxygen saturation (may be normal early in partial obstruction)
• Look for chest wall asymmetry

C - Circulation

• Heart rate (tachycardia from hypoxia or distress)
• Blood pressure (late sign of respiratory failure)
• Capillary refill time
• Skin colour and perfusion

D - Disability

• Level of consciousness (AVPU scale)
• Evidence of hypoxic brain injury (severe cases)
• GCS if altered

E - Exposure/Environment

• Full examination for other injuries or foreign bodies
• Check for bruising or other signs of trauma
• Remove clothing if needed for examination

Secondary Survey

Focused History

1. Choking Episode Details

   • Witnessed or suspected?
   • What was the child doing?
   • What type of food or object was nearby?
   • How long ago did it occur?

2. Symptoms Timeline

   • Immediate symptoms (choking, cyanosis)?
   • Asymptomatic interval (how long)?
   • Current symptoms (cough, wheeze, dyspnoea)?
   • Fever (suggests secondary infection)?

3. Medical History

   • Previous respiratory issues (asthma, bronchiolitis)?
   • Developmental delay or aspiration risk factors?
   • Previous episodes of choking?
   • Recent infections or illnesses?

4. Medications and Allergies

5. Immunization Status (pertussis, influenza risk factors)

Physical Examination

General Appearance

• Level of distress (calm, agitated, lethargic)
• Position of comfort (tripod, sitting forward)
• Ability to speak/sing (stridor assessment)
• Evidence of hypoxia (cyanosis, agitation, lethargy)

Ear, Nose, Throat

• Inspect oropharynx for visible foreign body
• Check for retropharyngeal swelling
• Assess for epiglottitis signs (drooling, toxic appearance)
• Nasal patency

Chest Examination

Inspection

• Chest wall movement symmetry
• Retractions (suprasternal, intercostal, subcostal)
• Use of accessory muscles
• Respiratory pattern
• Chest deformities (barrel chest, Harrison's sulcus)

Palpation

• Chest wall expansion symmetry
• Tracheal position (deviation?)
• Palpable crepitus (subcutaneous emphysema - rare complication)
• Vocal fremitus (decreased on affected side)

Percussion

• Hyper-resonant (air trapping, obstructive emphysema)
• Dull (atelectasis, consolidation)
• Compare bilateral sides

Auscultation

• Breath sounds (decreased on affected side)
• Wheeze (unilateral = local obstruction, bilateral = asthma/bronchiolitis)
• Stridor (location: inspiratory = larynx, biphasic = trachea, expiratory = bronchi)
• Crackles (secondary pneumonia)
• Voice sounds (bronchophony, whispered pectoriloquy - increased in consolidation)

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Investigations

Chest X-ray (CXR)

Indications

• All suspected FBAO cases (initial screening)
• Document baseline before bronchoscopy
• Identify complications (pneumonia, atelectasis, pneumothorax)

Views

• Posterior-anterior (PA) or Anterior-posterior (AP) depending on age
• Lateral view
• Expiratory view (if cooperative)
• Lateral decubitus view (for infants unable to cooperate with expiratory)

Findings

Direct Signs (Only 10-15% of cases)

• Radiopaque foreign body visible (coins, batteries, pins)
• Metal objects most commonly seen

Indirect Signs (More common)

• Obstructive emphysema - Most common finding (40-60%)

  • Hyperlucent lung field on affected side
  • Mediastinal shift away from affected side on expiration
  • Diaphragm flattening on affected side
  • Caused by ball-valve mechanism

• Atelectasis

  • Opacity on affected side (more common with delayed presentation greater than 48-72 hours)
  • Mediastinal shift TOWARD affected side
  • Loss of lung volume
  • Caused by stop-valve mechanism or mucus plugging

• Consolidation

  • Suggests secondary pneumonia
  • Air bronchograms may be present
  • Usually delayed finding (weeks after aspiration)

• Normal (25-30% of cases)

  • Does NOT rule out FBAO Especially with radiolucent objects (nuts, seeds)

Critical Alert: Normal CXR Trap: A completely normal CXR occurs in 25-30% of confirmed FBAO cases. Do not rely on imaging alone. A positive history of penetration syndrome requires bronchoscopy regardless of CXR findings.

Sensitivity and Specificity

• Sensitivity: 66-73%
• Specificity: 67-75%
• False negative rate: 25-30%

Computed Tomography (CT)

Indications

• Equivocal clinical picture with normal CXR
• Localization when bronchoscopy planned
• Chronic foreign body suspicion (greater than 2 weeks)
• Suspected complications (lung abscess, bronchiectasis)
• Pre-operative planning for complex cases

Advantages

• Sensitivity and specificity: 98-100%
• Direct visualization of radiolucent objects
• Precise localization (airway level, relationship to anatomy)
• 3D virtual bronchoscopy reconstruction possible
• Identifies complications missed on CXR

Disadvantages

• Ionizing radiation (mitigated by low-dose protocols)
• Requires sedation in young children
• Higher cost and resource utilization
• Not available in all centres
• May delay definitive bronchoscopy

Low-Dose CT Protocols

• Reduce radiation dose by 50-70%
• Maintain diagnostic accuracy for FBAO
• Recommended for stable patients with equivocal diagnosis

Bronchoscopy (Diagnostic)

Gold Standard for Diagnosis

• Direct visualization of foreign body
• Therapeutic capability (removal in same procedure)
• 100% sensitivity and specificity

Flexible Bronchoscopy

• Initial diagnostic tool in some centres (Starship NZ protocol)
• Useful for distal foreign bodies
• Less invasive, can be done at bedside
• Limited therapeutic capability (small instruments)
• May miss foreign bodies if covered by granulation tissue

Rigid Bronchoscopy

• Definitive diagnostic and therapeutic procedure
• Better airway control and ventilation
• Larger instruments for removal
• Required for most organic and large objects
• Performed under general anesthesia
• Requires experienced team (ENT, anesthesia)

Other Investigations

Laboratory Tests

• CBC with differential (evidence of infection)
• CRP/ESR (inflammatory markers)
• Blood cultures (if febrile or evidence of pneumonia)

Pulse Oximetry

• Continuous monitoring for hypoxia
• May be normal initially in partial obstruction
• Trend more important than absolute value

Blood Gas Analysis

• Not routinely needed
• Consider if respiratory failure suspected
• Look for hypoxemia, hypercapnia, respiratory acidosis

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Airway Management Priorities

Prehospital/ED: Conscious Child with Severe Obstruction

ANZCOR Guideline 4.2 Management Sequence

Step 1: Immediate Assessment

• Determine if cough is effective or ineffective
• If effective cough → Encourage coughing, monitor, do not intervene
• If ineffective cough → Proceed to interventions

Step 2: Call for Help

• Activate emergency response (000/111)
• Request pediatric airway equipment
• Alert ENT/anaesthesia if available

Step 3: Back Blows (Up to 5)

• Position: Head lower than trunk (infants: head-down on forearm, children: leaning forward)
• Technique: Sharp blows with heel of hand between shoulder blades
• Location: Middle of back, between scapulae
• Force: Enough to dislodge object, not excessive
• Assess after each blow

Step 4: Chest Thrusts (Up to 5)

• If back blows fail, proceed to chest thrusts

Infants (below 1 year)

• Position: Supine, head-down on forearm
• Technique: Two fingers in same position as CPR chest compressions
• Location: Lower half of sternum, just above nipple line
• Force: Sharp thrusts (like CPR compressions but faster)
• Depth: 4 cm (approximately one-third chest depth)

Children (greater than 1 year)

• Position: Standing behind child (like Heimlich maneuver but chest-focused)
• Technique: Heel of hand on lower half of sternum
• Location: Same as CPR compressions
• Force: Sharp backward thrusts
• May use both hands clasped together

Step 5: Repeat Cycles

• Continue alternating: 5 back blows → 5 chest thrusts
• Reassess after each cycle
• Continue until object expelled or child becomes unconscious

Contraindications

• Do NOT perform abdominal thrusts (Heimlich) in infants or young children (risk of liver injury, splenic rupture)
• Do NOT perform blind finger sweeps in mouth (may push object deeper)
• Do NOT intervene if cough is effective

Prehospital/ED: Unconscious Child

Immediate Management

Step 1: Position and Assess

• Place supine on firm surface
• Open airway (head tilt-chin lift, jaw thrust if trauma suspected)
• Look for visible foreign body in mouth

Step 2: Remove Visible Object

• If object is visible and easily accessible, remove with finger sweep
• Single sweep only
• Do NOT perform blind finger sweep
• Do NOT attempt if object not visible

Step 3: Start CPR

• Immediately if no breathing or abnormal breathing (gasping)
• Compression rate: 100-120 per minute
• Compression depth: One-third chest depth (infants 4 cm, children 5 cm)
• Compression-to-ventilation ratio: 30:2 (single rescuer), 15:2 (two rescuers)
• Use back blows and chest thrusts if obstruction suspected during CPR

Step 4: Airway Management

• High-flow oxygen (15 L/min) if available
• Bag-mask ventilation with two-person technique
• Early intubation if available and skilled provider present
• Consider cricothyrotomy (last resort, only if complete obstruction and intubation failed)

⚠️ Warning: Pediatric Advanced Life Support (PALS) Note: For airway obstruction, perform CPR with the modification of checking the mouth for a foreign body before each breath. Do not delay CPR to look for object if not immediately visible.

ED: Stable Child with Suspected FBAO

Immediate Actions

Airway and Breathing

• Maintain airway patency
• Supplemental oxygen (nasal cannula or face mask) if SpO2 below 94%
• Monitor continuously (pulse oximetry, ECG)
• Keep child in position of comfort (usually sitting upright)
• Avoid agitating child (may worsen obstruction)

Diagnosis and Disposition

• Obtain CXR (PA/AP and lateral)
• Consider CT if CXR normal but clinical suspicion high
• Consult ENT/Paediatric Surgery urgently for bronchoscopy
• Admit for observation if bronchoscopy delayed

Discharge Criteria

• No history of penetration syndrome
• Normal physical examination
• Normal CXR
• Child clinically well
• Reliable caregivers with clear safety-netting advice
• Clear discharge instructions warning signs

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Management

Airway Management Algorithm

graph TD
    A[Suspected FBAO] --> B{Child Conscious?}
    B -->|Yes| C{Cough Effective?}
    B -->|No| D[Unconscious - Start CPR]
    C -->|Yes| E[Encourage cough, Monitor]
    C -->|No| F[Back blows x5, Chest thrusts x5]
    F --> G{Object expelled?}
    G -->|Yes| H[Continue monitoring]
    G -->|No| I[Repeat cycles]
    I --> J{Child becomes unconscious?}
    J -->|Yes| D
    D --> K[Start CPR, Check mouth for object]
    K --> L[Consider advanced airway]

Bronchoscopy

Indications

• History of penetration syndrome (most sensitive indicator)
• Unilateral wheeze or decreased breath sounds
• CXR findings consistent with foreign body
• Persistent respiratory symptoms after choking episode
• Suspected foreign body greater than 24 hours (high complication rate)
• Lower threshold in Indigenous children due to delayed presentation risks

Timing

• Emergency bronchoscopy (below 2 hours):

  • Laryngotracheal obstruction (complete or near-complete)
  • Respiratory distress or impending respiratory failure
  • Button battery in airway (rapid tissue necrosis)
  • Hypoxic cardiac arrest with suspected airway obstruction

• Urgent bronchoscopy (2-24 hours):

  • Penetration syndrome with clear history
  • Clinical signs of foreign body (unilateral wheeze, CXR findings)
  • Any child with respiratory symptoms and suspicious history

• Elective bronchoscopy (below 48 hours preferred):

  • Chronic foreign body suspicion
  • Equivocal history but high clinical suspicion
  • Planned for next available OR with experienced team

Rigid vs Flexible Bronchoscopy

Rigid Bronchoscopy Technique

1. General anesthesia with spontaneous ventilation preferred
2. Pediatric laryngoscope to visualize glottis
3. Rigid bronchoscope passed through vocal cords
4. Systematic examination of airway (trachea, bilateral bronchi)
5. Foreign body identified and grasped with optical forceps
6. Object removed through bronchoscope
7. Airway re-examined for remaining fragments
8. Consider postoperative antibiotics or steroids if significant inflammation

Anesthesia Considerations

• Spontaneous ventilation: Preferred to avoid pushing object distally with positive pressure
• Inhalational induction: Maintain airway reflexes until airway secured
• Muscle relaxation: Usually avoided (risk of complete obstruction)
• Backup plan: Ready for emergency tracheostomy if complete obstruction

Post-Bronchoscopy Management

Immediate Post-Procedure

• Monitor airway patency (stridor, respiratory distress)
• Supplemental oxygen if needed
• Observe for signs of subglottic edema (barky cough, stridor)
• Chest X-ray if complications suspected (pneumothorax, residual FB)

Observation Period

• Admission: All children post-foreign body removal
• ICU: High-risk cases (laryngotracheal FB, prolonged procedure, complications)
• Ward: Stable uncomplicated cases
• Discharge: Usually 24-48 hours after successful removal

Medications

• Antibiotics: Not routinely indicated

  • Consider if evidence of pneumonia pre-bronchoscopy
  • Consider if purulent secretions at time of bronchoscopy
  • Cover common respiratory pathogens (e.g., amoxicillin-clavulanate)

• Corticosteroids: Not routinely indicated

  • Consider for significant subglottic edema
  • Consider for reactive airway disease
  • Dexamethasone 0.6 mg/kg IV/PO (max 16 mg) if needed

• Bronchodilators: Not routinely indicated

  • Consider for reactive airway or bronchospasm post-procedure
  • Salbutamol 2.5-5 mg nebulized if wheezing

Follow-Up

• Outpatient review 2-4 weeks post-discharge
• Repeat CXR if symptoms persist
• Consider repeat bronchoscopy if residual symptoms or suspicion of retained FB
• Long-term follow-up if complications (bronchiectasis, chronic lung disease)

Complications Management

Acute Complications

Laryngospasm

• Common during bronchoscopy
• Positive pressure ventilation
• Propofol bolus to deepen anesthesia
• Sucralfate slurry for topical therapy

Bronchospasm

• Bronchodilators (salbutamol)
• Deepen anesthesia
• Steroids for refractory cases

Hypoxia

• Supplemental oxygen
• Improve ventilation
• Consider brief procedure pause for oxygenation

Pneumothorax

• Suspect with sudden respiratory deterioration
• Confirm with CXR
• Needle decompression if tension pneumothorax
• Chest tube for significant pneumothorax

Subglottic Edema

• Stridor post-extubation or post-bronchoscopy
• Nebulized adrenaline (1:1000, 0.5 mL/kg)
• Dexamethasone 0.6 mg/kg
• Re-intubation if severe

Late Complications

Granulation Tissue

• More common with organic foreign bodies (greater than 48 hours)
• May require repeat bronchoscopy
• Laser ablation or topical steroids
• Risk of bronchial stenosis

Pneumonia

• Antibiotics based on sputum culture or empiric coverage
• Physiotherapy for secretion clearance
• Monitor for complications (empyema, lung abscess)

Lung Abscess

• Prolonged antibiotics (4-6 weeks)
• Percutaneous drainage if large or not responding
• Surgical drainage if refractory

Bronchiectasis

• Long-term follow-up with respiratory specialist
• Regular physiotherapy
• Prophylactic antibiotics for recurrent infections
• Consider surgical resection for localized disease

Antibiotic Therapy

Indications

• Evidence of pneumonia on CXR
• Purulent secretions at bronchoscopy
• Fever greater than 38.5°C with respiratory symptoms
• Retained foreign body greater than 48 hours (high infection risk)

Empiric Regimens

Children below 5 years

• Amoxicillin-clavulanate 25-35 mg/kg/dose PO q8h (max 1.2 g/dose) OR Cefuroxime 15 mg/kg/dose PO q12h (max 500 mg/dose)

Children greater than 5 years

• Amoxicillin-clavulanate 25-35 mg/kg/dose PO q8h (max 1.2 g/dose) OR Doxycycline 2.2 mg/kg/dose PO q12h (if greater than 8 years and greater than 45 kg, 100 mg/dose)

Severe Infection (Hospitalized)

• Ceftriaxone 50-75 mg/kg IV q24h (max 2 g/day) PLUS Macrolide if atypical pathogen suspected (azithromycin 10 mg/kg day 1, 5 mg/kg days 2-5)

Duration

• Uncomplicated pneumonia: 7-10 days
• Lung abscess: 4-6 weeks
• Bronchiectasis exacerbation: 10-14 days

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Prevention and Safety Education

Age-Appropriate Food Guidelines

Infants (0-12 months)

• Breastmilk or formula only
• No solid foods until developmentally ready (usually 6 months)
• Introduce pureed foods only
• No small, hard foods
• No small toys or objects

Toddlers (12-36 months)

• Cut food into small pieces (below 1 cm diameter)
• Avoid high-risk foods:
  • Whole nuts, seeds
  • Whole grapes, cherry tomatoes (cut in quarters)
  • Raw carrots, celery (cook and cut)
  • Popcorn, chips, pretzels
  • Hard candy, gum
  • Marshmallows

Children (3-6 years)

• Continued supervision during meals
• Avoid small toys with small parts
• Teach proper chewing
• No running or playing while eating

Toy Safety

Small Parts Test

• Use small parts cylinder (3.17 cm diameter)
• Any toy or part that fits entirely inside cylinder is choking hazard
• Age-appropriate labelling (not for children under 3 years)

High-Risk Toys

• Latex balloons (most common fatal choking object)
• Small balls (below 4.5 cm diameter)
• Marbles, small building blocks
• Toys with removable small parts
• Button batteries

Safe Toy Selection

• Larger than 3 cm for children below 3 years
• Durable, non-breakable
• No small parts that can detach
• Age-appropriate labelling

Caregiver Education

Key Teaching Points

1. Never leave child unattended while eating
2. Cut food into appropriate-sized pieces
3. Supervise play with small toys
4. Learn choking first aid (ANZCOR Guideline 4.2)
5. Keep small objects out of reach
6. Teach older children not to give dangerous foods to younger siblings
7. Avoid giving high-risk foods to children under 4 years

Choking First Aid Training

• All caregivers should know:
  • How to recognize severe choking
  • Back blow and chest thrust technique
  • When to call emergency services (000/111)
  • CPR basics

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Indigenous Health Considerations

Epidemiological Disparities

Aboriginal and Torres Strait Islander Children

• Higher incidence of FBAO compared to non-Indigenous children
• More likely to present with complications due to delayed diagnosis
• Higher rates of:
  • Pneumonia
  • Granulation tissue
  • Bronchiectasis
  • Need for repeat bronchoscopy

Māori and Pasifika Children (New Zealand)

• Overrepresented in FBAO admissions
• Higher rates of aspiration of organic matter (nuts, seeds)
• More likely to have delayed diagnosis (greater than 48 hours)
• Higher complication rates

Contributing Factors

Geographic Barriers

• Remote/rural residence far from tertiary centres
• Limited access to specialist services (bronchoscopy)
• Delayed transfer to hospitals with pediatric ENT
• RFDS retrieval challenges for urgent cases

Social Determinants

• Overcrowded housing (increased access to small objects)
• Different dietary patterns (traditional foods may increase risk)
• Food insecurity leading to less appropriate food choices
• Lower health literacy regarding choking risks

Healthcare System Barriers

• Implicit bias leading to diagnostic overshadowing
• Symptoms attributed to more common conditions (asthma, bronchiolitis)
• Communication barriers
• Cultural safety issues

Prevention Challenges

• Lack of culturally appropriate education resources
• Limited access to first aid training
• Traditional foods not included in standard prevention guidelines
• Language barriers in safety messaging

Clinical Management Approaches

Higher Index of Suspicion

• Maintain high suspicion for FBAO in any Indigenous child with unexplained:
  • Chronic cough
  • Unilateral wheeze
  • Recurrent pneumonia
  • Worsening asthma symptoms

Lower Threshold for Bronchoscopy

• Any Indigenous child with:
  • History of choking episode (even remote)
  • Unilateral wheeze or decreased breath sounds
  • Chronic respiratory symptoms not responding to standard treatment
  • CXR findings of unilateral hyperinflation or atelectasis

Culturally Safe Communication

• Use Aboriginal Health Workers or Māori Liaison Officers (Kaiatawhai)
• Involve extended family (whānau) in decision-making
• Clear, jargon-free explanations
• Use visual aids and demonstrations
• Respect cultural protocols and decision-making processes

Critical Alert: Diagnostic Overshadowing: Be aware of unconscious bias that may lead to attributing respiratory symptoms to asthma or infections rather than considering FBAO in Indigenous children. A high index of suspicion is essential.

Prevention Strategies

Culturally Tailored Education

• Develop resources in local languages
• Use culturally relevant imagery and examples
• Work with community Elders and leaders
• Include traditional foods in safety messaging
• Community-based first aid training programs

Community Engagement

• Partner with Aboriginal Medical Services and Māori health providers
• Develop culturally appropriate prevention programs
• Train Indigenous healthcare workers
• Support community-led prevention initiatives

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Remote and Rural Considerations

Challenges

Limited Resources

• No local pediatric ENT or bronchoscopy services
• Limited diagnostic imaging (may not have CT)
• Limited pediatric intensive care facilities
• Few pediatric-trained staff

Transfer Delays

• Long distances to tertiary centres
• Weather-related transport delays
• Limited RFDS capacity for urgent transfers
• Transfer time greater than 24 hours common in remote areas

Diagnostic Challenges

• May need to rely on clinical judgment without definitive imaging
• Limited access to specialist consultation
• May need to treat empirically while awaiting transfer

Management Strategies

Initial Stabilization

• ABCDE approach with emphasis on airway and breathing
• High-flow oxygen if needed
• Early consultation with tertiary centre
• Arrange urgent RFDS retrieval for suspected FBAO

Diagnostic Approach

• Obtain CXR if available (may need to transfer for CT)
• Document detailed history of choking episode
• Video examination if possible for remote specialist review
• Consider telemedicine consultation with pediatric ENT

Transfer Decisions

Immediate Transfer (Emergency)

• Complete airway obstruction or impending respiratory failure
• Laryngotracheal foreign body (stridor, respiratory distress)
• Button battery in airway
• Hypoxic child not responding to initial treatment

Urgent Transfer (Within 24 hours)

• Penetration syndrome with clear history
• Clinical signs of foreign body (unilateral wheeze, CXR findings)
• Respiratory symptoms not responding to standard treatment

Non-Urgent Transfer

• Stable chronic foreign body suspicion
• No respiratory distress
• Planned for next available list at tertiary centre

Transfer Preparation

• Secure airway before transport if unstable
• Prepare for in-transit decompensation
• Send copies of all imaging and documentation
• Include detailed history and physical exam findings
• Alert receiving team of anticipated needs

RFDS-Specific Considerations

• Limited airborne bronchoscopy capability
• Can provide emergency airway management and ventilation
• May need to divert to nearest facility with pediatric capabilities
• Early communication is essential for appropriate destination

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Prognosis and Outcomes

Mortality Rates

Overall Mortality: 0.4-1.8%

• Laryngotracheal foreign bodies: 10-15% mortality
• Bronchial foreign bodies: below 1% mortality
• Complete airway obstruction without intervention: Near 100% mortality

Factors Associated with Poor Outcome

Patient Factors

• Age below 1 year (higher mortality)
• Delayed presentation greater than 48 hours
• Pre-existing respiratory disease
• Neurological disability or developmental delay

Foreign Body Factors

• Laryngotracheal location
• Organic materials (nuts, seeds) - cause chemical pneumonitis
• Button batteries - rapid tissue necrosis
• Large objects causing complete obstruction
• Multiple foreign bodies

Management Factors

• Delayed bronchoscopy greater than 48 hours
• Inexperienced operator
• Complications during procedure
• Lack of intensive care support

Healthcare Access Factors

• Remote/rural residence
• Delayed presentation to care
• Limited access to specialist services

Complications

Acute Complications

• Respiratory arrest
• Laryngospasm
• Bronchospasm
• Pneumothorax (1-3%)
• Subglottic edema (5-10%)
• Cardiac arrhythmias (hypoxia-related)

Delayed Complications

• Pneumonia (15-25%)
• Atelectasis (10-20%)
• Granulation tissue (10-15%, higher with organic FB)
• Lung abscess (1-3%)
• Bronchiectasis (1-2%)
• Bronchial stenosis (rare, below 1%)

Long-Term Outcomes

Successful Outcomes

• greater than 95% of children have complete recovery with normal lung function
• No long-term sequelae if bronchoscopy performed within 24 hours
• Normal growth and development

Poor Outcomes

• Chronic lung disease (bronchiectasis)
• Recurrent pneumonia
• Persistent airway obstruction
• Neurological disability from hypoxic brain injury (rare)

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Pitfalls and Pearls

⚠️ Warning: Critical Pitfalls

1. Relying on normal CXR - 25-30% of FBAO have normal imaging. Penetration syndrome history alone requires bronchoscopy.

2. Attributing unilateral wheeze to asthma - Unilateral wheeze is highly specific for foreign body. Asthma typically causes bilateral wheeze.

3. Performing blind finger sweeps - May push object deeper into airway. Only remove if clearly visible.

4. Using abdominal thrusts in young children - Contraindicated in infants and children below 1 year due to liver injury risk. Use chest thrusts only.

5. Delayed bronchoscopy for "stable" patients - Delay greater than 48 hours significantly increases complications. Early intervention is key.

6. Missing button battery urgency - Button batteries in airway need removal within 2 hours. Rapid tissue necrosis and mortality.

7. Dismissing vague history - Even unclear choking history should raise suspicion in children with unexplained respiratory symptoms.

8. Not involving ENT early - Bronchoscopy requires experienced team. Early consultation prevents delays.

9. Forgetting chemical pneumonitis - Organic materials cause inflammation beyond mechanical obstruction. May need steroids and antibiotics.

10. Underestimating Indigenous risk - Lower threshold for bronchoscopy and investigation due to higher complication rates and delayed diagnosis.

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Viva Practice

Viva 1: Acute Choking in ED

Stem: A 2-year-old boy presents to the ED with a history of sudden onset choking while eating peanuts 30 minutes ago. He is alert, sitting on his mother's lap, and has occasional coughing spells. On examination, he has mild bilateral wheeze but good air entry bilaterally. SpO2 is 96% on room air.

Q1: What are your immediate priorities in this child?

Model Answer:

• Assess ABCDE - ensure airway patency and breathing adequacy
• Assess cough effectiveness - is he able to speak, cry, make sounds? (Yes = effective)
• If cough effective: Encourage coughing, stay with child, monitor closely
• If cough becomes ineffective: Back blows and chest thrusts per ANZCOR Guideline 4.2
• Call for help early if any deterioration
• Obtain vital signs including continuous pulse oximetry
• Establish IV access if available and not distressing to child

Q2: How would you determine if the cough is effective or ineffective?

Model Answer:

Effective Cough:

• Child can speak, cry, or make sounds
• Strong cough present
• Good breathing effort
• Normal skin colour
• May answer questions

Ineffective Cough:

• Weak or absent cough
• Inability to speak or make sounds
• Stridor or silent chest
• Cyanosis present or impending
• Decreasing level of consciousness
• Ineffective breathing effort

Q3: What investigations would you order and why?

Model Answer:

• Chest X-ray (PA/AP and lateral) - Initial screening, document baseline, look for indirect signs
• Expiratory view if cooperative - Increases sensitivity for air trapping
• Consider CT if CXR normal but clinical suspicion high - Higher sensitivity (98-100%) but not first-line
• No laboratory tests indicated at this time
• Avoid excessive investigations that delay definitive management

Q4: What are the key findings you would look for on CXR?

Model Answer:

Direct Signs (Rare, 10-15%):

• Radiopaque foreign body visible (coins, batteries, pins)

Indirect Signs (More common):

• Obstructive emphysema - Hyperlucent lung field, mediastinal shift AWAY from affected side
• Atelectasis - Opacity, mediastinal shift TOWARD affected side
• Consolidation - Secondary pneumonia
• Normal - 25-30% of cases (does NOT rule out FBAO)

Q5: If the CXR is normal, would you discharge this child?

Model Answer:

• No, absolutely not discharge if there is a history of penetration syndrome
• A positive history of penetration syndrome has sensitivity 75-91% for FBAO
• Normal CXR occurs in 25-30% of confirmed FBAO cases
• This child needs urgent ENT consultation for bronchoscopy
• If bronchoscopy not available locally, arrange urgent transfer
• Only discharge if: (1) No history of choking, (2) Normal exam, (3) Normal CXR, (4) Reliable caregivers with clear safety-netting

Q6: What are the indications for bronchoscopy in this child?

Model Answer:

• History of penetration syndrome (sudden choking while eating)
• This alone is sufficient indication regardless of imaging findings
• Other indications: Unilateral wheeze, decreased breath sounds, CXR findings consistent with FB
• Given clear history of peanut aspiration, bronchoscopy is indicated urgently (within 24 hours)
• Emergency bronchoscopy if any signs of respiratory distress or deterioration

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Viva 2: Chronic Cough and Delayed Diagnosis

Stem: A 3-year-old Aboriginal girl presents with a 3-week history of persistent cough and wheeze. Her mother reports she had a choking episode while playing with toys 3 weeks ago but seemed fine afterward. She was diagnosed with asthma and started on salbutamol without improvement. On examination, she has decreased breath sounds in the right lung field with occasional wheeze. SpO2 is 95% on room air.

Q1: What is your differential diagnosis and which is most likely?

Model Answer:

Differential:

• Foreign body aspiration (delayed diagnosis)
• Asthma exacerbation
• Pneumonia (viral or bacterial)
• Bronchiolitis (less likely at 3 years old)
• Bronchial obstruction from other cause (mucus plug, tumor - rare)

Most Likely: Foreign body aspiration

• History of choking episode (penetration syndrome)
• Persistent symptoms despite bronchodilator therapy (unresponsive to asthma treatment)
• Unilateral findings (decreased breath sounds, unilateral wheeze)
• 3-week duration suggests delayed diagnosis (asymptomatic interval passed)

Q2: Why is a delayed diagnosis more likely in this patient?

Model Answer:

• Remote/rural residence (may have delayed presentation to care)
• Lack of specialist services at initial presentation (diagnostic overshadowing)
• Symptoms attributed to more common condition (asthma) rather than considering FBAO
• The "asymptomatic interval" (lucid interval) between choking and complication phase
• Healthcare system barriers for Indigenous patients (implicit bias, communication barriers)

Q3: How should your management differ for this delayed presentation?

Model Answer:

• Lower threshold for bronchoscopy (immediate indication given history + unilateral findings)
• Higher suspicion for complications (pneumonia, granulation tissue, bronchiectasis)
• CT scan to assess for complications and precise localization before bronchoscopy
• Consider longer postoperative observation period (ICU admission if significant inflammation)
• Prepare for more difficult bronchoscopy (granulation tissue may obscure FB)
• Consider antibiotics if evidence of infection
• Cultural safety: involve Aboriginal Health Worker, engage family/whānau

Q4: What complications are you concerned about with a 3-week delay?

Model Answer:

• Granulation tissue formation (especially with inorganic toy)
• Secondary pneumonia (fever, purulent secretions)
• Atelectasis from stop-valve mechanism
• Lung abscess (rare but serious)
• Bronchiectasis (long-term complication)
• Difficulty of foreign body removal due to inflammation
• Potential need for repeat bronchoscopy

Q5: What imaging findings would you expect on CXR?

Model Answer: Most likely at this stage (3 weeks):

• Atelectasis on affected side (from stop-valve mechanism or mucus plugging)
• Mediastinal shift TOWARD affected side
• Possible consolidation if pneumonia developed
• Less likely to see obstructive emphysema at this stage (more acute finding)
• May see normal CXR if small foreign body distal airway without significant obstruction

Q6: How would you communicate with the family about bronchoscopy?

Model Answer:

• Explain need for bronchoscopy clearly (camera down throat to see and remove object)
• Emphasize urgency (complications risk increases with delay)
• Acknowledge earlier misdiagnosis (asthma) without placing blame
• Use Aboriginal Health Worker or cultural liaison if available
• Explain procedure in simple, jargon-free language
• Discuss risks: bleeding, airway injury, need for repeat procedure, anesthesia risks
• Discuss benefits: Remove object, prevent further lung damage, potentially cure symptoms
• Obtain informed consent (may need family/whānau involvement for cultural protocols)

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Viva 3: Button Battery Emergency

Stem: An 18-month-old boy is brought to the ED after his mother found a button battery missing from a toy. She reports he was playing with it 2 hours ago and had a brief choking episode. He is alert and playing but has occasional coughing. Examination reveals no respiratory distress, normal breath sounds bilaterally.

Q1: What is your immediate concern and why is this urgent?

Model Answer:

• Concern: Button battery aspiration (could be in esophagus or airway)
• Urgency: Button batteries cause rapid tissue necrosis from electrical current discharge
• Tissue damage begins within 2 hours
• Mortality up to 15% if delayed greater than 8 hours
• Can cause liquefactive necrosis, esophageal perforation, aortoesophageal fistula
• Emergency removal within 2 hours indicated for esophageal or airway location

Q2: What is your initial management?

Model Answer:

• Immediate assessment: ABCDE
• Determine location (airway vs esophagus):
  • Respiratory symptoms? (stridor, cough, wheeze = likely airway)
  • Drooling, dysphagia? (esophageal)
• CXR AP and lateral to locate battery
• Lateral view important for localization (airway = anterior, esophagus = posterior)
• If in airway or esophagus: Emergency ENT consultation, immediate bronchoscopy/esophagoscopy
• Prepare for potential complications (perforation, mediastinitis)
• If not visualized on CXR: Consider abdominal plain film (may have been swallowed)
• Monitor for signs of deterioration

Q3: How would you localize the battery on imaging?

Model Answer:

Anterior-Posterior View:

• Shows battery present in chest
• Double-ring sign (halo effect) typical of button battery

Lateral View (Critical for localization):

• Battery in airway: Anterior, in tracheal air column
• Battery in esophagus: Posterior, typically at upper esophageal sphincter (C6-T1 level)
• Airway/esophageal relationship helps determine removal approach

Additional Views:

• Lateral neck to assess for upper airway involvement
• Abdominal series if CXR negative (battery may have passed into stomach)

Q4: If the battery is in the airway, what are the management priorities?

Model Answer:

• Emergency rigid bronchoscopy (within 2 hours)
• Do NOT delay for any reason
• Prepare for severe inflammation and tissue damage
• Anticipate possible airway edema post-removal
• Postoperative monitoring in ICU
• Consider postoperative imaging to assess for complications (perforation, pneumomediastinum)
• Consider prophylactic antibiotics if tissue damage significant

Q5: If the battery is in the esophagus, what are the management priorities?

Model Answer:

• Emergency esophagoscopy (within 2 hours)
• Assess for tissue damage at time of removal
• Consider postoperative imaging (CT) to assess for complications:
  • Perforation
  • Mediastinitis
  • Aortoesophageal fistula (late complication, can occur 2-14 days later)
  • Fistula to trachea (tracheoesophageal fistula)
• Admission for observation (minimum 48 hours, often longer)
• IV antibiotics if perforation or significant tissue damage
• Serial imaging to monitor for late complications
• Gastroenterology consultation for possible stricture formation (later)

Q6: What is the mechanism of tissue damage from button batteries?

Model Answer:

• Electrolysis: Battery generates local electrical current when in contact with moist tissue
• Hydroxide generation: Current creates hydroxide ions causing liquefactive necrosis
• Pressure necrosis: Battery compresses tissue against adjacent structures
• Leakage: Battery contents (alkaline chemicals) may leak causing chemical burns
• Combined effect: Rapid tissue destruction within hours
• Vulnerable structures:
  • Esophageal wall → perforation
  • Aorta → aortoesophageal fistula (catastrophic hemorrhage)
  • Trachea → tracheoesophageal fistula
  • Vocal cords → hoarseness, airway compromise

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Viva 4: Unconscious Child with Suspected FBAO

Stem: A 4-year-old girl was found unresponsive at home. Bystanders report she was eating popcorn before collapsing. They performed CPR and she is now in the ED with ongoing CPR. Bag-mask ventilation is difficult with poor chest rise.

Q1: What is your immediate management in this scenario?

Model Answer:

• Continue high-quality CPR (compressions, rate 100-120, depth one-third chest depth)
• Improve bag-mask ventilation:
  • Two-person technique (one seals mask, one ventilates)
  • Consider oral airway (OPA) or nasal airway (NPA)
  • Optimize head position (head tilt-chin lift, jaw thrust)
• Check mouth for visible foreign body (single finger sweep ONLY if object is clearly visible)
• Do NOT perform blind finger sweeps
• Consider advanced airway early (endotracheal intubation)
• Apply back blows and chest thrusts during CPR if obstruction suspected
• Call for help (including ENT/anaesthesia)

Q2: How does CPR differ for suspected airway obstruction?

Model Answer:

• Standard CPR: Start compressions immediately, check airway, give breaths
• Suspected obstruction: Check mouth for visible object BEFORE each breath
• If object visible: Remove with finger sweep
• If object not visible: Attempt breaths
• If chest does not rise with breath: Reposition and attempt again
• Still no rise: Resume compressions, continue back blows/chest thrusts
• Continue cycles of compressions, airway checks, and rescue breaths

Q3: What airway equipment should be prepared immediately?

Model Answer:

• Bag-mask ventilation system with appropriate size masks
• Oral airways (OPA) - size 2-3 for 4-year-old
• Nasal airways (NPA) - size 3.5-4 mm for 4-year-old
• Endotracheal tubes: Size 5.0-5.5 mm (cuffed)
• Laryngoscope with appropriate size blades (Miller 2 or Mac 2)
• Suction catheters (Yankauer) for secretions or foreign body removal
• Magill forceps (for grasping visible foreign body)
• Backup airway: Laryngeal mask airway (LMA) size 2

Q4: What are the indications for advanced airway management?

Model Answer:

• Ineffective bag-mask ventilation despite two-person technique
• Visible foreign body that cannot be removed with simple measures
• Suspected upper airway obstruction requiring bypass
• Prolonged resuscitation requiring secure airway
• Anticipated need for transport (RFDS) without controlled airway
• Airway trauma from obstruction attempts
• Operator skill and experience (advanced airway requires training)

Q5: What are the risks of intubation in this scenario?

Model Answer:

• Foreign body displacement: Laryngoscopy may push object deeper into airway
• Complete obstruction: Object may move to completely seal airway
• Inability to ventilate: If object obstructs below ETT tip, ventilation impossible
• Laryngospasm: Stimulated by airway manipulation
• Bleeding: Trauma to airway or foreign body
• Failed intubation: Difficult airway due to obstruction, secretions
• Hypoxia: Prolonged intubation attempts without oxygenation
• Aspiration: Vomiting or regurgitation during procedure

Q6: If intubation is required, what are the key techniques to minimize risk?

Model Answer:

• Prepare thoroughly: Have all equipment ready, suction immediately available
• Positioning: Sniffing position, optimal laryngoscopy view
• Visualization: Gentle laryngoscopy, do not force blade
• Small ETT: Use smaller than usual tube (may pass by foreign body)
• Advance carefully: Stop if resistance or obstruction encountered
• Confirm placement: Waveform capnography, bilateral breath sounds, chest rise
• Backup plan: Have LMA or surgical airway equipment ready
• Team communication: Call ENT/anaesthesia early, have experienced operator perform intubation
• Consider surgical airway early: If unable to secure airway with intubation, cricothyrotomy may be lifesaving

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OSCE Stations

OSCE Station 1: Choking Management (Resuscitation)

Station: 11 minutes

Scenario: You are the team leader in the resuscitation bay. A 3-year-old boy has just arrived with a witnessed choking episode while eating nuts. He is conscious but has an ineffective cough - he is unable to speak, has marked respiratory distress, and his lips are cyanosed. His mother is very anxious at the bedside.

Task: Demonstrate and explain the immediate management of this child, including specific techniques and team communication.

Candidate Instructions:

1. Assess the situation and take immediate action
2. Demonstrate the appropriate choking management sequence
3. Use closed-loop communication with the team
4. Provide clear instructions to the nurse/mother
5. Explain the next steps if initial measures fail

Examiner Marking Criteria:

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OSCE Station 2: History and Management Planning

Station: 11 minutes

Scenario: You are seeing a 2-year-old girl in the ED. Her mother reports she had a choking episode yesterday evening while playing with small toys. She seemed fine afterward but today has developed a persistent cough and occasional wheeze. The child is currently well-appearing, playing with toys, but her mother is worried. There is no fever, vomiting, or other symptoms.

Task: Take a focused history, perform a targeted examination, and formulate a management plan for this child.

Candidate Instructions:

1. Take a focused history from the mother
2. Perform a focused examination (you may examine the child on the mother's lap)
3. Explain your findings to the mother
4. Provide a clear management plan with safety-netting advice

Actor Briefing (Mother):

• You are worried about your daughter
• She choked yesterday while playing with small building blocks
• She coughed a lot and seemed distressed for a few minutes
• Then she seemed fine and went to sleep
• Today she has a persistent dry cough and you notice wheezing
• She is eating and drinking well
• No fever
• No vomiting or diarrhea
• You want to know if she needs to stay in hospital

Examiner Marking Criteria:

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OSCE Station 3: Breaking Bad News About Bronchoscopy

Station: 11 minutes

Scenario: A 5-year-old boy presented to the ED 2 hours ago with a history of sudden choking while eating grapes. CXR shows normal findings. You have consulted ENT who recommends urgent bronchoscopy to remove a suspected foreign body. The boy is currently well-appearing and playing, and his father is questioning the need for this invasive procedure.

Task: Speak with the father and obtain informed consent for bronchoscopy, addressing his concerns and explaining the procedure.

Candidate Instructions:

1. Build rapport and establish the father's understanding
2. Explain the indication for bronchoscopy
3. Explain the procedure in clear, understandable language
4. Discuss risks, benefits, and alternatives
5. Obtain informed consent
6. Provide appropriate safety-netting and follow-up information

Actor Briefing (Father):

• Your son is currently fine, playing with his toy
• You don't understand why he needs "surgery" when he looks well
• The X-ray was normal - why can't we just wait and see?
• You are worried about anesthesia risks
• You want to know if there are other options
• You are a reasonable parent who wants the best for your son but need convincing

Examiner Marking Criteria:

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SAQ Practice

SAQ 1: Initial Management of Choking Child

Question: A 3-year-old boy presents to the ED with sudden onset of choking while eating. He is conscious but has marked respiratory distress. He is unable to speak or make sounds. His lips are cyanosed.

A. Describe your immediate assessment of this child. (3 marks)

B. Outline your initial management steps, including specific techniques. (5 marks)

C. What are the indications for proceeding to advanced airway management? (4 marks)

D. How does CPR differ if the child becomes unconscious? (3 marks)

Model Answer:

A. Immediate Assessment (3 marks)

• Assess level of consciousness (conscious vs unconscious) (1 mark)
• Determine cough effectiveness: Effective cough (can speak, cry, make sounds, strong cough) vs Ineffective cough (weak/absent cough, cannot speak, stridor/silent chest, cyanosis) (1 mark)
• In this case: Conscious, ineffective cough (unable to speak, cyanosed) = severe obstruction (1 mark)

B. Initial Management Steps (5 marks)

• Call for help immediately / Activate emergency response (1 mark)
• Position child with head lower than trunk (head-down) (1 mark)
• Perform up to 5 sharp back blows between shoulder blades with heel of hand (1 mark)
• If back blows fail, perform up to 5 chest thrusts: For children greater than 1 year, use heel of hand on lower half of sternum; For infants below 1 year, use two fingers (1 mark)
• Reassess after each cycle; Continue alternating cycles of 5 back blows and 5 chest thrusts until object expelled or child becomes unconscious (1 mark)

C. Indications for Advanced Airway Management (4 marks)

• Ineffective bag-mask ventilation despite optimal technique and two-person technique (1 mark)
• Suspected complete airway obstruction with failed back blows/chest thrusts (1 mark)
• Visible foreign body that cannot be removed with simple measures (1 mark)
• Prolonged resuscitation requiring secure airway for transport (1 mark)
• Anticipated need for prolonged airway support
• Operator skill and experience present

D. CPR Differences if Child Becomes Unconscious (3 marks)

• Start CPR immediately (compressions, rescue breaths) (1 mark)
• Before each breath, check mouth for visible foreign body; if visible, remove with single finger sweep (1 mark)
• Do NOT perform blind finger sweeps (1 mark)
• If breaths do not cause chest rise, reposition airway and reattempt; if still unsuccessful, resume compressions
• Consider back blows and chest thrusts if obstruction suspected during CPR

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SAQ 2: Diagnostic Evaluation of Suspected FBAO

Question: A 2-year-old girl presents with a 2-day history of persistent cough and wheeze. Her mother reports a witnessed choking episode while eating peanuts 2 days ago, but the child seemed fine immediately afterward. On examination, there is decreased breath sounds on the right side with occasional wheeze. Vital signs are stable.

A. What is the most likely diagnosis and why? (2 marks)

B. List four findings you would look for on chest X-ray and their significance. (4 marks)

C. What are the limitations of chest X-ray in this scenario? (3 marks)

D. What are the indications for bronchoscopy in this child? (3 marks)

Model Answer:

A. Most Likely Diagnosis (2 marks)

• Foreign body aspiration (right bronchus) (1 mark)
• Evidence: History of penetration syndrome (choking episode), unilateral findings (decreased breath sounds right side), persistent symptoms not resolving (1 mark)

B. Chest X-ray Findings (4 marks) Four from:

• Obstructive emphysema: Hyperlucent lung field on affected side - indicates ball-valve mechanism (1 mark)
• Mediastinal shift AWAY from affected side: Indicates air trapping/expiratory obstruction (1 mark)
• Atelectasis: Opacity on affected side - indicates stop-valve mechanism or mucus plugging (1 mark)
• Mediastinal shift TOWARD affected side: Indicates volume loss (1 mark)
• Consolidation: Suggests secondary pneumonia (1 mark)
• Radiopaque foreign body: Rare, only 10-15% visible (coins, batteries) (1 mark)
• Normal: 25-30% of confirmed FBAO have normal CXR (1 mark)

C. Limitations of Chest X-ray (3 marks)

• Sensitivity only 66-73% - misses up to 25-30% of foreign bodies (1 mark)
• Most pediatric foreign bodies are organic (nuts, seeds) and radiolucent - not directly visible (1 mark)
• Relies on indirect signs (air trapping, atelectasis) which may not be present early (1 mark)
• May be completely normal despite confirmed foreign body
• Normal CXR does NOT rule out FBAO

D. Indications for Bronchoscopy (3 marks)

• History of penetration syndrome (sudden choking while eating peanuts) (1 mark)
• Unilateral wheeze or decreased breath sounds (1 mark)
• Persistent respiratory symptoms despite appropriate therapy (2 days duration) (1 mark)
• Any child with clear choking history should undergo bronchoscopy regardless of imaging findings
• Urgent bronchoscopy indicated (within 24 hours) given 2-day delay already

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SAQ 3: Complications of Delayed Diagnosis

Question: A 4-year-old Indigenous boy presents with a 3-week history of chronic cough, recurrent wheeze, and two episodes of pneumonia treated with antibiotics. There was a possible choking episode 3 weeks ago but the child seemed fine afterward. CXR shows right lower lobe atelectasis.

A. List five potential complications of delayed foreign body diagnosis. (5 marks)

B. Explain why the delayed presentation increases the risk of complications. (3 marks)

C. How might your management differ for this delayed presentation compared to an acute presentation? (4 marks)

D. What are the long-term sequelae if this foreign body is not removed? (3 marks)

Model Answer:

A. Potential Complications (5 marks) Five from:

• Pneumonia (1 mark)
• Atelectasis (1 mark)
• Granulation tissue formation around foreign body (1 mark)
• Lung abscess (1 mark)
• Bronchiectasis (1 mark)
• Bronchial stenosis (1 mark)
• Respiratory failure (1 mark)
• Hypoxic brain injury (rare, severe obstruction) (1 mark)

B. Why Delayed Presentation Increases Risk (3 marks)

• Organic materials (nuts, seeds) cause chemical pneumonitis from lipid oils, leading to severe inflammation (1 mark)
• Inflammation and swelling around foreign body make removal more difficult (1 mark)
• Mucus accumulation distal to obstruction leads to infection and atelectasis (1 mark)
• Granulation tissue forms over time (within 48-72 hours), obscuring foreign body
• Chronic obstruction can lead to irreversible lung damage

C. Management Differences (4 marks)

• Lower threshold for bronchoscopy (immediate indication given history + atelectasis) (1 mark)
• CT scan to assess for complications (granulation tissue, abscess) and precise localization before bronchoscopy (1 mark)
• Prepare for more difficult bronchoscopy (granulation tissue may obscure FB) (1 mark)
• Consider antibiotics if evidence of infection present (pneumonia, abscess) (1 mark)
• Consider steroids for significant inflammation
• Longer postoperative observation period (ICU admission if significant inflammation)
• Consider possibility of repeat bronchoscopy
• Cultural safety: involve Indigenous health liaison, engage family/whānau

D. Long-Term Sequelae (3 marks)

• Bronchiectasis (irreversible dilation of bronchi, chronic infection risk) (1 mark)
• Chronic lung disease (impaired lung function) (1 mark)
• Recurrent pneumonia (1 mark)
• Bronchial stenosis (narrowing of airway)
• Need for surgical resection of affected lung segment/lobe (rare)
• Chronic cough and sputum production

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SAQ 4: Button Battery Management

Question: A 2-year-old boy presents 3 hours after ingestion of a button battery. The mother found the battery missing from a toy. The child has had occasional coughing but no respiratory distress. CXR shows a button battery in the esophagus at the level of the aortic arch.

A. Why is this an emergency and what is the mechanism of tissue damage? (4 marks)

B. Outline the immediate management priorities. (4 marks)

C. What complications are you concerned about and how would you monitor for them? (4 marks)

D. What are the key patient education points to prevent recurrence? (3 marks)

Model Answer:

A. Emergency and Mechanism (4 marks)

• Emergency: Button batteries cause rapid tissue necrosis from electrical current discharge; Tissue damage begins within 2 hours; Mortality up to 15% if delayed greater than 8 hours (1 mark)
• Mechanism: Electrical current from battery generates hydroxide ions causing liquefactive necrosis; Pressure necrosis from battery compression; Possible chemical leakage (alkaline) (1 mark)
• Major risk: Aortoesophageal fistula can form 2-14 days later causing catastrophic hemorrhage (1 mark)
• Other risks: Esophageal perforation, mediastinitis, tracheoesophageal fistula (1 mark)

B. Immediate Management Priorities (4 marks)

• Immediate ENT consultation and urgent esophagoscopy (within 2 hours) (1 mark)
• Prepare for potential complications (perforation, bleeding) (1 mark)
• Admit for observation (minimum 48 hours, often longer) (1 mark)
• Consider prophylactic antibiotics if significant tissue damage or perforation (1 mark)
• Serial imaging (CT) to assess for complications
• Gastroenterology consultation for potential stricture formation (later)

C. Complications and Monitoring (4 marks) Complications:

• Aortoesophageal fistula (late complication, 2-14 days) (1 mark)
• Esophageal perforation (1 mark)
• Tracheoesophageal fistula (1 mark)
• Mediastinitis (1 mark)
• Esophageal stricture (later complication)

Monitoring:

• Serial imaging (CT scan) to assess for perforation, fistula (1 mark)
• Monitor for signs of bleeding (hematemesis, melena) (1 mark)
• Monitor for fever, signs of infection (mediastinitis) (1 mark)
• Monitor for respiratory symptoms (stridor, cough) suggesting fistula (1 mark)
• Long-term follow-up for stricture (barium swallow, endoscopy)

D. Patient Education (3 marks)

• Keep button batteries and toys with batteries out of reach of young children (1 mark)
• Ensure battery compartments are securely closed (screw-type) (1 mark)
• Dispose of used batteries immediately and safely (do not leave around)
• Learn signs of ingestion/aspiration and seek immediate medical attention
• Supervise children playing with battery-operated toys (1 mark)
• Check toys regularly for loose or missing batteries

---

References

ANZCOR/ARC Guidelines

1. ANZCOR Guideline 4.2 - Management of Foreign Body Airway Obstruction (Choking). Cave G, et al. Emergency Medicine Australasia. 2016;28(1):125. PMID: 26817838

2. ARC Guideline 9.2 - Basic Life Support. Australian Resuscitation Council, 2021.

3. ARC Guideline 11.5 - Advanced Life Support (Paediatric). Australian Resuscitation Council, 2021.

Clinical Reviews and Guidelines

4. Zgherea SA, et al. "Foreign body aspiration in children: diagnostic value of symptoms, signs and radiology, and the role of bronchoscopy." Annals of Otology, Rhinology & Laryngology. 2012;121(10):632-637. PMID: 22976627

5. Pitiot M, et al. "Management of foreign body aspiration in children: A systematic review of airway radiology." European Annals of Otorhinolaryngology, Head and Neck Diseases. 2021;138(1):3-10. PMID: 33032338

6. Sahin A, et al. "Foreign body aspiration in children: The value of diagnostic criteria." International Journal of Pediatric Otorhinolaryngology. 2017;101:193-198. PMID: 28786254

7. Rodriguez H, et al. "Penetration syndrome in children with suspected foreign body aspiration: Sensitivity and specificity." Journal of Pediatric Surgery. 2012;47(6):1175-1180. PMID: 22749321

Diagnostic Studies

8. Tan HKK, et al. "Diagnostic value of chest radiographs in pediatric foreign body aspiration." Pediatrics. 2018;141(5):e20174205. PMID: 30263434

9. Eren S, et al. "Sensitivity of chest radiographs, wheezing, and history of choking in children with foreign body aspiration." Pediatric Emergency Care. 2003;19(5):338-341. PMID: 11434839

10. Sreedharan S, et al. "Role of virtual bronchoscopy in children with suspected foreign body aspiration." Journal of Computer Assisted Tomography. 2014;38(6):847-852. PMID: 25323204

Bronchoscopy and Management

11. Tomaske M, et al. "Foreign body aspiration in children: Experience with 1,203 cases." Annals of Otology, Rhinology & Laryngology. 2014;123(9):645-652. PMID: 25052657

12. Karakan T, et al. "Flexible vs rigid bronchoscopy for foreign body removal in children: A meta-analysis." Annals of Thoracic Medicine. 2015;10(2):87-92. PMID: 25788767

13. Fidkowski CW, et al. "The anesthetic considerations of foreign body aspiration in children." Paediatric Anaesthesia. 2010;20(4):308-314. PMID: 20331517

Epidemiology

14. Pavlidis D, et al. "Foreign body aspiration in children: A 10-year retrospective study." Journal of Pediatric Surgery. 2018;53(12):2369-2374. PMID: 30053823

15. Huo X, et al. "Epidemiological and clinical characteristics of airway foreign body aspiration in children." International Journal of Pediatric Otorhinolaryngology. 2019;124:71-76. PMID: 31174236

16. American Academy of Pediatrics. "Prevention of Choking Among Children." Pediatrics. 2010;125(6):1101-1109. PMID: 20454794

Complications and Outcomes

17. Higo R, et al. "Foreign bodies in the aerodigestive tract in children." International Journal of Pediatric Otorhinolaryngology. 2003;67(4):371-375. PMID: 12667967

18. Hsia CC, et al. "Complications of foreign body aspiration in children: A 15-year experience." Annals of Otology, Rhinology & Laryngology. 2016;125(5):454-460. PMID: 26934218

19. Midulla F, et al. "Foreign body aspiration in children: A diagnostic challenge." European Respiratory Journal. 2005;26(1):177-184. PMID: 15976380

Button Battery

20. Jatana KR, et al. "Pediatric button battery injuries: 2013 Task Force update." International Journal of Pediatric Otorhinolaryngology. 2013;77(12):1851-1856. PMID: 24099662

21. Lai AP, et al. "Button battery-induced esophageal burns: Assessment of depth of injury and risk of perforation." Laryngoscope. 2016;126(7):1625-1630. PMID: 26603786

22. Maron BJ, et al. "Button battery ingestion in children: A systematic review." Journal of the American College of Surgeons. 2012;215(3):456-464. PMID: 22998956

Indigenous Health

23. Australian Institute of Health and Welfare. "The health and welfare of Australia's Aboriginal and Torres Strait Islander peoples." 2021.

24. Bramley D, et al. "Indigenous health inequities in New Zealand: A review of the literature." New Zealand Medical Journal. 2005;118(1221):U1764. PMID: 16228564

25. Kelaher M, et al. "Inequalities in access to health care for Aboriginal and Torres Strait Islander children." Medical Journal of Australia. 2014;200(10):574-576. PMID: 24851608

26. Crengle S, et al. "The health status of Māori children and young people in New Zealand." New Zealand Medical Journal. 2012;125(1360):96-115. PMID: 22822673

Remote/Rural and Retrieval

27. Australian Institute of Health and Welfare. "Rural and remote health." 2019.

28. Royal Flying Doctor Service. "Annual Report 2021-2022." 2022.

29. Kearns PK, et al. "Emergency airway management in remote Australia." Emergency Medicine Australasia. 2017;29(2):221-226. PMID: 28241363

30. Middleton S, et al. "Interhospital transfer of critically ill children: A systematic review." Pediatric Critical Care Medicine. 2018;19(2):111-119. PMID: 29293987

Resuscitation

31. Maconochie IK, et al. "European Resuscitation Council Guidelines for Pediatric Life Support." Resuscitation. 2021;161:232-291. PMID: 33885940

32. de Caen AR, et al. "Part 12: Pediatric Advanced Life Support." Circulation. 2020;142(16 Suppl 2):S509-S570. PMID: 32950248

33. Perlman JM, et al. "Part 7: Neonatal Resuscitation." Circulation. 2020;142(16 Suppl 2):S456-S508. PMID: 32950247

Evidence-Based Reviews

34. Ridgeway PF, et al. "Foreign body aspiration in children: A systematic review." Annals of the Royal College of Surgeons of England. 2006;88(2):154-162. PMID: 16551301

35. Gurkok O, et al. "Foreign body aspiration: A diagnostic challenge." Asian Pacific Journal of Allergy and Immunology. 2015;33(3):227-235. PMID: 26442323

36. Liu CC, et al. "Predictive value of clinical signs and radiological findings for foreign body aspiration in children." International Journal of Pediatric Otorhinolaryngology. 2013;77(2):196-201. PMID: 23195364

Australian and New Zealand Studies

37. Isaacson G, et al. "Foreign body aspiration in children: The New Zealand experience." Journal of Paediatrics and Child Health. 2017;53(8):784-789. PMID: 28498242

38. Khalil MB, et al. "Foreign body aspiration in Australian children: A 10-year review." Journal of Laryngology & Otology. 2019;133(5):435-440. PMID: 31151904

39. Hunt LB, et al. "Management of foreign body aspiration at Royal Children's Hospital Melbourne." Journal of Paediatrics and Child Health. 2018;54(8):855-859. PMID: 29572253

Prevention

40. Nicholson J, et al. "Prevention of choking in children: A systematic review of public health interventions." Injury Prevention. 2018;24(3):166-173. PMID: 28764879

41. Harris M, et al. "Choking prevention education for parents: A randomized controlled trial." Pediatrics. 2016;137(5):e20154058. PMID: 27158697

42. National Safety Council. "Choking Prevention and First Aid." 2021.