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Foreign Body Airway Obstruction in Children: Diagnosis, Management & Equipment Preparation

Author Taylor Spurgeon-Hess covers Foreign Body Airway Obstruction in Children: Diagnosis, Management & Equipment Preparation on BackTable ENT

Taylor Spurgeon-Hess • Aug 10, 2023 • 39 hits

Accurate diagnosis and procedural preparedness are persistent challenges in the management of foreign body airway obstruction in children. The subtle presentation of affected toddlers often complicates diagnosis, making witness history and clinician acumen vital. Additionally, bronchoscopy procedure preparedness, especially during off-hours, necessitates careful attention to equipment availability and assembly. Amid these complexities, the Lean methodology emerges as a promising strategy. By focusing on process optimization and waste reduction, it can significantly enhance the management of pediatric airway foreign bodies, from patient categorization to improving overall care quality.

This article features excerpts from the BackTable ENT Podcast. We’ve provided the highlight reel in this article, and you can listen to the full podcast below.

The BackTable ENT Brief

• Pediatric airway foreign bodies predominantly affect toddlers and pose considerable diagnostic challenges.

• Conventional diagnostic tools like X-rays may not provide clear indications, with clinicians needing to rely on witness history and their observation.

• Advanced imaging techniques such as CT scans may only be employed in specific instances, such as chronic aspiration history or developed pneumonia.

• Bronchoscopy procedure preparedness requires careful attention to equipment availability, correct assembly, and effective communication among the medical team.

• Often clinicians encounter situations where crucial bronchoscopy instruments are missing or incompatible, underscoring the importance of thorough planning.

• The Lean methodology, aimed at reducing waste and optimizing operations, offers promising applications in managing pediatric airway foreign bodies.

• Applying Lean principles to pediatric bronchoscopy can enhance patient categorization, equipment setup, and overall care.

• The Lean methodology incorporates the 5S steps—sort, set in order, shine, standardize, and sustain—which can improve and maintain the quality of equipment and care.

Foreign Body Airway Obstruction in Children: Diagnosis, Management & Equipment Preparation

Table of Contents

(1) Diagnosing Foreign Body Airway Obstruction in Children

(2) Equipment Management in Pediatric Foreign Body Airway Obstruction Removal

(3) Streamlining Pediatric Foreign Body Airway Obstruction Removal: A Lean Methodology Approach

Diagnosing Foreign Body Airway Obstruction in Children

Pediatric airway foreign bodies often present complex diagnostic challenges. The most frequently affected demographic is toddlers who may ingest items like nuts and subsequently aspirate them. Often, their presentation can be deceptive as the child may appear perfectly healthy post the aspiration event. Conventional diagnostic tools like X-rays often provide no clear indications, making the task even more complicated. Listening to the child's breathing might reveal signs like wheezing or stridor, but these findings are not always present. Advanced imaging such as CT scans may be used in cases with a chronic or remote history of possible aspiration, or if a pneumonia has developed that indicates a poorly aerated lung segment. Ultimately, a clinician's astute attention to a witness history of choking or other respiratory distress incidents could prove to be the most reliable diagnostic clue.

[Dr. Wolfgang Stehr]
In our hospital, we did have pediatric ENT and we do have pediatric surgery and we were a trauma center. We always had pediatric surgeons on call in the house to take care of trauma patients and emergent acute patients. Children with airway foreign bodies, it's oftentimes the toddlers, they eat the nuts, which they're not as supposed to eat and then they aspirate the nut and they come in with a story of the parents sometimes saying, "I think he ate these nuts and he coughed for a while, but now he looks good." Then they end up in the emergency room. The emergency room doctors, they get an X-ray, which usually doesn't show anything, and if they're lucky, they'll listen to the child and hear some whistling in one of the bronchi. Sometimes you actually have the worst-case scenario where you have a child in significant respiratory distress.

[Dr. Gopi Shah]
Absolutely. I think what you describe is pretty common. I agree. It's mostly toddlers, although sometimes they can be quite young, under one, I've seen, and it can be even older kids that don't tell you about an incident that they had. I think you hit the nail in the head, they oftentimes look fine. Fortunately, most of the kids don't come in acute respiratory distress or extremis.

The clinical decision-making can be difficult if there wasn't a witnessed history of choking or maybe it happened and the x-ray most of the time looks fine. We'll get the lateral decubitus, see if there's any ear trapping, if there is a foreign body or something obstructing the bronchi. A lot of times it looks fine, and I think what you said, if they were lucky, the ER physician or maybe the pediatrician or somebody may hear something like wheezing or stridor, subtle stridor or if it's been a while, maybe [unintelligible 00:05:51] sounds on a single side. Again, those clinical physical exam and X-ray findings aren't always there, so I would say the witness history for me is very important as well. Do you ever get a CT, is there ever an indication for you to get a CT for a concern for an airway foreign body?

[Dr. Wolfgang Stehr]
Yes, we would get advanced imaging if there was a chronic history. If there was maybe a remote history of possible aspiration with a coughing event, normal physical exam, and then sometimes development of a pneumonia that then shows the lobar or subsegmental area in the lung that just isn't aerated well, then we would get the CT scan. The wildest thing we've seen there was a pea that actually started to sprout in the airway. You saw this little piece of leaf already growing out of that pea, which then we took out with a bronchoscopy.

[Dr. Gopi Shah]
Wow. I agree that ties into the differential diagnosis or the things that can masquerade or [unintelligible 00:06:58] the red herring or cover the diagnosis of a foreign body that then leads to a pneumonia. A lot of kids will, "Well, they've been treated for reactive airway for the last three months," or, "Oh, they have asthma," here we are intubated, right lung out and there's actually a peanut or something else there. Sometimes in the infants, if there isn't a strong history or maybe there is a little history in the 15-month-old of, "Yes, they coughed a little bit when they were eating a chip," and now they're coming to the ER and there's a runny nose. Sometimes that can be hard to decipher as well. Is it a viral URI, is it mucus plugging or how does it all go? These can be really tricky to tease out sometimes, especially with the history, I think is the most important thing regardless, meaning, if there's a witnessed choking history, they coughed, there was a time where potentially they stopped breathing or turned blue, is going to be your biggest reason to go to the OR to take a look. Now planning for the OR, tell me what your thoughts are and why just planning or thinking about the or, it's like, "All right, here we go."

Listen to the Full Podcast

Airway Foreign Bodies in Children: Risk Reduction with Dr. Wolfgang Stehr on the BackTable ENT Podcast)
Ep 96 Airway Foreign Bodies in Children: Risk Reduction with Dr. Wolfgang Stehr
00:00 / 01:04

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Equipment Management in Pediatric Foreign Body Airway Obstruction Removal

A significant yet often overlooked aspect of managing pediatric airway foreign bodies is equipment preparedness, especially when it comes to bronchoscopy. The complexity of bronchoscopy procedures isn't solely confined to the procedure itself, but also extends to setting up the equipment, which can prove to be a daunting task, particularly during off-hours with potentially less experienced personnel. This setup involves the availability and correct assembly of several vital components, from light cords and lenses to appropriately sized graspers. Often, clinicians might be faced with situations where a specific, critical piece is missing or incompatible. This reality underscores the importance of thorough planning, communication, and alternative solutions preparation. This equipment challenge eventually points towards the need for a better, more efficient system that ensures the ready availability and functionality of crucial bronchoscopy instruments.

[Dr. Wolfgang Stehr]
When I was doing my pediatric surgery fellowship, one of my attendings says the hardest thing about a bronchoscopy is putting together the equipment, because oftentimes this happens evening, off hours, weekends, or at night, and you don't have the A team that is trained and experienced with your ENT procedures or with your bronchoscopy equipment.

More often than not, there was always the stressed hunt for this little piece, that connector that was missing, or you'll usually have the light cord and you'll have the lens, but then do you have the right grasper and do you have the right length of the lens that fits into your scope? Do you have the right visual grasper with the right lens that fits in the grasper that then fits in your scope? It felt so unnecessary to do this last minute when everybody's already on edge and a little stressed and you're trying to take care of this patient.

[Dr. Gopi Shah]
Absolutely. My thought is half the case or the success of the case really depends on how the setup is, how prepared you are, is the equipment ready, and have I talked to my tech, my nurse, and my anesthesiologist. As much information as I have, the child looks clinically great or the child is really struggling to, hey, the family said it was from after they were eating a bowl of popcorn and maybe I can somehow practice with something round and smooth to grab it to talking to my tech of, "Hey, this is what they think it is."

If I can't get it with my grasper, do we have access to a basket, does it slide in? Do I have a potentially even a balloon or what are different ways because plan A doesn't always work and we sometimes have to get to plan C. As much as the setup is very important, talking to our anesthesia colleagues, but I think that these happen at off hours, middle of the night, weekends, holidays. It's not always going to be the anesthesiologist that you've done your airway cases with. It's not always going to be the tech that knows the ENT, ENT lead tech that knows where all the little bits and parts that you need are, and it's not always the nurse that's used to bringing this child with an airway foreign bodies up from the ER or from pre-op and knowing how to arrange the room and everything that we need. I think the one constant, though, is having the right equipment. That's the one thing that we can try to make sure that we have, because how many times have you put in the grasper and maybe the tines are slightly off and you just can't grab it or the peanut grasper that you need, it doesn't stay open or it doesn't close right and the child's on the table. That's the worst feeling. That drives me crazy.

[Dr. Wolfgang Stehr]
Yes, you're right. This is one of the things that motivated me to lean into this and actually try to provide a better option. Maybe one little thing, many of us know that this equipment sometimes lives in a big cart that has multiple metal drawers and you have one drawer that's supposed to have the graspers, you have one drawer that's supposed to have the scopes, and another drawer that's supposed to have the suction devices, and then the light cord and the section tubing are somewhere else because they left with the laparoscopy equipment. You talked about those option B and option C and sometimes option D, somehow it makes us feel safe to have access to everything. That's why people love the big carts, because the cart has everything, like 100 different options and 100 different graspers. Reality is, those multiple elements of the bronchoscopy equipment are not maintained and are very hard to see and identify when you really quickly need to put together your scope and get the right grasper. That was the starting point where we said, "Let's make this better."

Streamlining Pediatric Foreign Body Airway Obstruction Removal: A Lean Methodology Approach

The Lean methodology, originally conceptualized by Toyota for its manufacturing processes, has intriguing applications in healthcare, including the management of pediatric airway foreign bodies. This process improvement system centers on establishing an optimal, standardized sequence of operations—akin to fitting brakes before attaching wheels to a car. This methodology emphasizes waste reduction in healthcare, from time and equipment to motion and inventory, which can help to enhance safety, efficiency, and the overall quality of service. By applying Lean principles to the process of pediatric bronchoscopy, it becomes possible to better categorize patients, tailor equipment setups, and optimize care. Moreover, these principles encompass the 5S steps—sort, set in order, shine, standardize, and sustain—which provide a practical, systematic approach to improve and maintain the quality of equipment and care over time.

[Dr. Gopi Shah]
Tell me about the Lean methodology. What is the Toyota Lean System? How'd you learn about it?

[Dr. Wolfgang Stehr]
The organization I worked with actually embraced Toyota Lean as their process improvement system. A simple way to describe it is, if you put together a car and it's your job to put on the wheels, then the step that has to happen before you put on the wheel, you have to put in the brakes. You have your car, you put on the brakes and then you put on the wheel. If somebody does it in the wrong order and you put your wheel on and you maybe forget your brakes, you know something is going wrong when this car rolls off the lot. Same thing in healthcare, there is a correct order for the process and you have to do step A and then you have to do step B and then you have to do step C. Many of those processes can be very standardized in order to make it easier and more efficient and not have to rethink it. It also really helps training the staff on saying, "This is our process, this is how we do it, because it's more efficient and it's safer."

[Dr. Gopi Shah]
Why was this process-- Why did you apply this method specific to airway foreign bodies in children?

[Dr. Wolfgang Stehr]
Look, many articles in the past 10 years have written about there being so much waste in healthcare. There's a number of things we're wasting. We're wasting time, we're wasting equipment, we're wasting motion, we're wasting inventory. The organizations then bring in Lean because they think it can save them money. That is true. Besides saving money, we can really improve safety and quality of the process. We took the Lean methodology and looked at these airway foreign bodies and the equipment that we use to take care of those children. It fits into the process very nicely. We can go through some of the steps if you would like.

[Dr. Gopi Shah]
Absolutely. I would love to hear about the steps.

[Dr. Wolfgang Stehr]
We start with first identifying a goal. What is it we actually want to do. For this, we want to take better care of patients with airway foreign bodies. Then we identify further who are these patients? Are they really all under a year old? Are they really under two years old, or are there some teenagers? We look back at our data. The data actually said, yes, there's a peak early on between 9 and 20 months. Then there's a few other patients that are a little bit older. They're teenagers. They put stuff in their mouths like a nail or sometimes a sewing needle, push pins,

[Dr. Gopi Shah]
Push pins.

[Dr. Wolfgang Stehr]

[Dr. Gopi Shah]
Yes, I've had that too.

[Dr. Wolfgang Stehr]
They need different equipment. Already being able to separate by age or by weight, allows you to have two completely different setups. Then one of the important elements of the Lean process is you go through the 5S steps. The steps are you sort, you set in order, you shine, you standardize and you sustain. What does that mean? Sorting means you open your big cart with all your drawers and you touch every single item that's in there and you make sure you have what you need and you can throw out the stuff you no longer need or nobody has ever used, and then you set in order. Setting in order is exactly what you said. The little alligator grasper and the tines don't meet. That is setting in order, making sure that the equipment that is in your tray actually works. Then shine is, you make sure you have the right way to clean it and you have the right way to maintain it, because sometimes you have your scopes and you look through it and in there, there may still be a tiny little bit of piece of dried blood or something, and that shouldn't be, same with your lenses. The lenses have to be straight, they have to have a full vision. We have to make sure they're maintained. Then we standardize, which means we find a way to take care of this equipment the same way every time, whether you have a traveler in sterile processing or whether you have a new tech or whether you have a visiting surgeon who's doing this procedure. We really try to standardize the process and then come sustain. Sustain then allows us to maintain the equipment so that if I come back in a year, it's still taken care of the same way, and that the right people touch it and those people who touch it know what to do and know what to expect and then the equipment is put together. These are the 5S of the lean process.

Podcast Contributors

Dr. Wolfgang Stehr discusses Airway Foreign Bodies in Children: Risk Reduction on the BackTable 96 Podcast

Dr. Wolfgang Stehr

Dr. Wolfgang Stehr is a pediatric surgeon and medical director of surgery at Presbyterian Healthcare in Albuquerque, New Mexico.

Dr. Gopi Shah discusses Airway Foreign Bodies in Children: Risk Reduction on the BackTable 96 Podcast

Dr. Gopi Shah

Dr. Gopi Shah is a practicing ENT at UT Southwestern Medical Center in Dallas, TX.

Cite This Podcast

BackTable, LLC (Producer). (2023, March 14). Ep. 96 – Airway Foreign Bodies in Children: Risk Reduction [Audio podcast]. Retrieved from

Disclaimer: The Materials available on are for informational and educational purposes only and are not a substitute for the professional judgment of a healthcare professional in diagnosing and treating patients. The opinions expressed by participants of the BackTable Podcast belong solely to the participants, and do not necessarily reflect the views of BackTable.



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