2d:I[856015,["/_next/static/immutable/chunks/1xzisbplk9czp.js","/_next/static/immutable/chunks/3j2i1faptc_-9.js","/_next/static/immutable/chunks/0fma7nlq6immz.js","/_next/static/immutable/chunks/08tq8rmv423j5.js","/_next/static/immutable/chunks/1chr5wkk3j58k.js","/_next/static/immutable/chunks/37kmmh_zm4dov.js","/_next/static/immutable/chunks/311zvdjfxff-f.js","/_next/static/immutable/chunks/1a_hqhrsle_n_.js"],"default"] 2e:T6ebe,

Summary Table

Category	Details
Risk Factors	Children aged 1 to 3 years (peak incidence), toddlers who explore objects by mouthing, elderly patients, patients with altered mental status (intoxication, sedation, neurological disorders), poor dentition, eating while laughing or running
Etiology	Inhalation of an exogenous object into the tracheobronchial tree; most common objects in children: peanuts, seeds, grapes, hot dogs, small toys, coins; in adults: food bolus, dental materials
Patient Presentation	Acute choking episode (may or may not be witnessed), sudden onset of cough, dyspnea, wheezing; may have a "symptom-free interval" followed by recurrent respiratory symptoms days to weeks later
Classic Physical Exam	Unilateral decreased breath sounds, localized (unilateral) wheezing, asymmetric chest expansion; stridor if lodged in the larynx or trachea; cyanosis in complete obstruction
Key Diagnostic Results	Chest X-ray (inspiratory and expiratory): hyperinflation on the affected side with mediastinal shift away on expiration (air trapping); radiopaque objects directly visible; confirmatory test is rigid bronchoscopy
Management	Choking protocol per age group (back blows/chest thrusts in infants, abdominal thrusts in children and adults); definitive removal via rigid bronchoscopy; post-procedural observation for airway edema
Keywords	"Sudden choking episode," "unilateral wheezing," "air trapping," "hyperinflation on expiratory film," "symptom-free interval," "recurrent pneumonia in the same lobe," "wheezing unresponsive to bronchodilators"

1. Pathophysiology

Foreign body aspiration occurs when an object bypasses the protective laryngeal reflexes (epiglottic closure, cough reflex, vocal cord adduction) and enters the lower airway. This is most common in toddlers aged 1 to 3 years because they lack fully developed molars for effective chewing, they tend to explore objects orally, and their airway protective reflexes are still maturing.

The location of the foreign body determines the clinical picture. In older children and adults, the aspirated object preferentially lodges in the right main bronchus because it is wider in diameter, shorter in length, and takes a more vertical course from the trachea compared to the left. In children younger than 2 years, the bronchial angles are more symmetric, so left-sided aspiration occurs nearly as frequently as right-sided.

The mechanism of obstruction follows one of two patterns. Partial (ball-valve) obstruction allows air to enter during inspiration (when the bronchus dilates) but traps air during expiration (when the bronchus narrows and the object creates a seal). This produces air trapping and hyperinflation distal to the obstruction. This is the classic finding tested on exams. Complete obstruction prevents airflow entirely, leading to absorption atelectasis as trapped gas is gradually absorbed by pulmonary capillaries.

Prolonged retention of a foreign body causes a local inflammatory response with mucosal edema, granulation tissue formation, and bacterial superinfection. This explains why undiagnosed cases present weeks to months later with recurrent pneumonia in the same anatomical location or persistent wheezing that fails to respond to bronchodilators, both of which are classic vignette clues.

When the foreign body lodges at the laryngeal or tracheal level, the situation becomes immediately life-threatening. Complete supraglottic obstruction produces the "universal choking sign" (hands clutching the throat), inability to speak or cough, rapid cyanosis, and if unrelieved, cardiopulmonary arrest within minutes.

2. Classification and Clinical Manifestation

By Location

Location	Frequency	Presentation	Examination Findings
Laryngeal	~5% of cases	Hoarseness, stridor, aphonia, complete obstruction possible	Inspiratory stridor, voice changes, suprasternal retractions
Tracheal	~5-10%	Biphasic stridor, palpable "thud" or audible slap	Palpable tracheal foreign body sensation, biphasic stridor
Bronchial (most common)	~80-90%	Cough, unilateral wheezing, dyspnea; may have a symptom-free interval	Unilateral decreased breath sounds, localized wheezing, asymmetric chest expansion

By Degree of Obstruction

Degree	Pathophysiology	Clinical Picture	X-ray Finding
Partial (ball-valve)	Air enters on inspiration but is trapped on expiration	Wheezing, cough, mild dyspnea; patient may still vocalize	Hyperinflation of the affected lung on expiratory film; mediastinal shift away from the affected side
Complete	No airflow past the obstruction	Atelectasis develops over hours; increasing dyspnea, decreased breath sounds	Atelectasis/volume loss of the affected segment or lobe; mediastinal shift toward the affected side
Bypass valve	Air moves freely past the object in both directions	Minimal symptoms, intermittent cough	Chest X-ray may appear normal

By Timing of Presentation

Phase	Timing	Features
Acute	Minutes to hours	Sudden choking, paroxysmal cough, gagging, cyanosis
Asymptomatic (symptom-free interval)	Hours to days	Resolution of acute symptoms as airway accommodates; this phase is deceptive and causes delayed diagnosis
Chronic/Complications	Weeks to months	Recurrent pneumonia in the same lobe, persistent cough, non-resolving wheezing, bronchiectasis, lung abscess

3. Diagnostic Workup

Test	Role	Key Findings
Chest X-ray (PA, inspiratory and expiratory)	Best initial test	Radiopaque FB directly visible; radiolucent FB shows air trapping (hyperinflation on expiratory film), mediastinal shift away from affected side
Lateral decubitus chest X-ray	Alternative in young children who cannot cooperate with expiratory films	Affected side (dependent) fails to deflate normally; remains hyperinflated
Fluoroscopy	Dynamic assessment of air trapping	Real-time visualization of asymmetric diaphragm movement and mediastinal shift during respiration
CT Chest	Adjunct when plain films are inconclusive	Can identify radiolucent foreign bodies, post-obstructive changes, and guide bronchoscopy planning
Rigid bronchoscopy	Gold standard (diagnostic AND therapeutic)	Direct visualization and removal of the foreign body

The best initial test is a chest X-ray with both inspiratory and expiratory views. This distinction is critical for exam questions. An inspiratory film alone may appear completely normal because air flows past the object during the inspiratory phase. The expiratory film is where the diagnosis becomes apparent: the affected lung remains hyperinflated (it cannot empty) while the normal lung deflates, and the mediastinum shifts away from the obstructed side. This is the hallmark of ball-valve obstruction.

Only about 10 to 15% of aspirated foreign bodies are radiopaque (coins, metallic objects, teeth). The majority in children are organic materials such as peanuts and seeds, which are radiolucent. For these, you must rely on indirect signs of obstruction on the X-ray.

For infants and toddlers who cannot follow commands to exhale on cue, the lateral decubitus film serves as the alternative. When a child lies on the affected side (dependent position), the affected lung should normally compress under gravity and appear deflated. If the foreign body is creating a ball-valve effect, the affected lung remains hyperinflated despite being in the dependent position. This is a frequently tested concept.

Fluoroscopy provides a dynamic, real-time view of diaphragm movement and mediastinal shifting during the respiratory cycle. It is particularly useful when static films are equivocal but clinical suspicion remains high.

The most accurate and confirmatory test is rigid bronchoscopy. This is the gold standard because it simultaneously confirms the diagnosis and provides the definitive treatment by allowing foreign body extraction under direct visualization. If clinical suspicion is strong (a witnessed choking episode with subsequent respiratory symptoms), proceed directly to rigid bronchoscopy even if the chest X-ray appears normal. A normal X-ray does not exclude the diagnosis.

4. Management and Treatment

Emergency Management of Acute Choking (Basic Life Support)

This is one of the most commonly tested areas in clinical licensing exams. The approach differs by age group, and the distinctions are high-yield.

Infant (< 1 Year Old)

Key principle: NEVER perform abdominal thrusts (Heimlich maneuver) on an infant. The risk of liver and spleen injury is too high.

Step	Action
1. Assess severity	Determine if the infant has an effective cough (partial obstruction with adequate air exchange) or an ineffective cough (silent cough, inability to cry or breathe, cyanosis)
2. If effective cough	Do NOT intervene. Encourage coughing. Monitor closely.
3. If ineffective cough and infant is CONSCIOUS	Begin the 5-and-5 cycle:
3a. Back blows	Hold the infant face-down along your forearm, supporting the head and jaw. Keep the head lower than the trunk. Deliver 5 firm back blows between the scapulae using the heel of your hand.
3b. Chest thrusts	Turn the infant face-up on your forearm, keeping the head lower than the trunk. Deliver 5 chest thrusts using two fingers placed just below the intermammary line (same landmark as infant CPR compressions).
3c. Repeat	Alternate 5 back blows and 5 chest thrusts until the object is expelled or the infant becomes unconscious.
4. If infant becomes UNCONSCIOUS	Place on a firm, flat surface. Begin CPR (30 compressions : 2 breaths for a single rescuer). Each time you open the airway to deliver breaths, look into the mouth for the object. Remove it only if visible. Do NOT perform blind finger sweeps. Continue CPR until the object is expelled or advanced help arrives.

Child (> 1 Year Old)

Step	Action
1. Assess severity	Effective cough vs. ineffective cough (inability to speak, weak or silent cough, increasing cyanosis)
2. If effective cough	Encourage coughing. Do NOT intervene.
3. If ineffective cough and child is CONSCIOUS	Do 5 back blows and 5 abdominal thrusts repeatedly.
3a. Back blows	Keep the head lower than the trunk. Deliver 5 firm back blows between the scapulae using the heel of your hand.
3b. Abdominal thrusts	Perform 5 abdominal thrusts (Heimlich maneuver): Stand or kneel behind the child. Place one fist above the umbilicus and well below the xiphoid process. Grasp the fist with the other hand. Deliver quick inward and upward thrusts.
3c. Repeat	Alternate 5 back blows and 5 Abdominal thrusts until the object is expelled or the infant becomes unconscious.
4. If child becomes UNCONSCIOUS	Lower the child to the ground. Begin CPR (30:2 for single rescuer, 15:2 for two-rescuer). Each time the airway is opened, look for the object before delivering breaths. Remove only if clearly visible. No blind finger sweeps. Continue until object expelled or advanced help arrives.

Adult

Step	Action
1. Assess severity	Ask "Are you choking?" Look for the universal choking sign (hands to throat). Determine: Can the patient speak, cough, or breathe?
2. If partial obstruction with effective cough	Encourage forceful coughing. Stay with the patient and monitor. Do NOT perform thrusts.
3. If complete obstruction and patient is CONSCIOUS	Perform abdominal thrusts (Heimlich maneuver): Stand behind the patient. Place your fist above the umbilicus, below the xiphoid. Wrap the other hand around the fist. Deliver firm inward and upward thrusts. Repeat until the object is expelled or the patient becomes unconscious.
3a. EXCEPTION: Pregnant or obese patients	Use chest thrusts instead of abdominal thrusts. Place your fist at the center of the sternum (same location as CPR hand placement). Deliver firm, backward thrusts.
4. If patient becomes UNCONSCIOUS	Lower the patient to the ground. Begin CPR (30:2). Each time the airway is opened, look into the mouth. Remove the object only if visible. No blind finger sweeps. Continue CPR. If advanced airway management is available, attempt direct laryngoscopy with Magill forceps to remove the object under visualization.

Definitive Management (In-Hospital)

Setting	Management
Stable patient, suspected aspiration	Chest X-ray (inspiratory + expiratory) to confirm; then proceed to rigid bronchoscopy
Rigid bronchoscopy	Gold standard for removal; performed under general anesthesia; preferred in children
Flexible bronchoscopy	May be used in adults for smaller or more distal foreign bodies; less effective for large or irregular objects
Post-procedural care	Observation for airway edema, bleeding, bronchospasm; short course of corticosteroids if significant mucosal edema; antibiotics if evidence of post-obstructive infection
Surgical intervention (thoracotomy/bronchotomy)	Rarely needed; reserved for cases where bronchoscopic retrieval fails or the foreign body has eroded into surrounding tissue

Rigid bronchoscopy is the definitive treatment and should not be delayed when clinical suspicion is high, regardless of X-ray findings. It is preferred over flexible bronchoscopy in children because it provides a larger working channel, better airway control, and the ability to ventilate the patient during the procedure.

If the foreign body has been present for weeks to months, expect significant granulation tissue surrounding the object. In these cases, a short course of systemic corticosteroids (dexamethasone 0.5 mg/kg/day for 24 to 48 hours) may be given before bronchoscopy to reduce mucosal edema and improve visualization.

Post-obstructive pneumonia should be treated with appropriate antibiotics targeting common respiratory pathogens, guided by culture results when available.

5. Differential Diagnosis and Distractors

Differential	Why It Looks Similar	Key Discriminator
Asthma	Wheezing, cough, dyspnea in a young child	Asthma produces bilateral, diffuse wheezing that responds to bronchodilators. Foreign body aspiration causes unilateral wheezing that does NOT respond to bronchodilators. No acute choking history in asthma.
Croup (laryngotracheobronchitis)	Stridor, respiratory distress in a toddler	Croup has a barking (seal-like) cough, preceded by a viral upper respiratory prodrome and low-grade fever. X-ray shows a steeple sign (subglottic narrowing). No acute choking event.
Epiglottitis	Acute onset stridor, drooling, respiratory distress	Epiglottitis presents with high fever, toxic appearance, drooling, tripod positioning, and a muffled "hot potato" voice. Lateral neck X-ray shows the thumbprint sign. No choking event.
Bronchiolitis	Wheezing and respiratory distress in an infant	Bronchiolitis is preceded by a viral prodrome (rhinorrhea, low-grade fever) with bilateral wheezing and crackles. Typically caused by RSV in infants under 2 years. Chest X-ray shows bilateral hyperinflation, not unilateral air trapping.
Retropharyngeal abscess	Stridor, neck stiffness, drooling in a young child	Preceded by an upper respiratory infection. Presents with neck hyperextension, refusal to swallow, fever. Lateral neck X-ray shows widened prevertebral soft tissue (>7 mm at C2 or >14 mm at C6 in children).
Vascular ring	Chronic stridor and wheezing in an infant	Symptoms are chronic and positional, often worsening with feeding. Barium swallow shows posterior indentation of the esophagus. No acute onset.
Recurrent pneumonia (other causes)	Repeated infections in the same location	Consider immunodeficiency, cystic fibrosis, or congenital lung malformations. However, recurrent pneumonia always in the same lobe with a history of a prior choking episode points to a retained foreign body.

6. Traps and High-Yield Pearls

The single most common trap with foreign body aspiration questions is the normal inspiratory chest X-ray. Students see a normal-looking film and rule out the diagnosis, but they fail to recognize that the inspiratory film can be completely unremarkable in a ball-valve obstruction. The expiratory film is where the pathology is revealed. If a vignette describes a witnessed choking episode in a toddler with unilateral wheezing and a "normal chest X-ray," the next best step is to obtain expiratory films, lateral decubitus films, or proceed directly to bronchoscopy.

Another frequent trap is the symptom-free interval. A child chokes on a peanut, coughs violently for a minute, then appears totally fine. The parents do not seek medical attention. Weeks later, the child presents with recurrent pneumonia or persistent wheezing. Students often fail to connect the delayed presentation to the earlier choking event. Any vignette mentioning "recurrent pneumonia in the same lobe" or "wheezing refractory to bronchodilators" in a young child should trigger consideration of a retained foreign body.

For the choking management algorithm, the most tested distinction is infants versus older children and adults. The exam will test whether you know that abdominal thrusts are contraindicated in infants younger than 1 year due to the risk of hepatic and splenic injury. The correct sequence for a conscious choking infant is 5 back blows followed by 5 chest thrusts, not abdominal thrusts. Another tested point: if any choking patient becomes unconscious, the intervention changes to CPR with airway checks before each ventilation attempt, and blind finger sweeps are never performed regardless of age.

Finally, remember the laterality teaching point. When a vignette says "foreign body aspiration" and asks you to predict the location, the answer in older children and adults is the right main bronchus (wider, shorter, more vertical). In very young children (under age 2), the angle difference is less pronounced, so bilateral involvement is more equally distributed.

The core competency being tested across all question types on this topic is your ability to: (1) recognize foreign body aspiration from indirect clues in a vignette, even when the choking event is not the chief complaint, (2) correctly sequence the diagnostic workup with emphasis on expiratory or decubitus films, (3) apply age-appropriate choking interventions, and (4) identify rigid bronchoscopy as both the confirmatory diagnostic and the definitive therapeutic step.

1e:["$","$L2d",null,{"article":{"id":"cf5e11f7-88df-46d0-bb0a-e8552914a772","title":"Aspirasi Benda Asing","content":"$2e","category":"Respirologi","created_at":"2026-07-02T01:01:23.212296+00:00","status":"published","subcategory":null},"questionCount":3,"sections":[{"id":"section-pathophysiology","num":"01","title":"Pathophysiology"},{"id":"section-classification-and-clinical-manifestation","num":"02","title":"Classification and Clinical Manifestation"},{"id":"section-diagnostic-workup","num":"03","title":"Diagnostic Workup"},{"id":"section-management-and-treatment","num":"04","title":"Management and Treatment"},{"id":"section-differential-diagnosis-and-distractors","num":"05","title":"Differential Diagnosis and Distractors"},{"id":"section-traps-and-high-yield-pearls","num":"06","title":"Traps and High-Yield Pearls"}],"hasSummaryTable":true}]