Airway obstruction due to a foreign body (FB) mainly occurs in children under 3 years of age and is the leading cause of nondisease-related death in children under 12 months of age [1–3]. Airways in children are smaller in diameter than in adults, resulting in a higher risk of respiratory failure in situations with FB aspiration. Therefore, rapid removal is particularly important, and the widely recommended treatment is a rigid bronchoscope [4]. However, in life-threatening cases accompanied by respiratory failure at the emergency department (ED), initial lifesaving procedures are critical.

Herein, we report a case of an infant who visited the ED with respiratory failure due to subglottic FB aspiration.

A 12-month-old, boy presented in the ED with choking. According to his mother’s statement, he was eating bread that got stuck in his throat. He was born to nonconsanguineous, healthy parents; had a normal perinatal period; and was developmentally age appropriate. His estimated body weight was 10 kg.

On examination, his mental status was alert and response was appropriate. Initial heart rate was 175 beats/min, respiratory rate was 40 breaths/min, and body temperature was 36.6 °C. His peripheral oxygen saturation was 100%, but inspiratory chest wall retraction was observed. He was crying but his voice was gradually decreasing. No FB was found in the oral cavity, and three cycles of five chest thrusts and five back blows were performed but were unsuccessful. However, a chest x-ray showed a 2-cm-sized, radio-opaque, oval-shaped FB at the carina (Fig. 1). A team for rigid bronchoscopy was activated. Because respiratory distress worsened, endotracheal intubation was initiated using a 4F, cuffed endotracheal tube (ET). While attempting intubation, his heart rate suddenly decreased to 40 beats/min and resulted in respiratory arrest, for which chest compressions were started. Return of spontaneous circulation was obtained within 2 minutes of compression, but the bag valve mask was stiff due to high airway resistance.

Then, we attempted to move the FB through physical force with the ET. However, airway resistance was not resolved. We marked a stylet at a length 2 cm longer than the ET and with the same size as the intubated tube. The stylet was pushed into the patient’s ET to the marked length. Immediately after this procedure, bagging was performed smoothly, and cyanosis was resolved. In 5 minutes, the patient opened his eyes and showed signs of regaining consciousness. Figs. 1 and 2 show the FB moved into the proximal right bronchus.

A rigid bronchoscope was used to remove a 2.5-cm-sized FB blocking the right bronchus (Fig. 3). The postoperative x-ray is shown in Fig. 4. The patient was discharged without any sequelae on the 3rd day of hospitalization.

We report a case of subglottic FB aspiration in an infant who developed respiratory failure and respiratory arrest that was not resolved with endotracheal intubation. FB aspiration can be a life-threatening event, especially at a young age, and can have irreversible results if not resolved in a timely manner. According to a study in 2022 by Igarashi et al. [5], the rate of progression to vegetative state or death significantly increases if an FB obstructs the airway for more than 6 minutes. If more than 10 minutes elapses, the rate of progression to Cerebral Performance Category score 4 or 5 is 70%. Data on the time from recognition of FB aspiration to insertion of a rigid bronchoscopy are lacking. In the present case that occurred on a weekday, during the daytime, approximately 45 minutes elapsed from call to execution. The operation required an additional 15 minutes. Korlacki et al. [6] reported an operation time range of 5 to 90 minutes in 27 children who underwent bronchoscopy for FB aspiration, with a mean time of 24 minutes.

Based on educational and review literature, intubation past an obstruction or forcing a blockage into a mainstem bronchi can be attempted to resolve choking [7,8]. The two major factors that contributed to the success in the present case were the following. First, one-lung ventilation was attempted immediately after we recognized that ventilation was not effective after endotracheal intubation. Second, when one-lung ventilation was not achieved with the ET fully inserted, a new ET of the same size with a pre-marked stylet for deeper insertion was used as a guide to reach the FB. Real-time fluoroscopy was not available, as is typical in emergency and resuscitation rooms.

There is no evidence to support the effectiveness of this approach in the setting of complete subglottic airway obstruction due to an FB [8]. In addition, information regarding the expected complications are scarce. The treatment decision should be based on the type of FB, as organic materials can absorb fluid and swell, oils from nuts cause localized inflammation, and sharp objects can pierce the airway [9]. While detailed history taking is crucial to predict the nature of the FB, it is also important to consider the possibility that the actual situation may differ from the initial statement, as seen in this case.

Herein, a successful case of a lifesaving procedure by forcing an FB further into the right mainstem of the bronchus was reported. This procedure could lead to safe bronchoscopic removal and discharge without sequelae.