A 22-month-old toddler is evaluated in the emergency department for a persistent cough and… — USMLE Step 2 CK

A $22$ -month-old toddler is evaluated in the emergency department for a persistent cough and noisy breathing that started abruptly while he was eating a snack mix containing peanuts at a family gathering the previous day. Initially, he had a vigorous coughing fit that resolved after several minutes, prompting the parents to monitor him at home. Today, he developed a mild fever of $37.6^\circ\text{C}$ ( $99.7^\circ\text{F}$ ) and ongoing tachypnea. He has no history of atopy, prior wheezing, or recent upper respiratory infections. Current vital signs show a heart rate of $128\text{/min}$ , respiratory rate of $46\text{/min}$ , and oxygen saturation of $93\%$ on room air. Physical examination reveals asymmetric chest expansion. Auscultation demonstrates prolonged expiration with a high-pitched wheeze exclusively over the right hemithorax. The left lung field has normal vesicular breath sounds. Which of the following is the most appropriate next step in management?

A
Right decubitus chest radiography
B
Administration of nebulized albuterol
C
Flexible bronchoscopy
Rigid bronchoscopyAnswer
E
Empiric intravenous ceftriaxone

Answer

Rigid bronchoscopy

The correct intervention is rigid bronchoscopy. This patient presents with a witnessed choking episode and focal abnormal lung findings (unilateral wheezing, asymmetric expansion), which makes the clinical diagnosis of foreign body aspiration highly probable. In pediatric patients with high clinical suspicion for FBA, the most appropriate next step is to proceed directly to rigid bronchoscopy. It allows for secure airway control, direct visualization, and immediate therapeutic removal of the object. Delaying for radiographic imaging is not indicated when the diagnosis is clinically evident.

Step-by-Step Solution

Analyze the patient's history for risk factors and onset of symptoms.

The patient is a toddler with an abrupt onset of coughing and choking while eating peanuts, which is the classic presentation for foreign body aspiration (FBA).

Identifying the timeline and trigger establishes the pre-test probability of mechanical airway obstruction.

Evaluate the physical examination findings to differentiate between generalized and focal pathology.

The presence of asymmetric chest expansion and a unilateral high-pitched wheeze confirms a focal obstruction in the right lower respiratory tract.

Focal lung findings in the context of a witnessed choking episode solidify the diagnosis of FBA over systemic viral illnesses like bronchiolitis or asthma.

Determine the optimal diagnostic and therapeutic algorithm based on the level of clinical suspicion.

Because both the history and physical exam are highly indicative of FBA, the patient must bypass screening radiography and proceed directly to definitive airway evaluation and extraction.

In high-suspicion FBA cases, radiographs may delay care and are frequently falsely reassuring; rigid bronchoscopy is the gold standard for secure pediatric airway management and foreign body removal.

Key Concept

Management algorithm for suspected pediatric foreign body aspiration

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