Examkin

Question

Difficulty: HardPediatric Respiratory Disorders

Emergency medical services transport a 14-month-old male toddler to the hospital following an acute episode of respiratory distress. The parents report that two hours prior to arrival, the child experienced an abrupt, violent choking spell while playing unsupervised in his older sibling's bedroom. The initial severe coughing subsided, but a persistent, noisy breathing pattern developed immediately afterward. He has been previously healthy with no recent history of fever, rhinorrhea, or diagnosed pulmonary conditions. Vital signs upon arrival include a temperature of 37.0°C (98.6°F), a heart rate of 142/min, a respiratory rate of 48/min, and an oxygen saturation of 94% on ambient air. Physical examination shows a conscious, alert child with mild subcostal retractions. Chest auscultation identifies noticeably decreased air entry over the right hemithorax, accompanied by a focal monophonic wheeze during expiration. An expiratory chest radiograph reveals asymmetric hyperlucency of the right lung alongside a leftward deviation of the mediastinum. Which of the following is the most appropriate next step in the management of this patient?

  1. Rigid bronchoscopyAnswer
  2. B
    Flexible bronchoscopy
  3. C
    Administration of nebulized albuterol
  4. D
    Intravenous administration of ceftriaxone
  5. E
    Computed tomography of the chest

Answer

Rigid bronchoscopy is the most appropriate next step for diagnosing and treating pediatric foreign body aspiration.
The correct answer is rigid bronchoscopy. This toddler's presentation is highly suspicious for foreign body aspiration (FBA), characterized by a sudden choking episode, unilateral decreased breath sounds, and a focal monophonic wheeze. The expiratory chest radiograph confirms the diagnosis by demonstrating air trapping (right-sided hyperlucency and contralateral mediastinal shift), which occurs due to a 'ball-valve' effect at the site of bronchial obstruction. In pediatric patients, rigid bronchoscopy is the gold standard intervention. It serves as both a diagnostic and therapeutic modality, allowing the physician to secure the airway, maintain ventilation, and safely extract the foreign object using specialized rigid forceps.

Step-by-Step Solution

1
Analyze the patient's history and acute presentation.
The patient had a sudden, unwitnessed choking episode followed by persistent respiratory symptoms without a preceding viral prodrome.
An abrupt choking spell in an unattended toddler is the hallmark historical clue for a foreign body aspiration (FBA).
2
Interpret the physical examination and radiographic findings.
Focal monophonic wheezing, decreased right-sided breath sounds, and an expiratory radiograph showing right lung hyperlucency with leftward mediastinal shift.
These findings indicate a 'ball-valve' obstruction in the right mainstem bronchus, where air enters during inspiration but is trapped distally during expiration.
3
Determine the definitive management strategy based on the diagnosis of FBA.
The patient requires immediate rigid bronchoscopy.
Rigid bronchoscopy is the standard of care for pediatric FBA as it provides superior airway control, ventilation capability, and accommodates the optical forceps needed to safely extract the object.

Key Concept

Diagnosis and definitive management of pediatric foreign body aspiration.
Rate this question

Topics

Pediatric Respiratory Disorders

More questions from this topic