Examkin

Question

Difficulty: HardPediatric Respiratory Disorders

A 16-month-old boy is brought to the emergency department by his parents with a 3-day history of a persistent, harsh cough. The parents note that the cough started abruptly while the child was playing unsupervised in the living room, where his older siblings had been eating popcorn. He has no fever, rhinorrhea, or history of reactive airway disease. On physical examination, the child is alert and in mild respiratory distress. His temperature is 37.0°C (98.6°F), pulse is 120/min, respirations are 38/min, and oxygen saturation is 96% on room air. Lung auscultation reveals diminished breath sounds over the right hemithorax and a focal, monophonic expiratory wheeze on the right side. An expiratory chest radiograph shows increased radiolucency of the right lung field and a leftward shift of the mediastinum. Which of the following is the most appropriate next step in management?

  1. A
    Computed tomography scan of the chest
  2. B
    Flexible bronchoscopy
  3. Rigid bronchoscopyAnswer
  4. D
    Administration of nebulized albuterol
  5. E
    Administration of oral amoxicillin

Answer

Rigid bronchoscopy
The correct answer is rigid bronchoscopy. The patient's presentation of abrupt-onset coughing, focal monophonic wheezing, and diminished breath sounds on the right side strongly suggests foreign body aspiration. Because many aspirated objects (like popcorn or peanuts) are radiolucent, they do not appear directly on standard radiographs. Instead, they produce secondary signs such as unilateral hyperinflation (hyperlucency) due to a ball-valve mechanism: the bronchus dilates during inspiration, allowing air past the object, but constricts during expiration, trapping the air. Rigid bronchoscopy is the gold standard for management in pediatric patients because it allows for direct visualization, provides a secure airway, and enables the passage of appropriate grasping instruments for definitive removal.

Step-by-Step Solution

1
Identify the primary clinical presentation.
A toddler presents with an abrupt onset of cough, unilateral wheezing, and decreased breath sounds after potentially having access to a common choking hazard (popcorn).
Establishing the timeline and focal nature of the symptoms strongly points toward a mechanical airway obstruction.
2
Interpret the radiographic findings.
The expiratory chest radiograph shows right lung hyperlucency and a leftward mediastinal shift.
This confirms a 'ball-valve' effect where air enters the right lung during inspiration but gets trapped behind a radiolucent foreign body during expiration.
3
Determine the appropriate intervention.
Rigid bronchoscopy is indicated.
It is both diagnostic and therapeutic, providing a secure airway and allowing for the safe extraction of the foreign body in children.

Key Concept

Pediatric foreign body aspiration often presents with focal wheezing and unilateral air trapping (hyperlucency) on expiratory radiographs; the standard of care for removal is rigid bronchoscopy.
Estimated Time:1m 15s
Rate this question

Topics

Pediatric Respiratory Disorders

More questions from this topic