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Difficulty: EasyPediatric Respiratory Disorders

Emergency medical services transport a 15-month-old girl to the emergency department following a sudden episode of severe choking and coughing. The babysitter reports the child was playing near a coffee table with a bowl of mixed nuts when the event occurred. The acute coughing fit has now subsided. Her vital signs show a temperature of 37.0°C (98.6°F), a heart rate of 128/min, a respiratory rate of 34/min, and an oxygen saturation of 97% on room air. Auscultation of the lungs reveals noticeably decreased air entry and a distinct expiratory wheeze localized to the right lower lung field. An expiratory chest radiograph displays hyperinflation of the right lung alongside a mild shift of the mediastinum toward the left. 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
    Nebulized albuterol
  4. D
    Oral amoxicillin
  5. E
    Chest physiotherapy

Answer

Rigid bronchoscopy is the most appropriate next step to safely evaluate and remove the aspirated foreign body.
The clinical picture of a sudden choking episode followed by unilateral wheezing and decreased breath sounds in a toddler is highly indicative of foreign body aspiration. The expiratory chest radiograph confirms a ball-valve obstruction in the right mainstem bronchus, trapping air and pushing the mediastinum to the contralateral side. Rigid bronchoscopy is the procedure of choice because it provides excellent visualization, allows for simultaneous ventilation, and accommodates the large optical forceps needed to safely grasp and remove the foreign object.

Step-by-Step Solution

1
Analyze the clinical history.
The patient experienced a sudden choking episode while near small nuts, which highly suggests foreign body aspiration.
Sudden onset of respiratory symptoms in a previously healthy toddler playing with small objects is the classic presentation of foreign body aspiration.
2
Evaluate the physical exam and imaging findings.
The patient has focal right-sided wheezing and unilateral hyperinflation with mediastinal shift on an expiratory radiograph.
These findings indicate a ball-valve effect, where air enters the right lung during inspiration but is trapped during expiration by the foreign body.
3
Determine the definitive management.
Rigid bronchoscopy.
Rigid bronchoscopy is required for therapeutic removal in children because it allows for ventilation and passage of large grasping instruments.

Key Concept

Foreign body aspiration in young children classically presents with a sudden choking episode, unilateral wheezing, and focal hyperinflation on expiratory radiography. The definitive management is rigid bronchoscopy.
Estimated Time:1m 0s
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Topics

Pediatric Respiratory Disorders

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