Examkin

Question

Difficulty: MediumPediatric Respiratory Disorders

A 2-year-old boy is brought to the emergency department after a witnessed choking episode while eating mixed nuts 1 hour ago. He had a severe fit of coughing initially, which has since subsided. On physical examination, he is alert and in mild respiratory distress. Vital signs show a temperature of 37.1°C (98.8°F), heart rate of 122/min, respiratory rate of 28/min, and oxygen saturation of 96% on room air. Lung auscultation reveals diminished breath sounds and localized expiratory wheezing over the right middle lobe. Arrange the following interventions in the most appropriate chronological sequence for the evaluation and management of this patient.

  1. 1Conduct a primary assessment to ensure airway stability and adequate oxygenation
  2. 2Obtain anteroposterior and bilateral decubitus chest radiographs
  3. 3Perform rigid bronchoscopy for definitive visualization and extraction
  4. 4Observe for post-procedural complications and administer corticosteroids if airway edema is present

Answer

The correct sequence is: 1) Conduct a primary assessment to ensure airway stability, 2) Obtain anteroposterior and bilateral decubitus chest radiographs, 3) Perform rigid bronchoscopy for visualization and extraction, and 4) Observe for post-procedural complications.
In a toddler presenting with a witnessed choking episode and focal lung findings (e.g., unilateral wheezing, diminished breath sounds), the diagnosis of a lower airway foreign body aspiration is highly suspected. The first step in management is always to evaluate the airway and ensure clinical stability. Because this patient is alert, maintaining oxygen saturation, and in only mild distress, the next appropriate step is to obtain chest radiographs. In toddlers, bilateral decubitus films are used to identify air trapping (the affected lung remains hyperinflated in the dependent position) since they cannot follow instructions for inspiratory/expiratory films. After radiographic confirmation, rigid bronchoscopy is performed under general anesthesia to safely remove the object. Following the procedure, the child must be observed for potential airway edema, which can be managed with corticosteroids if needed.

Step-by-Step Solution

1
Conduct a primary assessment
The patient is determined to be clinically stable with a patent airway, normal oxygenation, and only mild respiratory distress.
Immediate life threats must be ruled out. If the patient had severe respiratory distress or complete airway obstruction, immediate intervention (such as rigid bronchoscopy or age-appropriate choking rescue maneuvers) would bypass imaging.
2
Obtain anteroposterior and bilateral decubitus chest radiographs
Imaging provides evidence of air trapping in the right lung (the dependent lung fails to deflate on the decubitus film), supporting the diagnosis of a radiolucent foreign body.
Because the patient is stable, non-invasive imaging is utilized to confirm clinical suspicion and localize the foreign body before subjecting the child to general anesthesia.
3
Perform rigid bronchoscopy
The foreign body (nut fragment) is successfully visualized and extracted from the right mainstem bronchus.
Rigid bronchoscopy is the definitive diagnostic and therapeutic standard of care for tracheobronchial foreign bodies in children, allowing for secure airway control and the use of optical forceps.
4
Observe for post-procedural complications
The patient is monitored in the recovery area to ensure resolution of wheezing and absence of stridor.
Instrumentation of the pediatric airway can cause reactive edema, which may necessitate observation and administration of corticosteroids to prevent post-extubation respiratory distress.

Key Concept

Evaluation and Sequential Management of Suspected Pediatric Foreign Body Aspiration
Estimated Time:1m 30s
Rate this question

Topics

Pediatric Respiratory Disorders

More questions from this topic