You see a 20 month old with no PMH who has been wheezing and coughing for a few days. His cousin has RAD. Should you just give him a little albuterol and see how he does?
Here’s his x-ray:
What are you concerned for?
This child has evidence of aspiration with an airway foreign body, seen here with moderate hyperlucency/hyperexpansion of R hemithorax with mild deviation of mediastinum toward L chest.
- Presentation
- Most often (acute): sudden episode choking w/subsequent wheezing, coughing or stridor
- Less often (delayed diagnosis): unwitnessed aspiration leading to persistent cough, wheezing, recurrent PNA/lung abscess, focal bronchiectasis or hemoptysis
- Physical Exam
- Often: unilateral wheezing, stridor or decreased breath sounds
- Depending on placement of FB (i.e. intrathoracic trachea) and size of lung lobes v stethoscope head, may be symmetric
- Often: unilateral wheezing, stridor or decreased breath sounds
- Imaging (usually FB is radiolucent food object so indirect findings observed):
- PA CXR: hyperinflation or atelectasis of affected side (depending on degree of obstruction)
- May obtain inspiratory/expiratory films if child cooperates
- Normal XR does NOT rule out airway FB
- Lateral decubitus CXR: failure to collapse 2/2 air trapping on affected side
- AP/lateral soft tissue neck XR: may show infraglottic opacity and/or edema
- Other: fluoroscopy, chest CT, MRI [focal airway edema, overinflation/air trapping, FB]
- PA CXR: hyperinflation or atelectasis of affected side (depending on degree of obstruction)
- Treatment:
- If in respiratory distress/unable to speak: attempt back blows/chest compressions (infants) or Heimlich maneuver (older children)
- Otherwise, AVOID Heimlich maneuver as can dislodge FB into complete airway obstruction
- Definitive treatment: rigid bronchoscopy
- If unconfirmed dx, obtain flexible bronchoscopy first (can explore deeper/upper airways); may be able to remove FB, but usually requires subsequent rigid bronchoscopy
- If in respiratory distress/unable to speak: attempt back blows/chest compressions (infants) or Heimlich maneuver (older children)
- Disposition:
- Once FB removed and patient stable, discharge (often same day)
- If swelling/granulation tissue observed, corticosteroids may be administered
- No need for antibiotics unless secretions appear infected
- Once FB removed and patient stable, discharge (often same day)
Airway foreign bodies are the third most common cause of death due to unintentional injury in children younger than 1 year, so don’t forget this one!
