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
  • 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]
  • 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
  • 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

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!

May 2024