A 3-year-old boy is brought to the emergency department by his mother due to cough and difficulty breathing. The patient was playing outside with his older sisters when he started coughing uncontrollably. He has been coughing with audible wheezing for the past 30 minutes. The patient has no chronic medical conditions but has had rhinorrhea for the past few days. Temperature is 36.7 C (98.1 F), blood pressure is 92/48 mm Hg, pulse is 114/min, and respirations are 48/min. Pulse oximetry is 91% on room air. The right lung has diminished breath sounds and expiratory wheezing. The left lung is clear. Supplemental oxygen is applied. Chest x-ray reveals hyperinflation of the right lung and left mediastinal shift. Which of the following is the best next step in management of this patient?

Question

A 3-year-old boy is brought to the emergency department by his mother due to cough and difficulty breathing.  The patient was playing outside with his older sisters when he started coughing uncontrollably.  He has been coughing with audible wheezing for the past 30 minutes.  The patient has no chronic medical conditions but has had rhinorrhea for the past few days.  Temperature is 36.7 C (98.1 F), blood pressure is 92/48 mm Hg, pulse is 114/min, and respirations are 48/min.  Pulse oximetry is 91% on room air.  The right lung has diminished breath sounds and expiratory wheezing.  The left lung is clear.  Supplemental oxygen is applied.  Chest x-ray reveals hyperinflation of the right lung and left mediastinal shift.  Which of the following is the best next step in management of this patient?

Quizplus · Accepted Answer

11ec25c8_d1f8_243a_bc81_af79f1bff356_MD0003_00 This patient's sudden-onset respiratory distress and x-ray findings are concerning for foreign body aspiration. Foreign body aspiration is most common in children age 1-3 and usually involves foods (eg, nuts, seeds) or small toys. Patients typically have acute-onset dyspnea and cough. Decreased breath sounds on the affected side and wheezing (focal or generalized) are characteristic. There is often a history of a preceding choking episode; however, foreign body aspiration should always be considered in a child with sudden onset of unexplained respiratory symptoms, as in this patient. Over half of aspirated foreign bodies lodge in the right mainstem bronchus. Although x-ray may be normal, classic findings include hyperinflation distal to the obstruction (due to air trapping during expiration) and mediastinal shift away from the affected side, as seen here. Complete obstruction of a bronchus can result in ipsilateral atelectasis and, over time, postobstructive pneumonia and/or localized bronchiectasis. Most aspirated objects are radiolucent and not identified on x-ray. When foreign body aspiration is suspected, immediate rigid bronchoscopy is performed to confirm the diagnosis and remove the aspirated object. (Choice A) CT scan of the chest is sometimes used to identify a foreign body in an asymptomatic or stable patient in whom foreign body aspiration is suspected but who has a normal x-ray. This patient has respiratory distress and x-ray findings suggestive of foreign body aspiration, so urgent bronchoscopy is required. (Choice B) Chest tube is placed for respiratory distress secondary to a large pneumothorax. Although mediastinal shift occurs with tension pneumothorax, x-ray findings would include air (without lung markings) outside the pleural line and ipsilateral lung collapse (not hyperinflation). In addition, wheezing would not be expected. tension pneumothorax (Choice C) Epinephrine is the treatment for anaphylaxis, which presents with respiratory distress, angioedema/urticaria, and hypotension. This patient does not have a rash, and his blood pressure is normal for his age. (Choice D) Albuterol treats asthma exacerbations, which cause generalized wheezing and diffuse hyperinflation on x-ray. This patient's sudden onset of symptoms and unilateral hyperinflation make foreign body aspiration more likely. Because of the fixed bronchial obstruction, bronchodilators are not used to treat foreign body aspiration with focal wheezing. (Choice E) Nebulized racemic epinephrine treats croup, which is characterized by a barky cough, inspiratory stridor, and steeple sign on x-ray, none of which are seen in this patient. Educational objective: Sudden-onset respiratory distress with unilateral hyperinflation and mediastinal shift on x-ray are concerning for foreign body aspiration. Rigid bronchoscopy can identify and remove the aspirated object. References: Extraction of tracheobronchial foreign bodies in children and adults with rigid and flexible bronchoscopy. (http://www.ncbi.nlm.nih.gov/pubmed/23207261) Foreign body aspiration in children: experience from 2624 patients. (http://www.ncbi.nlm.nih.gov/pubmed/23962764) Tracheobronchial aspiration of foreign bodies and rigid bronchoscopy in children. (http://www.ncbi.nlm.nih.gov/pubmed/22414345)

A 3-Year-Old Boy Is Brought to the Emergency Department by His