An 18-month-old boy is brought to the emergency department due to respiratory distress. Severe cough and wheezing began an hour ago while the patient was playing at his cousin's house. Temperature, blood pressure, and pulse are normal. Respirations are 46/min, and pulse oximetry is 90% on room air. Oropharynx is unremarkable. There are suprasternal and intercostal retractions. Auscultation reveals a prolonged expiratory phase as well as wheezing without crackles over the right lung. There is hyperresonance to percussion on the right chest. The left lung is clear without crackles or wheezes. Cardiac examination shows normal S1 and S2. The abdomen is soft and nontender. Skin examination shows no rashes. The patient receives a dose of nebulized albuterol and supplemental oxygen with no improvement. Chest radiograph is shown in the image below: Which of the following is the most likely cause of this patient's symptoms?

Question

An 18-month-old boy is brought to the emergency department due to respiratory distress.  Severe cough and wheezing began an hour ago while the patient was playing at his cousin's house.  Temperature, blood pressure, and pulse are normal.  Respirations are 46/min, and pulse oximetry is 90% on room air.  Oropharynx is unremarkable.  There are suprasternal and intercostal retractions.  Auscultation reveals a prolonged expiratory phase as well as wheezing without crackles over the right lung.  There is hyperresonance to percussion on the right chest.  The left lung is clear without crackles or wheezes.  Cardiac examination shows normal S1 and S2.  The abdomen is soft and nontender.  Skin examination shows no rashes.  The patient receives a dose of nebulized albuterol and supplemental oxygen with no improvement.  Chest radiograph is shown in the image below:  Which of the following is the most likely cause of this patient's symptoms?

Quizplus · Accepted Answer

11ec25c8_d1f9_0e9c_bc81_a3bb87d265d8_MD0003_00 Wheezing, a common chief complaint in children, is primarily due to asthma or a viral illness. However, sudden-onset, unilateral wheezing that is unresponsive to albuterol raises suspicion for foreign body (FB) aspiration. FB aspiration most commonly occurs in children age 1-3 due to oral exploratory behavior and a relatively narrow airway diameter. Following aspiration, patients classically develop abrupt-onset respiratory distress (eg, cough, dyspnea, hypoxia). The aspiration event may be unwitnessed, and a history of choking is not always present. In most cases, the object partially obstructs one of the bronchi, resulting in a prolonged expiratory phase due to air trapped distal to the obstruction. Wheezing and decreased breath sounds on the affected side are characteristic, and hyperresonance to percussion can occur over the hyperexpanded lung. Although x-ray may be normal, findings suggestive of FB aspiration include unilateral lung hyperinflation with mediastinal shift toward the unaffected side, as seen in this patient. Atelectasis may be present in cases of complete bronchial obstruction. Most aspirated objects are radiolucent and therefore not identified on x-ray. FB aspiration Management includes immediate rigid bronchoscopy to confirm the diagnosis and remove the object. (Choice A) Anaphylaxis presents with acute-onset respiratory distress, angioedema/urticaria, and hypotension. This patient has no rash, and blood pressure is normal for age. In addition, wheezing in anaphylaxis would be diffuse (ie, nonfocal). (Choice B) Patients with asthma have diffuse wheezing, prolonged expiratory phase, and bilateral hyperinflation on x-ray. In contrast, this patient has localized wheezing unresponsive to albuterol and unilateral lung hyperinflation. (Choice C) Bronchiolitis is a lower respiratory tract infection that presents in children age <2 with fever, cough, rhinorrhea, and diffuse wheezing. X-ray may show bilateral hyperinflation as well as peribronchial thickening. This patient lacks infectious symptoms (eg, fever, rhinorrhea) and has asymmetric lung findings. (Choice E) Pneumonia can present with cough and respiratory distress but also typically causes fever, crackles, and a lobar consolidation on x-ray (not seen in this patient). (Choice F) Pneumothorax can present abruptly with cough and hypoxia but does not typically cause wheezing. In addition, x-ray shows air without lung markings outside the pleural line with ipsilateral lung collapse (not hyperinflation). Educational objective: Foreign body aspiration should be suspected in a child with abrupt-onset cough and wheeze (with or without a choking episode) that is unresponsive to albuterol. Supportive findings include a focal lung examination (eg, wheeze, decreased breath sounds, hyperresonance) and/or unilateral lung hyperinflation with mediastinal shift on x-ray. References: Factors predicting early diagnosis of pediatric laryngotracheobronchial foreign bodies. (http://www.ncbi.nlm.nih.gov/pubmed/26860607)

An 18-Month-Old Boy Is Brought to the Emergency Department Due