A 3-year-old girl with a history of asthma is brought to the clinic for follow-up. Five days ago, the patient had a choking episode during a meal. She subsequently developed persistent cough and wheezing and was taken to the emergency department the same day. The wheezing improved with 3 treatments of nebulized albuterol, and chest radiograph was unremarkable. The patient was discharged with instructions to continue the albuterol and begin oral corticosteroids. She finished her corticosteroid course this morning, but the cough has persisted despite albuterol use. The patient has had no fever, congestion, or rhinorrhea. Vital signs are normal. The oropharynx is clear. Lung examination shows symmetric chest expansion, with diminished breath sounds and a faint wheeze in the right middle lobe. There are no crackles. The left lung is clear. Cardiac examination is unremarkable. Pulses are 2+ bilaterally. The abdomen is soft and nontender. Skin examination shows no rashes. Repeat chest radiograph is unchanged. Which of the following is the best next step in management of this patient?

Question

A 3-year-old girl with a history of asthma is brought to the clinic for follow-up.  Five days ago, the patient had a choking episode during a meal.  She subsequently developed persistent cough and wheezing and was taken to the emergency department the same day.  The wheezing improved with 3 treatments of nebulized albuterol, and chest radiograph was unremarkable.  The patient was discharged with instructions to continue the albuterol and begin oral corticosteroids.  She finished her corticosteroid course this morning, but the cough has persisted despite albuterol use.  The patient has had no fever, congestion, or rhinorrhea.  Vital signs are normal.  The oropharynx is clear.  Lung examination shows symmetric chest expansion, with diminished breath sounds and a faint wheeze in the right middle lobe.  There are no crackles.  The left lung is clear.  Cardiac examination is unremarkable.  Pulses are 2+ bilaterally.  The abdomen is soft and nontender.  Skin examination shows no rashes.  Repeat chest radiograph is unchanged.  Which of the following is the best next step in management of this patient?

Quizplus · Accepted Answer

11ec25c8_d71b_c18a_bc81_31b245659b68_MD0003_00 This patient has persistent cough and wheezing following a choking episode, findings concerning for foreign body (FB) aspiration. Typical presentation involves a young child (ie, age 1-3) with sudden-onset cough after choking on food (eg, seed, nut) or a small toy. Diminished breath sounds and/or wheezing are often heard over the affected lung field due to air trapping distal to the obstruction. Because of the fixed bronchial obstruction, focal wheezing caused by FB aspiration is generally not responsive to albuterol. However, particularly in patients with asthma, the FB may also trigger airway reactivity and diffuse wheezing that does improve with albuterol (as seen in this patient). Chest x-ray findings suggestive of FB aspiration include unilateral lung hyperinflation, with mediastinal shift to the unaffected side. However, a normal radiograph does not rule out FB aspiration because at least 30% of radiographs are normal, particularly if a radiolucent FB (eg, food) is lodged in a small airway. Therefore, if clinical suspicion remains high, bronchoscopy is indicated to confirm the diagnosis and remove the aspirated object. (Choice A) Allergies can trigger diffuse wheezing, but examination findings would be nonfocal and resolve with albuterol and corticosteroids. This patient has persistent focal wheeze with a recent choking history, making FB aspiration more likely. (Choice B) Antibiotic therapy is indicated for pneumonia, which can occur with a retained foreign body and cause focal lung findings. However, fever, crackles, and a consolidation on x-ray would be expected. (Choices D and E) Pulmonary function testing (PFT) and corticosteroids may be considered to diagnose and treat asthma, respectively. This patient's history of choking, focal lung findings, and persistent symptoms despite appropriate asthma therapy make FB aspiration more likely. In addition, children age ≤5 typically cannot perform PFT. (Choice F) Treatment of cough due to viral respiratory infection includes supportive care with an antitussive such as honey. Over-the-counter cough medications are not recommended in young children. This patient's lack of infectious symptoms (eg, fever, rhinorrhea) and sudden onset of cough after a choking episode is more consistent with FB aspiration. Educational objective: Foreign body aspiration should be considered in a patient with persistent cough or wheezing following a choking episode. X-ray may reveal classic findings of unilateral lung hyperinflation and mediastinal shift; however, x-ray findings also may be normal, and bronchoscopy is indicated if clinical suspicion remains high. References: Factors predicting early diagnosis of pediatric laryngotracheobronchial foreign bodies. (http://www.ncbi.nlm.nih.gov/pubmed/26860607)

A 3-Year-Old Girl with a History of Asthma Is Brought