Foreign Body Aspiration

Question 1

PARTIAL OBSTRUCTION UPPER AIRWAY

Answer 1

Stridor with ability vocalize
Inspiratory stridor = UPPER AIRWAY
Allowing patient to use cough reflex to expel object
If that doesn’t work – BRONCHOSCOPY (NO BLIND SWEEPS)

Question 2

COMPLETE OBSTRUCTION UPPER AIRWAY

Answer 2

Cyanosis with marked distress, cannot vocalize or cough
1yr or less, awake = 5 rapid blows to back/5 chest thrusts, repeat
>1yr old, awake = Heimlich maneuver
Any age, unconscious = CPR!

Question 3

LOWER AIRWAY OBSTRUCTION

Answer 3

Wheezing on expiration = LOWER, diminished breath sounds on 1 side
CXR forced expiratory (normal CXR doesn’t exclude FB from diagnosis)
Admit to hospital for treatment
Neb tx with chest PT after removal of object

Question 4

What age group is HIGHEST risk for extrathoracic FB aspiration?

Answer 4

Answer: 6 mo-3 yr

Question 5

A mother rushes her 7-month-old daughter to your ED stating that she cannot breathe. Upon exam, you note stridor with the ability to vocalize. What diagnosis is HIGHEST on your differential?

Answer 5

Answer: Partial Foreign Body Obstruction (Aspiration)

Question 6

In this same patient, what area of the respiratory tract do you suspect is affected – upper or lower airway obstruction?

Answer 6

Answer: Upper airway

Question 7

Stridor

Answer 7

Low-pitched noisy breathing when the infant/child breathes IN = upper airway obstruction

Question 8

Wheezing

Answer 8

High-pitched noise when the infant/child breathes OUT = lower airway obstruction

Question 9

In a patient that presents with FB aspiration, you note cyanosis with marked distress. What are these findings consistent with?

Answer 9

Answer: COMPLETE obstruction

Question 10

Without prompt treatment of an upper airway obstruction, what complications could occur? SELECT ALL THAT APPLY!
A: loss of consciousness
B: tachycardia
C: diaphragm paralysis
D: seizures

Answer 10

A: loss of consciousness
D: seizures

Answer: A, D (THINK IMPENDING RESPIRATORY ARREST! Bodies functions are slowing and shutting down – progressive cyanosis, LOC, seizures, bradycardia, cardiac arrest)

Question 11

What is considered the GOLD STANDARD for diagnosis of upper airway FB aspiration?

Answer 11

Answer: REFER! Requires rigid bronchoscopy

Question 12

What is the treatment of a partial airway obstruction of the upper airway?

Answer 12

Answer: allowing choking subject to use his/her own cough reflex to remove object

Question 13

A 1 yr old child presents to your clinic with cyanosis with marked distress. Patient is awake and alert. What do you suspect and what is your treatment?

Answer 13

Answer: COMPLETE obstruction; place patient face down deliver 5 rapid blows to the back, roll patient over and deliver an additional 5 rapid chest thrusts (repeat until obstruction is relieved)

Question 14

A 5 yr old child presents to your clinic with cyanosis with marked distress. Patient is awake and alert. What do you suspect and what is your treatment?

Answer 14

Answer: COMPLETE obstruction; perform Heimlich maneuver (abdominal thrusts)

Question 15

A 10 yr old child is rushed in by his mother who states 30 minutes PTA, they were eating food when he began to choke. This patient is currently unresponsive What do you suspect and what is your treatment?

Answer 15

Answer: COMPLETE obstruction with airway collapse; immediately begin CPR

Question 16

T or F: Blind finger sweeps in an infant or child is a good alternative if the parents do not know how to perform CPR

Answer 16

Answer: False; this can push FB further into airway (Open airway by jaw thrust – if FB can be visualized – carefully remove with fingers or instrument)

Question 17

A patient presents to your clinic with sudden onset of wheezing on expiration, diminished breath sounds on the right side, and mild respiratory distress. What diagnosis is HIGHEST on your differential?

Answer 17

Answer: Lower airway FB aspiration

Question 18

What past medical history should lead the FNP to suspect lower airway FB aspiration?

Answer 18

Answer: chronic cough, persistent wheezing, or recurrent pneumonia

Question 19

What is an important diagnostic study that can be performed to visualize the affected area / FB in lower airway FB aspiration?

Answer 19

Answer: inspiratory and forced expiratory CXR (+forced expiratory study: unilateral hyperinflation, mediastinal shift AWAY from affected side; complete obstruction: atelectasis and related volume loss)

Question 20

A patient presents to your clinic with sudden onset of wheezing on expiration, diminished breath sounds on the right side, and mild respiratory distress. You suspect lower airway FB aspiration and order a CXR, which is normal. What is your next intervention?

Answer 20

Answer: Admit to hospital for evaluation and treatment (NORMAL CXR CANNOT RULE OUT FB!)

Question 21

Following removal of lower airway FB, what is the recommended treatment?

Answer 21

Answer: b-adrenergic neb treatments + Chest PT (helps to clear mucus or treat bronchospasm)

Question 22

Without prompt treatment of a lower airway obstruction, what complications could occur? SELECT ALL THAT APPLY!
A: empyema
B: bronchiectasis
C: lung abscess
D: recurrent pneumonia

Answer 22

B: bronchiectasis
C: lung abscess
D: recurrent pneumonia

Answer: B, C, D (risk justifies an AGGRESSIVE approach to suspected FB in suspicious cases)

Question 23

VIRAL CROUP

Answer 23

6mo – 5 yr old
recent URI
Fall or early winter
onset
Parainfluenza virus
Barking seal cough
XR: Steeple sign

Question 24

EPIGLOTTITIS

Answer 24

H. influenzae (unimmunized kids)
Non-typeable H.influenzae
(immunized kids)
3 D’s: drooling, dysphagia,
distress; NO COUGH
Sniffing dog position
XR: Thumbprint sign

Question 25

BACTERIAL TRACHEITIS

Answer 25

rhinorrhea, low-grade fever, cough, sore
throat)
Progresses (high fever, COUGH, acutely worsening
STRIDOR)
Prefers to lie flat
UNRESPONSIVE TO STANDARD CROUP THERAPY!
Elevated WBC with left shift [NEW INFECTION – bands]
Lateral Neck XR: Normal epiglottis with severe subglottic and
tracheal narrowing

Question 26

VIRAL CROUP

Answer 26

Treatment is determined by how stable patient is

Discharge is determined by response to treatment

Question 27

EPIGLOTTITIS and BACTERIAL TRACHEITIS

Answer 27

REFER for ADMIT to ICU! Intubation

Order blood cultures + initiate IV abx to cover H influenza and S. aureus
ceftriaxone or equiv. cephalosporin