Foreign Body inhalation + wheeze

Question 1

FB inhalation definition and C/P

Answer 1

Definition: Accidental inhalation of both organic and non-organic foreign bodies
 Most common in children 1 to 3 years old.
 Food items (e.g., peanuts) are the most commonly aspirated objects.
 Aspirated foreign bodies lodge in a bronchus in 80-90% of cases.
 The aspiration event may not be witnessed, thus foreign body aspiration should be considered any time a child has:
o Acute onset of respiratory symptoms, especially coughing or choking
o New wheezing that does not respond to usual treatment (e.g., bronchodilators)
o Unexplained recurrent or persistent pneumonia

Signs and Symptoms:
 Classic triad of cough, wheezing, and diminished breath sounds may not be present.
 Patients often have an episode of choking and prolonged coughing, but symptoms may cease as the cough reflex is exhausted and/or the object lodges in a bronchus
 Other signs and symptoms:
o Dyspnoea, neck, or throat pain
o Stridor and hoarseness may occur if object is lodged in upper airway.
o Asymmetric breath sounds, tachypnoea, nasal flaring, cyanosis

Question 2

FB inhalation work-up and management + complications

Answer 2

1- For patients with a life-threatening complete airway obstruction in whom a foreign body is suspected:
 Proceed with basic life support (BLS) to attempt to remove the object
o Back blows and chest thrusts for infants less than 1 year old
o Abdominal thrusts for older children (in conscious child in sitting or standing and position if unconscious in lying down)
o If unsuccessful, visualization via direct laryngoscopy and removal with Magill forceps may be attempted.
o If unable to visualize object, it may lifesaving to intubate and dislodge the object into a more distal airway, followed by removal via rigid bronchoscopy in OR if failed surgical interference.

2- For patients who are stable:
 Proceed with history, physical examination, and imaging.
 Object removal, however, should be done promptly
o Imaging:
o Chest x-ray may show
o Radiopaque foreign body with hyperinflation or atelectasis with mediastinal shift.
o Consolidation if diagnosis is delayed
o Expiratory chest x-ray may be helpful in demonstrating air trapping.
o Fluoroscopy may also be helpful
o CT rarely used
o Normal imaging does NOT rule out foreign body aspiration!
o Definitive management is visualization and removal of object via rigid bronchoscopy
o Possible complications of delayed diagnosis:
- Recurrent pneumonia and abscess
- Airway granulomas
- Bronchiectasis
- Esophageal erosion or perforation or stricture
- Pneumothorax

Question 3

Wheeze definition and DD according to age.

Answer 3

Wheeze definition: musical high-pitched noise (mainly in expiration) due to impaired airflow secondary to narrowing in lower respiratory tract airways.

Differential diagnosis of wheezy chest according to the age:
1- Infants < 1 year: Bronchiolitis, Bronchopulmonary dysplasia, Foreign body aspiration , Aspiration syndromes.
2- Children (1-4 y): Viral-induced wheeze, Asthma, Foreign body aspiration, Community-acquired P.
3- Children (5-15 y): Asthma, Community-acquired pneumonia, Hypersensitivity pneumonitis, Tuberculosis.
4- Causes that can occur at any age: Inherited disorders (example: cystic fibrosis. immunodeficiency), Pulmonary oedema from congestive heart failure, External mass compressing the airway especially lymphoma, lipoma, teratoma.