This young patient presents with sudden-onset respiratory distress and complete obstruction of his left lung, which suggests a diagnosis of foreign body aspiration. The best next step in management is rigid bronchoscopy.
Foreign body aspiration classically presents with a history of choking or coughing and sudden-onset respiratory distress. The incidence of foreign body aspiration is highest between one and three years of age, and the most common anatomic location is the right main bronchus. The best initial step in stable patients is a chest radiograph, and patients with imaging consistent with foreign body aspiration should undergo rigid bronchoscopy for airway control and removal of the foreign object.
Figure A demonstrates obstruction of the left main bronchus with complete collapse of the left lung on chest radiograph, which is consistent with foreign body aspiration.
Answer 1: Placement of a chest tube would be the appropriate next step in management for a pneumothorax, which would appear as increased lucency on the affected side. This patient’s chest radiograph is more consistent with obstruction secondary to foreign body aspiration.
Answer 2: A CT of the chest is not necessary to make the diagnosis as this patient’s chest radiograph is consistent with foreign body aspiration. Additional imaging would further delay therapeutic intervention.
Answer 3: Direct laryngoscopy can be used to visualize the larynx and identify causes of upper airway obstruction, including laryngomalacia. This patient’s obstruction is at the level of the left main bronchus, which could not be seen on laryngoscopy.
Answer 4: Flexible bronchoscopy may be used to confirm the diagnosis of foreign body aspiration in cases where the suspicion is low, but direct bronchoscopy is necessary for removal of the foreign body and has the added benefit of providing control of the airway.
Pediatric patients with suspected foreign body aspiration should undergo rigid bronchoscopy for airway control and removal of the foreign body.