questions 3

Foreign Body Aspiration

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Topic updated on 06/14/17 5:40pm

Snapshot
  • A frantic mother brings her 2-year-old child to the emergency department after he swallowed an earring. Radiographs are shown.foreign body aspiration
Introduction
  • Aspirated solid or semi-solid object, usually lodged in the larynx or trachea
    • most often food, but can range from small toys to coins to pens, and so on
  • May be life-threatening is large enough to completely obstruct the airway
  • Can lead to chronic, recurrent infection if retrieval is delayed
  • Epidemilogy
    • usually presents after 6 months of age
  • Risk factors include
    • institutionalization
    • advanced age
    • poor dentition
    • alcohol
    • sedative use
Presentation
  • Symptoms
    • severe obstruction may present with
      • respiratory distress
      • aphonia
      • cyanosis
      • loss of consciousness
      • and death in quick succession
    • partial, long-term obstruction may present with
      • less severe respiratory symptoms
      • dysphagia
      • fever
      • hemoptysis
      • dyspnea
      • chest pain
      • symptoms indicative of secondary infection
  • Physical exam
    • unresolved pneumonia
    • decreased breath sounds
    • wheezing
Evaluation
  • CXR
    • shows hyperinflation of the affected side
  • ABG
    • necessary for appropriately evaluating ventilation
    • may be useful for following progression of respiratory failure when it is of concern
Differential
  • Chronic URI, pneumonia, tonsillitis, pneumonia, pneumothorax, emphysema, respiratory failure
Treatment
  • Medical intervention
    • endoscopic (flexible or rigid) retrieval of foreign body
      • flexible broncoscopy is both diagnostic and therapeutic 
      • rigid broncoscopy is preferred in children due to wider instrument lumen (as compared to flexible counterpart), which allows for ventilation and easier removal of objects
    • surgical removal
      • indicated when endoscopy is impossible or unsuccessful
  • If the object is thought to be in the esophagus, based on imaging and clinical presentation:
    • Observe for 24 hours with serial radiographs and remove endoscopically if the object does not pass distally within that time frame
    • If object causes symptoms or time-point of ingestion is unknown - attempt immediate endoscopic removal
    • If the ingested item appears relatively benign and has already progressed inferior to the diaphragm on imaging, observe and wait for spontaneous passage 
Prognosis, Prevention, and Complications
  • Prognosis
    • very good to excellent if identified and resolved early
  • Prevention
    • limit exposure to objects approved for specific age group (i.e. toys, etc)
  • Complications
    • may lead to chronic pneumonia
    • can cause sudden respiratory failure and death


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Qbank (1 Questions)

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(M2.PD.4837) An 18-month-old male with a past medical history of mild intermittent asthma presents to the emergency department with shortness of breath. His mother reports that the patient was playing with his older sister in another room when he began having difficulty breathing. He initially appeared to be wheezing, and the patient’s mother gave him his prescribed albuterol without improvement. In the emergency department, the patient’s temperature is 99.0°F (37.2°C), blood pressure is 81/59 mmHg, pulse is 136/min, and respirations are 46/min. His oxygen saturation is 92% on room air. On physical exam, the patient is in moderate respiratory distress with nasal flaring and intercostal retractions. Breath sounds are absent on the left. His chest radiograph can be seen in Figure A.

Which of the following is the best next step in management? Topic Review Topic
FIGURES: A          

1. Chest tube placement
2. CT of the chest
3. Direct laryngoscopy
4. Flexible bronchoscopy
5. Rigid bronchoscopy

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