What is the best next step in managing a 3-year-old girl with asthma and persistent cough and wheezing after a choking episode, despite treatment with albuterol (albuterol) and a course of oral corticosteroids (corticosteroids)?

From the Guidelines

The best next step in management for this 3-year-old girl is bronchoscopy (option C). This patient presents with persistent cough and localized wheezing in the right middle lobe despite appropriate asthma treatment with albuterol and a completed course of oral corticosteroids. The history of choking during a meal followed by immediate respiratory symptoms strongly suggests foreign body aspiration, which can be missed on standard chest radiographs. The physical examination findings of diminished breath sounds and localized wheezing in only one lung field (right middle lobe) while the left lung remains clear are classic signs of partial airway obstruction from a foreign body. Bronchoscopy would allow direct visualization of the airway and removal of any foreign material. This is particularly important in young children who are at high risk for aspiration and may not be able to report the event clearly. The persistence of symptoms despite appropriate asthma therapy and the absence of other symptoms like fever or upper respiratory symptoms further supports foreign body aspiration as the diagnosis rather than an asthma exacerbation or infection. Prompt bronchoscopy is indicated to prevent complications such as recurrent pneumonia, bronchiectasis, or complete airway obstruction.

The American Thoracic Society clinical practice guidelines suggest an airway survey via flexible fiberoptic bronchoscopy for infants with persistent wheezing despite treatment with bronchodilators, inhaled corticosteroids, or systemic corticosteroids 1. Although the evidence is conditional and of very low quality, the potential benefits of bronchoscopy in this scenario outweigh the risks. The guidelines also recommend considering bronchoalveolar lavage (BAL) and video-fluoroscopic swallowing studies, but bronchoscopy is the most direct and effective way to diagnose and treat a potential foreign body aspiration.

In contrast, allergy testing (option A) may not be immediately relevant to the patient's current symptoms, and antibiotic therapy (option B) is not indicated without evidence of infection. Extended corticosteroid course (option D) may not be effective if the underlying cause is a foreign body, and pulmonary function testing (option E) may not be feasible or necessary in a 3-year-old child. Supportive care with antitussives (option F) may help manage symptoms, but it does not address the potential underlying cause of the symptoms.

Key points to consider:

• The patient's history of choking and immediate respiratory symptoms suggests foreign body aspiration.
• The physical examination findings are consistent with partial airway obstruction.
• Bronchoscopy is the most direct and effective way to diagnose and treat a potential foreign body aspiration.
• The American Thoracic Society clinical practice guidelines support the use of bronchoscopy in this scenario 1.

From the FDA Drug Label

The FDA drug label does not answer the question.

From the Research

Patient Presentation and History

• The patient is a 3-year-old girl with a history of asthma, presenting with persistent cough and wheezing after a choking episode during a meal.
• She was treated with nebulized albuterol and oral corticosteroids, but the cough has persisted despite albuterol use.
• The patient has had no fever, congestion, or rhinorrhea, and vital signs are normal.

Diagnostic Considerations

• The patient's symptoms and history suggest possible foreign body aspiration, which is a common cause of respiratory symptoms in children 2.
• Bronchoscopy is the gold standard for diagnosis and management of foreign body aspiration 3, 2, 4.
• Imaging studies such as chest radiography may not be diagnostic, and bronchoscopy is frequently necessary for diagnosis and treatment 2.

Management Options

• Bronchoscopy is the best next step in management of this patient, as it allows for diagnosis and removal of the foreign body 3, 2, 4.
• The use of nebulized albuterol and budesonide combination may help reduce intra-operative complications during bronchoscopy 5.
• Surgical treatment may be necessary in cases of late-diagnosed bronchial foreign body aspiration with substantial lung lesions 6.

Recommended Course of Action

• The patient should undergo bronchoscopy to diagnose and remove any foreign body, as this is the most effective way to manage foreign body aspiration 3, 2, 4.
• The use of nebulized albuterol and budesonide combination may be considered to reduce intra-operative complications during bronchoscopy 5.