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 five days ago, followed by immediate onset of respiratory symptoms, strongly suggests foreign body aspiration rather than an asthma exacerbation. The physical examination finding of diminished breath sounds and localized wheezing in only the right middle lobe, with the left lung being clear, further supports this diagnosis. Foreign bodies may not always be visible on chest radiographs, explaining why her imaging was unremarkable. Bronchoscopy is indicated in this scenario as it allows for both diagnostic confirmation and therapeutic removal of the aspirated foreign body. This is particularly important in young children, who are at higher risk for foreign body aspiration due to their tendency to place objects in their mouths and their immature swallowing coordination. Prompt removal of the foreign body is necessary to prevent complications such as recurrent pneumonia, lung abscess, or bronchiectasis that can develop from prolonged foreign body retention. According to the American Thoracic Society clinical practice guidelines 1, for infants with persistent wheezing despite treatment with bronchodilators, inhaled corticosteroids, or systemic corticosteroids, an airway survey via flexible fiberoptic bronchoscopy is suggested. Although the evidence is conditional and of very low quality, the potential benefits of bronchoscopy in this scenario outweigh the risks, especially considering the patient's age and presentation. Other options, such as allergy testing, antibiotic therapy, extended corticosteroid course, pulmonary function testing, or supportive care with antitussives, are not supported by the clinical presentation and guidelines.
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 can be difficult to diagnose due to nonspecific symptoms and normal chest x-rays 2.
- Bronchoscopy is considered the gold standard for diagnosis and management of foreign body aspiration 3, 4, 5.
Management Options
- Bronchoscopy is the most appropriate next step in management, given the patient's persistent symptoms and history of choking episode 3, 4, 5.
- The use of preoperative nebulized albuterol and budesonide combination may decrease perioperative complications of bronchoscopy 6.
- Other options, such as allergy testing, antibiotic therapy, extended corticosteroid course, pulmonary function testing, and supportive care with antitussives, are not directly relevant to the diagnosis and management of foreign body aspiration in this patient.