What is the next step in management for an infant with episodic coughing, wheezing, decreased aeration of the left chest, and an overinflated left lung on chest x-ray?

Management of Suspected Foreign Body Aspiration in an Infant

The next step in management should be (e) rigid bronchoscopy to remove the suspected foreign body causing unilateral airway obstruction.

Clinical Reasoning

This infant's presentation is classic for foreign body aspiration:

• Episodic coughing for 48 hours with unilateral findings (decreased aeration of left chest, wheezing) strongly suggests a focal obstructive process rather than diffuse bronchospasm 1
• Overinflated left lung on chest x-ray indicates a ball-valve mechanism where air enters during inspiration but cannot escape during expiration, pathognomonic for endobronchial foreign body 1
• Unilateral physical findings that fail to respond to bronchodilators argue against asthma and warrant investigation for alternative diagnoses 1

Why Rigid Bronchoscopy is the Correct Answer

Rigid bronchoscopy is the definitive diagnostic and therapeutic intervention for foreign body aspiration in infants 2. The French guidelines on pediatric airway management specifically list rigid bronchoscopy as a rescue technique for airway obstruction in children 2. When chest X-ray shows foreign body or obstruction, the appropriate next step is to proceed to bronchoscopy for removal 1.

Advantages of Rigid Bronchoscopy:

• Allows both diagnosis and immediate removal of the foreign body in a single procedure 2
• Provides superior airway control compared to flexible bronchoscopy in infants 2
• Enables jet ventilation if needed during the procedure 2

Why Other Options Are Incorrect

Chest Tube Insertion (Options a & b)

• Chest tubes are contraindicated in this clinical scenario 2, 1
• The overinflated lung is due to air trapping from endobronchial obstruction, not pneumothorax requiring drainage 1
• Inserting a chest tube would not address the underlying foreign body and could cause serious complications including re-expansion pulmonary edema 3, 4
• Chest tubes are indicated for pleural effusions or pneumothorax, neither of which is present here 2, 5

Endotracheal Intubation (Option c)

• Intubation alone does not remove the foreign body and may actually push it deeper into the airway 2
• Intubation is only indicated if the child develops severe respiratory failure requiring ventilatory support before bronchoscopy can be performed 2
• The infant is currently stable enough to proceed directly to definitive management 1

Steroid Inhaler and Observation (Option d)

• This approach dangerously delays definitive treatment 1
• Unilateral findings and failure to respond to bronchodilators argue strongly against asthma 1
• The British Thoracic Society guidelines emphasize not delaying imaging or intervention when physical exam shows unilateral findings 1
• Progressive symptoms over 3 days warrant immediate investigation, not observation 1

Critical Management Principles

Timing is Essential:

• Do not delay bronchoscopy in favor of empiric treatment when unilateral findings are present 1
• Foreign bodies can migrate distally or cause complete obstruction if not removed promptly 2

Pre-Procedure Considerations:

• Maintain spontaneous ventilation when possible during induction to avoid converting partial obstruction to complete obstruction 2
• Have experienced ENT/pulmonology available for the procedure 2
• Ensure oxygen saturation monitoring throughout, as levels below 92% indicate severe disease requiring aggressive management 1

Common Pitfalls to Avoid:

• Do not assume asthma simply because the child has wheezing—unilateral findings make this diagnosis unlikely 1
• Do not perform flexible bronchoscopy as first-line in infants with suspected foreign body, as rigid bronchoscopy provides better control and therapeutic capability 2
• Do not insert chest tubes for air trapping from endobronchial obstruction 2, 1