What is the most appropriate management strategy for an elderly nonverbal woman with a history of Chronic Obstructive Pulmonary Disease (COPD), esophageal reflux, and prior stroke, presenting with acute onset cough and shortness of breath?

Admission for Bronchoscopy

This patient requires admission for bronchoscopy to evaluate and manage suspected foreign body aspiration. The clinical presentation—witnessed choking episode 5 hours prior, acute onset cough and dyspnea, unilateral (right-sided) crackles, and atelectasis on chest X-ray in a high-risk patient (nonverbal, history of stroke, GERD)—strongly suggests aspiration with possible retained foreign material requiring direct visualization and removal 1.

Clinical Reasoning for Bronchoscopy

The constellation of findings points to aspiration rather than COPD exacerbation:

• Witnessed choking episode followed immediately by respiratory symptoms is the hallmark of aspiration 2
• Unilateral crackles (right-sided only) suggest localized pathology rather than the bilateral findings typical of COPD exacerbation 3
• Atelectasis on chest X-ray indicates airway obstruction, potentially from aspirated material 2
• Dry cough without purulent sputum argues against infectious COPD exacerbation 4

High-Risk Patient Profile

This patient has multiple risk factors for aspiration that increase morbidity and mortality 1:

• Prior stroke with resultant nonverbal status suggests dysphagia and impaired protective airway reflexes 1
• GERD increases risk of aspiration through regurgitation and abnormal swallowing reflexes 5
• Elderly and residing in skilled nursing facility indicates functional impairment 1

Patients with stroke and swallowing dysfunction have severe morbidity from recurrent aspiration pneumonia when the underlying aspiration risk is not addressed 1.

Why Not the Other Options

Observation alone is insufficient because:

• Retained foreign material will not resolve spontaneously and leads to recurrent pneumonia 1
• The witnessed aspiration event requires definitive evaluation 2

Antibiotics and admission without bronchoscopy misses the diagnosis:

• No evidence of bacterial infection (no fever [T 99.2°F], no purulent sputum, no leukocytosis mentioned) 4
• Antibiotics should be withheld in aspiration pneumonitis until superinfection is documented 2
• The initial lung injury after aspiration is chemical, not bacterial 2

Antibiotics, corticosteroids, and admission treats COPD exacerbation, but this presentation lacks key features:

• No wheezing or signs of bronchospasm 3
• No increased sputum production or purulence 3
• Unilateral rather than bilateral findings 3
• Corticosteroids are contraindicated in aspiration pneumonitis and provide no benefit 2

Management Algorithm

Immediate bronchoscopy is indicated when:

1. Witnessed or suspected aspiration event occurs 2
2. Localized findings (unilateral crackles, atelectasis) suggest airway obstruction 2
3. High-risk patient with stroke history and GERD 1, 5

Supportive care during admission:

• High-flow oxygen targeting SpO2 88-92% (current 93% is acceptable) 3
• Volume replacement as needed 2
• Withhold antibiotics unless bronchoscopy reveals purulent secretions or clinical deterioration suggests superinfection 2
• Avoid corticosteroids as they have no role in aspiration pneumonitis 2

Critical Pitfalls to Avoid

• Do not empirically treat as COPD exacerbation when aspiration is witnessed—this delays definitive diagnosis and allows complications to develop 1, 2
• Do not give prophylactic antibiotics for chemical pneumonitis, as bacteria play no role in initial lung injury 2
• Do not use corticosteroids in aspiration cases 2
• Do not discharge without swallowing evaluation once acute issue is resolved, as untreated dysphagia leads to recurrent aspiration and severe morbidity 1