What is the management approach for a 20-month-old girl presenting with cough, wheezing, shortness of breath, changes in voice, stridor, and drooling, with wheezing on the right side upon auscultation?

Emergency Management of Suspected Foreign Body Aspiration with Severe Airway Obstruction

This 20-month-old child with acute onset stridor, drooling, voice changes, and unilateral wheezing requires immediate recognition and treatment for foreign body airway obstruction (FBAO), which is a life-threatening emergency in this age group.

Immediate Recognition and Assessment

The clinical presentation strongly suggests severe FBAO rather than infectious causes like croup:

• Sudden onset of respiratory distress without fever or antecedent upper respiratory symptoms distinguishes FBAO from infectious etiologies like croup 1
• Stridor with drooling indicates significant upper airway compromise 2
• Unilateral wheezing on the right suggests partial bronchial obstruction from an aspirated foreign body 1
• Children aged 12-36 months are at highest risk, with 65% of FBAO deaths occurring in infants and over 90% in children under 5 years 1

Critical Initial Management Steps

If the Child Can Still Cough or Make Sounds (Mild Obstruction):

• Do NOT interfere - allow the child to clear the airway by coughing while observing closely for deterioration 1
• Position the child upright and provide supplemental oxygen 2
• Prepare for immediate intervention if obstruction becomes severe 1

If the Child Cannot Cough or Make Sounds (Severe Obstruction):

For this 20-month-old infant, perform:

1. Five back blows (back slaps) followed by five chest compressions in repeated cycles 1
2. Continue until the object is expelled or the child becomes unresponsive 1
3. Do NOT perform abdominal thrusts (Heimlich maneuver) in children under 2 years, as this can damage the relatively large and unprotected liver 1

If the Child Becomes Unresponsive:

1. Start CPR immediately with chest compressions (do not check pulse first) 1
2. After 30 compressions, open the airway and look for a visible foreign body 1
3. Remove visible foreign bodies but never perform blind finger sweeps, as these can push objects deeper or damage the oropharynx 1
4. Attempt 2 rescue breaths and continue CPR cycles 1
5. After 2 minutes, activate emergency medical services if not already done 1

Definitive Airway Management

Immediate Interventions:

• Apply 100% oxygen to the face using high-flow delivery 2
• Position with chin lift and jaw thrust to optimize airway patency 1, 2
• Monitor with pulse oximetry continuously 2
• Call for immediate help including anesthesia and ENT/surgical teams 1, 2

Signs Requiring Emergency Airway Intervention:

• SpO2 < 90% despite oxygen supplementation 2
• Bradycardia or decreasing heart rate 1, 2
• Inability to speak or drink 2
• Progressive respiratory failure despite initial maneuvers 1

Diagnostic Bronchoscopy

Rigid bronchoscopy under anesthesia is the gold standard for both diagnosis and therapeutic removal of foreign bodies in this clinical scenario 1, 2:

• Flexible laryngoscopy in the awake child can identify upper airway pathology but may not be feasible with severe distress 1
• Rigid bronchoscopy with jet ventilation allows both visualization and removal of foreign bodies while maintaining oxygenation 1
• Direct laryngobronchoscopy should be performed with the child spontaneously breathing under anesthesia when possible 1

Critical Pitfalls to Avoid

• Never sedate a child with moderate-to-severe respiratory distress without airway expertise present, as sedation can worsen obstruction 2
• Avoid blind finger sweeps which can push foreign bodies deeper into the airway 1
• Do not perform abdominal thrusts in children under 2 years due to risk of liver injury 1
• Do not delay emergency intervention for imaging studies when severe obstruction is present 1, 2
• In children under 8 years old, cricothyroid catheter approaches carry major risks of failure and complications and are not recommended 1

Hospital Admission and Follow-up

• All children with suspected or confirmed FBAO require hospital admission for observation and definitive management 1
• Post-bronchoscopy monitoring for complications including laryngeal edema, which may require epinephrine nebulization and corticosteroids 2
• Assess for secondary complications such as pneumonia or atelectasis from prolonged obstruction 1