Foreign Body Aspiration with Severe Airway Obstruction
This 20-month-old child has foreign body aspiration (FBA) with severe airway obstruction requiring immediate recognition and urgent rigid bronchoscopy under anesthesia for definitive diagnosis and removal. 1
Immediate Recognition and Initial Management
The clinical presentation is classic for FBA rather than infectious causes like croup:
- Acute onset during play (sudden respiratory distress without fever or antecedent upper respiratory symptoms) 1
- Stridor with drooling indicates significant upper airway compromise 1
- Unilateral wheezing on the right suggests partial bronchial obstruction from an aspirated foreign body 1
- Voice changes further support upper airway involvement 2
Critical First Steps
If the child can still cough or make sounds, do not interfere - allow the child to clear the airway by coughing while observing closely for deterioration 1. However, given the presence of stridor and drooling, this child likely has severe obstruction.
For severe obstruction with inability to cough effectively:
- Perform five back blows followed by five chest compressions in repeated cycles until the object is expelled or the child becomes unresponsive 1
- Position the child upright and provide supplemental oxygen while preparing for immediate intervention 1
- Do NOT perform abdominal thrusts in children under 2 years due to risk of liver injury 1
Critical Pitfalls to Avoid
- Never sedate a child with moderate-to-severe respiratory distress without airway expertise present, as sedation can worsen obstruction 1
- Avoid blind finger sweeps, which can push foreign bodies deeper into the airway 1
- Do not delay definitive management with empiric bronchodilator or corticosteroid therapy, as this is not asthma 2, 1
Definitive Management
Rigid bronchoscopy under anesthesia is the gold standard for both diagnosis and therapeutic removal of foreign bodies in this clinical scenario 1. This must be performed urgently given the severity of symptoms.
- Flexible bronchoscopy is superior for assessing airway dynamics but foreign body extraction must be performed with rigid bronchoscopy 2, 3
- Flexible laryngoscopy in the awake child can identify upper airway pathology but may not be feasible with severe distress 1
Hospital Admission and Post-Procedure Care
All children with suspected or confirmed FBA require hospital admission for observation and definitive management 1.
Post-bronchoscopy monitoring should include:
- Assessment for laryngeal edema, which may require epinephrine nebulization and corticosteroids 1
- Evaluation for secondary complications such as pneumonia or atelectasis from prolonged obstruction 1
- Continuous monitoring of respiratory status until stable 4
Distinguishing from Other Diagnoses
This presentation differs from asthma or infectious causes: