Images in Emergency Medicine
Article Outline
[Ann Emerg Med. 2007;49:822.]
A 7-year-old patient with asthma presented with worsening coughing and wheezing despite 4 days of albuterol and oral steroids. His temperature was 38.1°C, respiratory rate 32 breaths/min, and oxygen saturation 97% on room air. Pulmonary examination revealed faint wheezing and decreased breath sounds over the left hemithorax, with no improvement after nebulized albuterol therapy. Further questioning revealed the patient had choked on a plastic bead before the onset of his symptoms. A chest radiograph was obtained (Figure 1).
Figure 1.
Chest radiograph showing mediastinal shift, right-sided hyperinflation, and low lung volumes and diffuse haziness on the left consistent with atelectasis.
Diagnosis
Foreign body aspiration
There was asymmetric inflation of the 2 hemithoraces, with tracheal deviation and mediastinal shift. These findings are concerning for foreign body aspiration. Emergency bronchoscopy was performed, and a yellow bead was removed from the left mainstem bronchus (Figure 2). Culture of the purulent secretions (Figure 3) grew Haemophilus influenzae. Follow-up chest radiograph result the next day was normal (Figure 4).
Figure 2.
Image from bronchoscopy showing bead in takeoff from left mainstem bronchus.
Figure 3.
Image from bronchoscopy showing mucopurulent secretions from lower airway after removal of foreign body.
Figure 4.
Follow-up chest radiograph 1 day later, demonstrating normal lung expansion bilaterally. Used with permission of Joshua Nagler, MD, the Division of Emergency Medicine, Children’s Hospital, Boston, MA.
The diagnosis of foreign body aspiration in children can be elusive, particularly when the choking event is not witnessed or reported. Initial symptoms may be subtle, or respiratory findings may be attributed to bronchiolitis, asthma, or pneumonia, delaying further evaluation. The diagnosis is delayed more than 24 hours in nearly 50% of patients and more than 1 month after the aspiration in 10% of cases.1 Although foreign bodies are occasionally aspirated into the larynx or trachea, they are most commonly located in the bronchi.2 Radiographic findings with bronchial foreign bodies may include hyperinflation, atelectasis, mediastinal shift, or pneumonia, although a normal radiograph result does not rule out foreign body aspiration.1, 3 Inspiratory/expiratory chest radiographs or fluoroscopy can increase yield. However, when clinical suspicion is high, rigid bronchoscopy is the diagnostic and therapeutic procedure of choice.
References
For the diagnosis and teaching points, see page 829.To view the entire collection of Images in Emergency Medicine, visit www.annemergmed.com
PII: S0196-0644(06)02534-0
doi:10.1016/j.annemergmed.2006.11.011
© 2007 American College of Emergency Physicians. Published by Elsevier Inc. All rights reserved.
