PANCE Blueprint Pulmonary (10%)

Foreign body aspiration

Patient will present as → a 2-year-old male child who is brought to the emergency department by his mother with a sudden onset of choking, gagging, coughing, and wheezing. Vital signs are temperature 37 ° C; pulse 120/ min; and respirations 28/min. The physical examination reveals decreased breath sounds over the right lower lobe with inspiratory rhonchi and localized expiratory wheezing. The chest X-ray reveals normal inspiratory views but expiratory views show localized hyperinflation with mediastinal shift to the left.

foreign body in the right main stem bronchus.

Ball-valve action caused by foreign body in the right main stem bronchus. (A), Inspiration appears normal. (B) On expiration, the right lung remains hyperinflated due to trapping of air from the ball-valve effect of the foreign body. The left lung shows normal decrease in volume and the heart has shifted to the left (arrows).

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Aspirated solid or semi-solid object, usually lodged in the larynx or trachea

  • Most often food, but can range from small toys to coins, pens, etc.
  • May be life-threatening is large enough to completely obstruct the airway
  • Can lead to chronic, recurrent infection if retrieval is delayed - complications include pneumonia, acute respiratory distress syndrome, asphyxia

Presentation depends on location of obstruction

  • Inspiratory stridor if high in the airway (*listen to stridor)
  • Wheezing and decreased breath sounds if low in the airway
  • 80% in mainstem or lobar bronchus, 20% in upper airway, right > left

Risk factors include

  • Institutionalization, advanced age, poor dentition, alcohol, and sedative use

CXR - expiratory radiograph may reveal regional hyperinflation of the affected side

  • ABG - necessary for appropriately evaluating ventilation, may be useful for following progression of respiratory failure when it is of concern
Contrasing foreign body in main right bronchus

Contrasting foreign body in main right bronchus

Endoscopic (flexible or rigid) may help to establish the diagnosis and can also be the treatment of choice for removal of the object

  • Flexible bronchoscopy is both diagnostic and therapeutic
  • Rigid bronchoscopy is preferred in children due to wider instrument lumen (as compared to flexible counterpart), which allows for ventilation and easier removal of objects
  • Surgical removal - indicated when endoscopy is impossible or unsuccessful
  • Cultures should be obtained if pneumonia is suspected
Question 1
A foreign body lodged in the trachea that is causing partial obstruction will most likely produce what physical examination finding?
A
stridor
B
aphonia
Hint:
Aphonia, inability to cough and progressive cyanosis are seen with complete obstruction of the trachea, not partial obstruction.
C
inability to cough
Hint:
See B for explanation.
D
progressive cyanosis
Hint:
See B for explanation.
Question 1 Explanation: 
An inspiratory wheeze is called stridor, which indicates a partial obstruction of the trachea or larynx
Question 2
Upon auscultation of a patient's lungs, there are harsh, hollow breath sounds which have a long inspiratory component in the region of the suprasternal notch. Throughout the periphery of the lung fields, softer breath sounds are heard. Which of the following best describes these findings?
A
Normal
B
Asthmatic
Hint:
Breath sounds in an asthmatic patient are usually obscured by wheezing.
C
Atelectasis
Hint:
Breath sounds are usually absent over an area of atelectasis.
D
Foreign body Explanations
Hint:
Foreign body aspiration can present with stridor, wheezing or decreased breath sounds depending on where it has lodged.
Question 2 Explanation: 
Bronchial breath sounds are normally heard near the sternum and vesicular breath sounds are heard over the periphery of the lungs in a healthy, normal patient.
Question 3
A 2-year-old presents with sudden onset of cough and stridor. On examination the child is afebrile and appears non- toxic with a respiratory rate of 42 breaths per minute. What is the next step in the evaluation of this patient?
A
Lateral soft tissue x-ray of the neck
Hint:
See D for explanation.
B
Indirect laryngoscopy
Hint:
See D for explanation.
C
Finger sweep
Hint:
See D for explanation.
D
Chest x-ray
Question 3 Explanation: 
Chest x-ray should be done first when foreign body aspiration is suspected.
Question 4
Which of the following is accurate about foreign body aspiration?
A
The location of an aspirated foreign body inside a patient may depend on the patient's age
B
The likelihood of complications decreases after 24-48 hours
Hint:
The likelihood of complications increases after 24-48 hours, making expeditious removal of the foreign body imperative.
C
Inflammatory changes are completely reversible
Hint:
Even if the object is removed, the inflammatory changes may not be completely reversible. Some investigators believe that scar carcinoma may develop over time.
D
Foreign body aspiration is more commonly seen in females than in males
Hint:
The male-to-female ratio of foreign body aspiration is 2:1, depending on the study.
Question 4 Explanation: 
Near-total obstruction of the larynx or trachea can cause immediate asphyxia and death. Should the object pass beyond the carina, its location depends on the patient's age and physical position at the time of the aspiration. Because the angles made by the mainstem bronchi with the trachea are identical until age 15 years, foreign bodies are found on either side with equal frequency in persons in this age group. After age 15 years, the right main stem bronchus is straighter, allowing most aspirated foreign bodies to enter the right lower lobe of the lung. Bronchoscopically, the object may appear as a tumor. Even if the object is removed, the inflammatory changes may not be completely reversible. Some investigators believe that scar carcinoma may develop over time. The likelihood of complications increases after 24-48 hours, making expeditious removal of the foreign body imperative. The male-to-female ratio of foreign body aspiration is 2:1, depending on the study.
Question 5
Which of the following is accurate about complications of pediatric foreign body ingestion?
A
The most common site of esophageal impaction is at the lower esophageal sphincter (LES) at the gastroesophageal junction
Hint:
Most complications of pediatric foreign body ingestion are due to esophageal impaction, usually at one of three typical locations. The most common site of esophageal impaction is at the thoracic inlet. Defined as the area between the clavicles on chest x-ray, this is the site of anatomic change from the skeletal muscle to the smooth muscle of the esophagus. The cricopharyngeus sling at C6 is also at this level and may "catch" a foreign body. About 70% of blunt foreign bodies that lodge in the esophagus do so at this location. Another 15% become lodged at the mid esophagus, in the region where the aortic arch and carina overlap the esophagus on chest x-ray. The remaining 15% become lodged at the LES at the gastroesophageal junction.
B
Most complications occur once the foreign body reaches a child's stomach
Hint:
Once a swallowed foreign body reaches the stomach of a child with a normal gastrointestinal (GI) tract, it is much less likely to lead to complications
C
Migration of a foreign body from the esophagus most often leads to aortoenteric fistula
D
Swallowed button batteries may cause substantial mucosal injury within just 2 hours
Question 5 Explanation: 
Esophageal button batteries may cause substantial mucosal injury in as few as 2 hours. Once a swallowed foreign body reaches the stomach of a child with a normal gastrointestinal (GI) tract, it is much less likely to lead to complications. Most complications of pediatric foreign body ingestion are due to esophageal impaction, usually at one of three typical locations. The most common site of esophageal impaction is at the thoracic inlet. Defined as the area between the clavicles on chest x-ray, this is the site of anatomic change from the skeletal muscle to the smooth muscle of the esophagus. The cricopharyngeus sling at C6 is also at this level and may "catch" a foreign body. About 70% of blunt foreign bodies that lodge in the esophagus do so at this location. Another 15% become lodged at the mid esophagus, in the region where the aortic arch and carina overlap the esophagus on chest x-ray. The remaining 15% become lodged at the LES at the gastroesophageal junction. A foreign body lodged in the GI tract may have little or no effect; cause local inflammation leading to pain, bleeding, scarring, and obstruction; or erode through the GI tract. Migration from the esophagus most often leads to mediastinitis but may involve the lower respiratory tract or aorta and create an aortoenteric fistula.
Question 6
Which of the following is accurate about the presentation of GI foreign bodies?
A
Direct examination typically provides better information than indirect laryngoscopy
Hint:
In cooperative patients, indirect laryngoscopy or fiberoptic nasopharyngoscopy provides better information than a direct examination.
B
The most common cause of GI foreign bodies in adults involves accidental swallowing of small objects like toothpicks
Hint:
The most common cause of GI foreign bodies in adults involves food that does not pass through the esophagus because of underlying mechanical problems.
C
In children, tracheal compression and stridor suggest a large foreign body at the upper esophageal sphincter
D
In adults, dysphagia is associated with foreign bodies in the oropharynx but not in the esophageal regions
Hint:
Dysphagia is the norm in adults with esophageal foreign bodies. If the obstruction is complete, an inability to handle secretions is common.
Question 6 Explanation: 
In children, tracheal compression and stridor suggest a large foreign body at the upper esophageal sphincter. In cooperative patients, indirect laryngoscopy or fiberoptic nasopharyngoscopy provides better information than a direct examination. The most common cause of GI foreign bodies in adults involves food that does not pass through the esophagus because of underlying mechanical problems. Dysphagia is the norm in adults with esophageal foreign bodies. If the obstruction is complete, an inability to handle secretions is common.
Question 7
Which of the following is accurate regarding the imaging studies of foreign bodies in soft tissue injuries?
A
Radiography is the recommended imaging study in all foreign body soft tissue injuries
Hint:
X-rays are most useful in detecting radiopaque foreign bodies with sensitivities above 95% with adequate penetration and multiple views (anteroposterior and lateral). However, for the detection of nonradiopaque foreign bodies (eg, wood, rubber, plastic, and other plant-based foreign bodies), the sensitivity of radiography is low.
B
Fluoroscopy allows for real-time visualization and allows precise location of the foreign body using skin markers
C
Ultrasonography use is generally discouraged in foreign body soft tissue injuries
Hint:
The use of bedside ultrasonography to detect and localize soft tissue foreign bodies in the emergency department (ED) is gaining in acceptance and popularity because of its ease of use, increased availability, lack of radiation exposure, safety, and sensitivity with detection of certain types of foreign bodies
D
MRI is commonly used for foreign body detection upon initial presentation and is less valuable in nonacute presentations
Hint:
The use of bedside ultrasonography to detect and localize soft tissue foreign bodies in the emergency department (ED) is gaining in acceptance and popularity because of its ease of use, increased availability, lack of radiation exposure, safety, and sensitivity with detection of certain types of foreign bodies
Question 7 Explanation: 
Fluoroscopy can be useful in foreign body removal if a C-arm or other appropriate imaging equipment is accessible. This technique allows for real-time radiographic visualization of the foreign body and affords the clinician the opportunity to precisely locate the foreign body using skin markers. X-rays are most useful in detecting radiopaque foreign bodies with sensitivities above 95% with adequate penetration and multiple views (anteroposterior and lateral). However, for the detection of nonradiopaque foreign bodies (eg, wood, rubber, plastic, and other plant-based foreign bodies), the sensitivity of radiography is low. The use of bedside ultrasonography to detect and localize soft tissue foreign bodies in the emergency department (ED) is gaining in acceptance and popularity because of its ease of use, increased availability, lack of radiation exposure, safety, and sensitivity with detection of certain types of foreign bodies. MRI is rarely used for foreign body detection during the initial ED visit. However, MRI can provide detailed information regarding tissue inflammatory reactions, osteoblastic or osteolytic changes, and secondary tissue reactions that can aid in determining the presence and location of an otherwise occult foreign body.
Question 8
Which of the following is accurate regarding treatment of foreign body ingestion?
A
Flexible bronchoscopy is generally preferred to rigid bronchoscopy in removing tracheobronchial foreign bodies
Hint:
The rigid bronchoscope has important advantages over the flexible bronchoscope. The larger diameter of the rigid bronchoscope facilitates the passage of various grasping devices, including a flexible bronchoscope. A better chance of quick, successful extraction and better capabilities of suctioning clotted blood and thick secretions are offered by the rigid bronchoscope.
B
The bougienage method should only be performed if ingestion of a blunt object by a child was witnessed within 24 hours of the procedure
C
Foley catheter removal is indicated for patients who have foreign bodies present for longer than 72 hours
Hint:
Foley catheter removal is contraindicated in patients with foreign bodies that have been present for more than 72 hours, those with a history of esophageal disease or surgery, those who are experiencing respiratory distress, and those who are uncooperative.
D
Relaxation of the LES with glucagon is recommended more than watchful waiting for foreign bodies confirmed by imaging studies to be lodged at the LES
Hint:
Foreign bodies lodged at the LES can be managed by relaxation of the LES, although in some studies, success rates associated with this technique are no greater than those associated with watchful waiting.
Question 8 Explanation: 
Blunt esophageal foreign bodies may be advanced into the stomach with a bougie. While the child is sitting upright, the lubricated instrument is gently passed down the esophagus, dislodging the object. The object is then expected to pass through the rest of the GI tract; thus, this procedure should not be performed on children with known lower GI tract abnormalities. A brief observation period and a repeat x-ray should follow any removal procedure to rule out retained foreign bodies and other complications (eg, pneumomediastinum). Because any esophageal foreign body may pass spontaneously, chest x-ray should be performed immediately prior to any removal procedure. Again, only experienced personnel should perform this procedure, and it should be reserved for healthy children whose ingestion of a blunt object was witnessed less than 24 hours prior to the procedure. The rigid bronchoscope has important advantages over the flexible bronchoscope. The larger diameter of the rigid bronchoscope facilitates the passage of various grasping devices, including a flexible bronchoscope. A better chance of quick, successful extraction and better capabilities of suctioning clotted blood and thick secretions are offered by the rigid bronchoscope. Foley catheter removal is contraindicated in patients with foreign bodies that have been present for more than 72 hours, those with a history of esophageal disease or surgery, those who are experiencing respiratory distress, and those who are uncooperative. Foreign bodies lodged at the LES can be managed by relaxation of the LES, although in some studies, success rates associated with this technique are no greater than those associated with watchful waiting.
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