Case 12

Question 1

What are key history findings in an infant with a cough due to foreign body?

Answer 1

Cough, wheezing, runny nose, prev. healthy.

Question 2

What are key physical exam findings in an infant with a cough due to a foreign body?

Answer 2

Tachypnea at rest, retractions, asymmetric breath sounds with unilateral wheezing, wet cough, afebrile.

Question 3

What is on the differential diagnosis for lung foreign body?

Answer 3

Asthma, epiglottitis, anatomic, pertussis, bronchiolitis, croup, gastroesophageal reflux, foreign body, pneumonia

Question 4

What are key findings from testing with a foreign body?

Answer 4

• Inspiratory/expiratory chest X-rays: Unilateral air trapping in left lung indicative of a foreign body.
• Rigid bronchoscopy: Piece of popcorn lodged in lumen of left mainstem bronchus

Question 5

Effectiveness of immunizations:

Answer 5

Three causes of cough in a child are now uncommon due to vaccines, but must be considered in unimmunized or partially immunized children: Pertussis, Diphtheria, Epiglottitis.

Question 6

Pertussis (“whooping cough”):

Answer 6

• Etiology: Bordatella pertussis
• Course of disease: Triphasic:
  1. Catarrhal stage (one to two weeks): URI like symptoms (often indistinguishable from URI)
  2. Paroxysmal stage (lasts four to six weeks): Repetitive, forceful coughing episodes followed by massive inspiratory effort, which results in characteristic “whoop” (quick staccato cough).
  3. Convalescent stage: Cough gradually decreases in severity and frequency. Episodic cough may persist for months.

Question 7

Diphtheria

Answer 7

• Etiology: Corynebacterium diphtheria
• Should be considered in a child with pharyngitis and low-grade fever, particularly if stridor or hoarseness is present
• A characteristic gray pseudomembrane is seen in the pharynx

Question 8

Epiglottitis

Answer 8

• Etiology: Almost always due to Homophiles influenza, type B.
• Life-threatening illness
• Consider in child with stridor and severe respiratory distress, especially if with drooling, dysphonia, and/or dysphagia.

Question 9

These questions are important to help evaluate diagnosis of cough:

Answer 9

• Is the patent drinking fluids?
• Has the patient had a fever?
• Did the cough begin suddenly? Did the patient appear to choke on anything?
• Has the patient’s voice or cry been hoarse?
• Has the cough been barky?
• Does patient make any noises when she/he breathes?
• Does patient have any medical problems (eg ear infections, history of pneumonia, spitting up, chronic diarrhea, trouble gaining weight)?

Question 10

Is the patient drinking fluids?

Answer 10

Gives sense of hydration status and degree of difficulty breathing. Also helps assess for dysphagia.

Question 11

Has the patient had a fever?

Answer 11

History of fever would make an infectious process more likely.

Question 12

Did the cough begin suddenly? Did the patient appear to choke on anything?

Answer 12

Important to find out if aspiration is likely, although most cases at this age are unwitnessed.

Question 13

Has patient’s voice or cry been hoarse?

Answer 13

Can help distinguish whether problem is in lower or upper airway. (Problems isolated to lower airway typically do not affect voice or cry.)

Question 14

Has the cough been barky?

Answer 14

Would suggest a diagnosis of croup, a viral illness most common in winter months and in children two to five years of age.

Question 15

Does the patient make any noises when she/he breathes?

Answer 15

Wheezing more typically expiratory, stridor more typically inspiratory, but both can be present throughout respiratory cycle.

Question 16

Does patient have medical problems (eg ear infections, history of pneumonia, spitting up, chronic diarrhea, trouble gaining weight)?

Answer 16

Important to gather information about possible chronic illnesses (eg reflux disease, malabsorptive disorder, immunodeficiency) and birth history.

Question 17

What are visible signs of respiratory distress in infants?

Answer 17

Paradoxical breathing, Tachypnea, Grunting, Nasal flaring, Head bobbing, Subcostal/intercostal retractions.

Question 18

What is paradoxical breathing?

Answer 18

Drawing in the chest wall during inspiration instead of moving outward with the abdomen. This indicates respiratory muscle fatigue and is an ominous sign.

Question 19

What about tachypnea?

Answer 19

Note depth and degree of effort.

Question 20

What about grunting?

Answer 20

Forced expiration against a partially closed glottis. Suggests diseases of air space such as atelectasis, pneumonia or pulmonary edema.

Question 21

What is nasal flaring?

Answer 21

Enlargement of both nares during inspiration to increase air entry.

Question 22

What is head bobbing?

Answer 22

Best observed during sleep. In synchrony with each inspiration, shows use of accessory muscles.

Question 23

What are subcostal/intercostal retractions?

Answer 23

An inspiratory sinking-in of soft tissues in relation to cartilaginous and bony thorax.

Question 24

Stridor:

Answer 24

• Due to airway narrowing above thoracic inlet

- Usually heard with inspiration, but may be biphasic if obstruction is severe

Question 25

Wheezing:

Answer 25

• Due to airway narrowing below thoracic inlet
• Usually heard only in expiration, but may become biphasic
• Typically diffuse
• Polyphonic or monophonic

Question 26

Rhonchi:

Answer 26

• Due to secretions and airway narrowing
• Coarse, low-pitched, rattling sounds
• Heard best in expiration

Question 27

Crackles:

Answer 27

• Due to fluid in alveoli or opening and closing of stiff alveoli
• Heard on inspiration
• Described as either coarse or fine

Question 28

Bronchial breath sounds:

Answer 28

• Lower in pitch and hollow-sounding

- Caused by air moving through areas of consolidated lung

Question 29

What is on the differential diagnosis for a 10 month old with a cough?

Answer 29

URI, Asthma, Bronchiolitis, Pneumonia, Foreign body aspiration.

Question 30

Upper respiratory infection (URI):

Answer 30

Extremely common in childhood. Presents with wet cough, rhinorrhea, usually no wheezing. Asymmetric breath sounds are not consistent with a viral process.

Question 31

Asthma:

Answer 31

Disease of airway inflammation resulting in reversible airway obstruction. Infiltration of inflammatory cells into airway mucosa causes mucus hypersecretion, mucosal edema and bronchoconstriction. Acute presentations include cough, wheezing, tachypnea, and dyspnea, with wheezing and diminished air exchange on chest exam. Chronic symptoms include recurrent episodes of dyspnea and/or cough. CXR findings include hyperinflation, increased interstitial markings, and patchy atelectasis.

Question 32

Bronchiolitis:

Answer 32

Viral disease of lower respiratory tract in infants. Most common cause of wheezing in this population. Respiratory syncytial virus (RSV) is most common pathogen, but other viruses can also cause bronchiolitis. Characterized by bronchiolar obstruction from edema, mucus, and cellular debris. Initial symptoms usually mild upper respiratory tract symptoms, then progressing to cough, wheezing, dyspnea, and irritability. Chest X-ray shows hyperinflation, peribronchial cuffing, and scattered atelectasis.

Question 33

Pneumonia

Answer 33

Inflammation of lung parenchyma. Typically caused by microorganisms, but there are also non-infectious causes, such as aspiration of gastric contents or hydrocarbons. Most common cause in children is respiratory viruses (eg adenovirus, RSV, parainfluenza, and influenza). Pneumonia caused by bacteria (eg Group B strep, E. coli, Klebsiella, Chlamydia trachomatis, Strep pneumoniae, Mycoplasma pneumoniae) tends to be more severe. Chest X-rays typically show airspace disease with lobar or segmental consolidation and air bronchograms.

Question 34

Foreign body aspiration:

Answer 34

Foreign bodies that lodge in the upper airway (trachea and bronchi) can be immediately life-threatening. Results in over 500 childhood deaths a year in the US. Usually find asymmetric wheezing on exam. Chest X-ray shows unilateral air trapping in one lung. Local tissue reaction depends on foreign body composition. Fatty oils in aspirated food (such as peanuts) create a more severe pneumonitis than a similarly sized object made of plastic or metal, while a disc battery may erode through the bronchial wall.

Question 35

What are the most commonly aspirated foods?

Answer 35

Hot dogs, hard candy, nuts, grapes, popcorn.

Question 36

Inspiratory/expiratory chest X-rays:

Answer 36

Can evaluate whether obstruction of the larger airways is present by finding of asymmetric deflation with expiration.

Question 37

Decubitus chest X-rays:

Answer 37

Performed with patient lying on her/his side. Causes dependent lung to deflate slightly compared to the non-dependent lung due to gravity. If one side does not deflate as expected, this suggests an obstruction in a large airway.

Question 38

Chest fluoroscopy:

Answer 38

Dynamic evaluation that allows visualization of the airways over several breaths. Excellent radiographic test to evaluate for airway foreign body in an infant or toddler as does not require child to hold her/his breath. However, more radiation is administered compared with plain films.

Question 39

Rigid bronchoscopy:

Answer 39

Typically not performed as initial diagnostic test for foreign body because of need for trained physician and special equipment. But once object in airway is identified, can be removed with forceps under general anesthesia.

Question 40

After removal of foreign body, what is the appropriate management?

Answer 40

• Best to give parents of an infant or toddler some anticipatory guidance before they leave the ED, even if you are not the child’s usual physician.
• In cases of recurrent ingestions or signs of abuse or neglect, would be necessary to contact social services for a home visit.
• When counseling family on how to prevent future similar events it is important to do so gently in a non-accusatory manner.