What are key history findings in an infant with a cough due to foreign body?
Cough, wheezing, runny nose, prev. healthy.
What are key physical exam findings in an infant with a cough due to a foreign body?
Tachypnea at rest, retractions, asymmetric breath sounds with unilateral wheezing, wet cough, afebrile.
What is on the differential diagnosis for lung foreign body?
Asthma, epiglottitis, anatomic, pertussis, bronchiolitis, croup, gastroesophageal reflux, foreign body, pneumonia
What are key findings from testing with a foreign body?
- 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
Effectiveness of immunizations:
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.
Pertussis (“whooping cough”):
- 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.
- 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
- 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.
These questions are important to help evaluate diagnosis of cough:
- 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)?
Is the patient drinking fluids?
Gives sense of hydration status and degree of difficulty breathing. Also helps assess for dysphagia.
Has the patient had a fever?
History of fever would make an infectious process more likely.
Did the cough begin suddenly? Did the patient appear to choke on anything?
Important to find out if aspiration is likely, although most cases at this age are unwitnessed.
Has patient’s voice or cry been hoarse?
Can help distinguish whether problem is in lower or upper airway. (Problems isolated to lower airway typically do not affect voice or cry.)
Has the cough been barky?
Would suggest a diagnosis of croup, a viral illness most common in winter months and in children two to five years of age.
Does the patient make any noises when she/he breathes?
Wheezing more typically expiratory, stridor more typically inspiratory, but both can be present throughout respiratory cycle.
Does patient have medical problems (eg ear infections, history of pneumonia, spitting up, chronic diarrhea, trouble gaining weight)?
Important to gather information about possible chronic illnesses (eg reflux disease, malabsorptive disorder, immunodeficiency) and birth history.
What are visible signs of respiratory distress in infants?
Paradoxical breathing, Tachypnea, Grunting, Nasal flaring, Head bobbing, Subcostal/intercostal retractions.
What is paradoxical breathing?
Drawing in the chest wall during inspiration instead of moving outward with the abdomen. This indicates respiratory muscle fatigue and is an ominous sign.
What about tachypnea?
Note depth and degree of effort.
What about grunting?
Forced expiration against a partially closed glottis. Suggests diseases of air space such as atelectasis, pneumonia or pulmonary edema.
What is nasal flaring?
Enlargement of both nares during inspiration to increase air entry.
What is head bobbing?
Best observed during sleep. In synchrony with each inspiration, shows use of accessory muscles.
What are subcostal/intercostal retractions?
An inspiratory sinking-in of soft tissues in relation to cartilaginous and bony thorax.
- Due to airway narrowing above thoracic inlet
- Usually heard with inspiration, but may be biphasic if obstruction is severe
- Due to airway narrowing below thoracic inlet
- Usually heard only in expiration, but may become biphasic
- Typically diffuse
- Polyphonic or monophonic
- Due to secretions and airway narrowing
- Coarse, low-pitched, rattling sounds
- Heard best in expiration
- Due to fluid in alveoli or opening and closing of stiff alveoli
- Heard on inspiration
- Described as either coarse or fine
Bronchial breath sounds:
- Lower in pitch and hollow-sounding
- Caused by air moving through areas of consolidated lung
What is on the differential diagnosis for a 10 month old with a cough?
URI, Asthma, Bronchiolitis, Pneumonia, Foreign body aspiration.
Upper respiratory infection (URI):
Extremely common in childhood. Presents with wet cough, rhinorrhea, usually no wheezing. Asymmetric breath sounds are not consistent with a viral process.
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.
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.
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.
Foreign body aspiration:
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.
What are the most commonly aspirated foods?
Hot dogs, hard candy, nuts, grapes, popcorn.
Inspiratory/expiratory chest X-rays:
Can evaluate whether obstruction of the larger airways is present by finding of asymmetric deflation with expiration.
Decubitus chest X-rays:
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.
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.
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.
After removal of foreign body, what is the appropriate management?
- 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.