A 3-year-old boy is brought to the emergency department by his mother with a 6-hour history of sudden onset coughing and difficulty breathing. She reports he was playing with peanuts in the living room when he suddenly started coughing violently. On examination, he is anxious, with stridor present. Chest auscultation reveals diminished breath sounds on the right side with hyperresonance to percussion. Chest X-ray (inspiratory) shows hyperinflation of the right lung with mediastinal shift to the left. What is the most appropriate immediate management?

Explanation

## Clinical Diagnosis **Key Point:** This child has a **foreign body (FB) in the right main bronchus** — a classic presentation of unilateral hyperinflation with mediastinal shift due to ball-valve obstruction. ### Pathophysiology of Ball-Valve Obstruction When a FB lodges in a bronchus, it acts as a one-way valve: - Air enters during inspiration (bronchus dilates) - FB blocks expiration (bronchus narrows) - Result: **air trapping → hyperinflation** of that lung - Mediastinal shift away from the affected side ## Management Algorithm ```mermaid flowchart TD A[Foreign Body Airway Suspected]:::outcome --> B{Airway patent?}:::decision B -->|No - Stridor/Apnea| C[Immediate removal: Abdominal thrusts/Back blows]:::urgent B -->|Yes - Partial obstruction| D[Secure airway, NPO]:::action D --> E[Rigid bronchoscopy under GA]:::action E --> F[FB removal with appropriate forceps]:::action F --> G[Post-removal: Observe for edema/aspiration]:::outcome ``` ### Why Rigid Bronchoscopy? | Feature | Rigid | Flexible | |---------|-------|----------| | **Airway control** | Excellent (ventilating scope) | Poor | | **Instrumentation** | Full range of FB forceps | Limited | | **Anesthesia** | General (safe airway) | Topical (risky if FB dislodges) | | **FB retrieval success** | 95–98% | <50% | | **Aspiration risk** | Minimal | High | **High-Yield:** In a **symptomatic child with confirmed FB**, rigid bronchoscopy under general anesthesia with a **ventilating scope** is the gold standard. This allows: - Continuous oxygenation during the procedure - Full visualization and instrumentation - Immediate airway control if FB dislodges **Clinical Pearl:** The **inspiratory chest X-ray** showing unilateral hyperinflation is pathognomonic for FB with ball-valve obstruction. An expiratory film would show even more dramatic shift. [cite:Dhingra 8e Ch 12] ## Why This Child Needs Urgent Intervention 1. **6-hour duration** — risk of mucosal edema, granulation, and impaction increases with time 2. **Organic FB (peanut)** — swells with moisture, becomes friable, increases aspiration risk 3. **Stridor present** — suggests partial airway obstruction; risk of complete obstruction 4. **Age 3 years** — cannot cooperate with flexible scope; GA mandatory **Warning:** Do NOT attempt flexible bronchoscopy under topical anesthesia in a young child with a FB — if the FB dislodges, there is no airway control and aspiration is likely.