A 3-year-old boy is brought to the emergency department with a 2-hour history of sudden onset coughing and stridor after playing with small toys. On examination, he has inspiratory stridor, mild respiratory distress, and decreased air entry on the right side. Chest X-ray shows a radiopaque foreign body at the level of the right mainstem bronchus. What is the most appropriate immediate next step in management?

Explanation

## Management of Foreign Body Airway — Acute Presentation ### Clinical Context This child presents with **acute foreign body aspiration** with: - Confirmed diagnosis (radiopaque FB on CXR) - Anatomical localization (right mainstem bronchus) - Signs of airway obstruction (stridor, decreased air entry) - Haemodynamic stability ### Why Rigid Bronchoscopy is the Gold Standard **Key Point:** Rigid bronchoscopy is the procedure of choice for foreign body removal in the tracheobronchial tree, especially in children with confirmed FB and airway compromise. **High-Yield:** Rigid bronchoscopy offers: 1. Superior airway control and ventilation capability 2. Better visualization and manipulation of the FB 3. Lower risk of FB migration distally during removal 4. Ability to use multiple instruments simultaneously (forceps, hooks, baskets) 5. Rapid airway management if complications arise ### Procedural Essentials | Aspect | Rigid Bronchoscopy | Flexible Bronchoscopy | |--------|-------------------|----------------------| | **Airway control** | Excellent (can ventilate) | Limited (risk of obstruction) | | **FB manipulation** | Superior (rigid instruments) | Difficult (limited angles) | | **Safety in children** | Gold standard | Contraindicated in acute FB | | **Complication management** | Rapid intervention possible | Limited options | **Clinical Pearl:** Even if the FB is radiolucent, rigid bronchoscopy under direct visualization allows identification and removal. Flexible bronchoscopy is reserved for diagnostic purposes or removal of small, non-obstructing FBs in stable, cooperative patients. **Mnemonic: RIGID FIRST** — Rigid bronchoscopy for acute Foreign Body, Immediate removal, Guaranteed airway control, Instrumentation capability, Diagnostic AND therapeutic. ### Why Observation is Dangerous Nebulised adrenaline and dexamethasone manage oedema but do NOT remove the FB. Risk of complete airway obstruction, aspiration pneumonia, and bronchiectasis with delayed removal. [cite:Dhingra Textbook of ENT 8e Ch 24]