A 3-year-old boy is brought to the emergency department by his mother with a 6-hour history of sudden-onset coughing and choking while playing with small toys. He has persistent cough, mild stridor, and is able to speak in short sentences. Chest examination reveals decreased air entry on the right side. Neck X-ray (AP and lateral) shows a radiopaque object at the level of the right main bronchus. The child is conscious, alert, and maintaining oxygen saturation of 94% on room air. What is the most appropriate immediate management?

Explanation

## Management of Foreign Body Airway in Children ### Clinical Context This child presents with a **confirmed foreign body** (radiopaque object on imaging) causing **partial airway obstruction** with maintained oxygenation and conscious level. The key decision point is timing and method of removal. ### Immediate Management Principle **Key Point:** Any foreign body in the lower airway (trachea, bronchi) that is **confirmed on imaging** and causing **symptoms** requires **urgent rigid bronchoscopy** under general anaesthesia — this is the gold standard for removal. **High-Yield:** The presence of: - Radiopaque foreign body on imaging ✓ - Persistent cough and stridor ✓ - Unilateral decreased air entry ✓ - Stable airway (no complete obstruction) ✓ → Indicates **urgent but controlled removal** via rigid bronchoscopy, NOT emergency airway intervention. ### Why Rigid Bronchoscopy? 1. **Visualization** — allows direct visualization of foreign body and airway anatomy 2. **Control** — prevents aspiration of fragments during removal 3. **Instrumentation** — enables use of grasping forceps, hooks, and baskets 4. **Safety** — performed under controlled anaesthesia with airway management backup **Clinical Pearl:** Rigid bronchoscopy is superior to flexible bronchoscopy in children because: - Better airway control and oxygenation - Larger working channel for instrumentation - Ability to manage complications (airway edema, bleeding) ### Timing - **Immediate/urgent** (within 1–2 hours) if foreign body is in lower airway with symptoms - **Emergency** (within minutes) only if complete airway obstruction or severe hypoxia This child is stable enough for controlled rigid bronchoscopy under GA, not emergency cricothyrotomy. [cite:Cummings Otolaryngology 6e Ch 197]