A 3-year-old boy is brought to the emergency department by his mother with a 6-hour history of sudden onset coughing and stridor after playing with peanuts in the kitchen. He has a weak cry, difficulty swallowing saliva, and is drooling. On examination, he is sitting upright, appears anxious, and has inspiratory stridor with subcostal retractions. Chest auscultation reveals decreased air entry bilaterally. A chest X-ray shows hyperinflation of both lungs with mediastinal shift. What is the most appropriate immediate management?

Explanation

## Immediate Management of Airway Foreign Body in a Child **Key Point:** A child with signs of airway foreign body obstruction (stridor, weak cry, drooling, respiratory distress) requires urgent rigid bronchoscopy under general anaesthesia with spontaneous respiration maintained. **Clinical Pearl:** The hyperinflation on chest X-ray indicates a ball-valve mechanism — the foreign body allows air entry during inspiration but obstructs expiration, causing air trapping. This is a hallmark of lower airway foreign body and demands immediate removal. **High-Yield:** Rigid bronchoscopy is the gold standard for foreign body removal in children because: - Provides superior airway control and visualization - Allows use of appropriate forceps for secure extraction - Permits immediate intervention if complete obstruction occurs - Spontaneous respiration (not jet ventilation) is maintained to avoid pushing the foreign body distally **Warning:** Do NOT delay with observation, topical anaesthesia, or medical management (steroids/epinephrine) when there is clinical and radiological evidence of foreign body. These measures may mask symptoms and allow aspiration deeper into the bronchial tree. ### Why Rigid Bronchoscopy Under GA? | Feature | Rigid Bronchoscopy | Flexible Bronchoscopy | |---------|-------------------|----------------------| | Airway control | Excellent | Limited in emergency | | Forceps control | Optimal | Difficult | | Aspiration risk | Minimized | Higher | | Spontaneous ventilation | Maintained easily | Compromised | | Pediatric suitability | Gold standard | Adjunct only | **Mnemonic: RB-GA** — **R**igid **B**ronchoscopy under **G**eneral **A**naesthesia for airway foreign body in children with stridor and respiratory distress. [cite:Cummings Otolaryngology 6e Ch 196]