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 while playing with small toys. On examination, he is alert but anxious, with inspiratory stridor and mild intercostal retractions. Oxygen saturation is 94% on room air. Chest auscultation reveals asymmetric breath sounds with decreased air entry on the right side. A chest X-ray (inspiratory and expiratory views) shows hyperinflation of the right lung with mediastinal shift to the left. What is the most appropriate next step in management?

Explanation

## Clinical Diagnosis: Foreign Body in Right Main Bronchus ### Key Clinical Features - **Acute presentation** with sudden coughing during play (classic history) - **Unilateral stridor** with asymmetric breath sounds (right side decreased) - **Hyperinflation on expiratory film** with mediastinal shift — pathognomonic for **ball-valve obstruction** of a bronchus - **Age 3 years** — peak incidence of foreign body aspiration (6 months to 5 years) ### Why Rigid Bronchoscopy is Correct **Key Point:** Any child with clinical and radiological evidence of foreign body aspiration requires urgent rigid bronchoscopy for removal under general anaesthesia. 1. **Diagnostic confirmation** — rigid scope allows direct visualization and removal in one procedure 2. **Airway control** — rigid scope provides superior airway management compared to flexible scope in pediatric emergencies 3. **Retrieval capability** — equipped with forceps, baskets, and hooks for safe extraction 4. **Time-sensitive** — delayed removal risks **pneumonia, atelectasis, and bronchial stenosis** **High-Yield:** Rigid bronchoscopy is the gold standard for foreign body removal in children; flexible scope is contraindicated in acute airway obstruction. ### Radiological Findings Explained | Finding | Mechanism | Significance | |---------|-----------|-------------| | Hyperinflation (right lung) | Ball-valve effect: air enters during inspiration, trapped during expiration | Confirms bronchial obstruction | | Mediastinal shift (to left) | Increased pressure in right hemithorax | Indicates significant obstruction | | Asymmetric breath sounds | Right mainstem blockade | Localizes foreign body | **Clinical Pearl:** The **expiratory film is more sensitive** than inspiratory for detecting air trapping; a normal inspiratory film does NOT exclude foreign body if clinical suspicion is high. ### Why Observation/Steroids Are Inadequate - Adrenaline and steroids address **croup** (viral laryngitis), not mechanical obstruction - Observation risks **complete airway occlusion** and **hypoxia** - Foreign body will not resolve spontaneously [cite:Dhingra 7e Ch 18]