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 after playing with peanuts. On examination, he is in mild respiratory distress with stridor. Chest auscultation reveals decreased air entry on the right side with occasional wheezing. Anteroposterior and lateral neck radiographs show no radiopaque foreign body. What is the most appropriate next step in management?

Explanation

## Clinical Assessment **Key Point:** A child with acute-onset coughing, unilateral decreased air entry, and history of foreign body aspiration has a high clinical suspicion for foreign body airway obstruction, even if imaging is negative. ### Why Imaging May Be Negative Organicforeign bodies (peanuts, seeds, food particles) are **radiolucent** and do not appear on plain radiographs. Up to 20% of aspirated foreign bodies are not visible on X-ray. The clinical history and unilateral findings are more diagnostic than imaging in these cases. ### Management Algorithm ```mermaid flowchart TD A[Suspected foreign body aspiration]:::outcome --> B{Clinical signs present?}:::decision B -->|Yes: stridor, unilateral decreased air entry| C[Rigid bronchoscopy under GA]:::action B -->|No: stable, no respiratory distress| D[Observe, repeat imaging at 24-48 hrs]:::action C --> E[Visualization and removal]:::outcome D --> F{Foreign body seen?}:::decision F -->|Yes| C F -->|No| G[Discharge if asymptomatic]:::outcome ``` **High-Yield:** Rigid bronchoscopy is the gold standard for diagnosis AND treatment of airway foreign bodies in children. It provides superior visualization, airway control, and allows instrumentation for safe removal. ### Why This Patient Needs Bronchoscopy 1. **Acute presentation** with stridor and respiratory distress 2. **Unilateral findings** (decreased air entry on right) suggest localized obstruction 3. **Radiolucent foreign body** (peanut) will not be visible on X-ray 4. **Risk of complete obstruction** or migration—urgent intervention needed **Clinical Pearl:** The "peanut sign" on imaging refers to the appearance of aspiration pneumonia or atelectasis distal to the obstruction, not the peanut itself. Absence of this sign does NOT exclude foreign body. **Warning:** Delaying bronchoscopy in a symptomatic child risks sudden complete airway obstruction, aspiration pneumonia, and granulation tissue formation around the foreign body, making removal more difficult. [cite:Dhingra 7e Ch 18]