Pediatric Case of the Week 7: choking/gagging episode

A mother brings her 18 month old to your emergency department after the babysitter reports that he had episode of choking and gagging while eating lunch. Mom does not think that he turned blue or lost consciousness during the episode.  He resumed normal activity after the episode. She is, however, concerned because he continues to have "coughing spells."  The patient has two other siblings who have nothing else to add to the story.

(Our patient wasn't smoking, but I thought this picture was amazing and will add the story behind this photo to the update. Stay tuned.)  


VS: Temp 37,  Pulse 103,  Resp 28,  BP  98/55, O2 sat  96% on RA

PE: Playing comfortably in the exam room floor. No distress.  On lung exam you note an occasional low-pitched, monophonic expiratory wheeze heard best over the sternal notch.

Are you concerned?

Would you get any tests?  If so, what?

Would you recommend Chantix? (just kidding)

________________________________________________________________________

The story of "choking and gagging" followed by "intermittent expiratory wheeze" is concerning for foreign body aspiration. There are several conditions that could mimic an aspirated foreign body: asthma, croup, pneumonia, bronchitis, tracheomalacia, bronchomalacia, vocal cord dysfunction, or psychogenic cough. We'll assume you thought foreign body first...what would you do?

X-ray?...only be helpful if the foreign body were radio-opaque.
The xray on the left is from a 2 year old who was playing with his parents IKEA furniture.  Can you identify the official name of this foreign body ?
In our case, the AP CXR was normal.
You could perform a series of xrays to look for AIR TRAPPING. A recent AEMArticle (See recent In da' lit post) concluded: The addition of decubitus to standard views increases false positives without increasing true positives and lacks clinical benefit. The addition of expiratory to standard views increases true positives without increasing false positives, but test accuracy remains low and the clinical benefit is uncertain.




Bottom line: If the story is suspicious for foreign body, someone needs to take a look.  You need a pediatric surgeon with a rigid bronchoscope.

In this case, surgery was notified, the patient was taken to the OR, and a whole sunflower seed was removed from the right main stem bronchus.








Pediatric Foreign Body :

There are several conditions that could mimic an aspirated foreign body. Some of these illnesses are: asthma, croup, pneumonia, bronchitis, tracheomalacia, bronchomalacia, vocal cord dysfunction, or psychogenic cough.  It is important to think about FB in all cases of wheezing or stridor.

Inhalation/ingestion of food or objects is the 5th leading cause of death in the United States for all age groups. Toddlers, probably due to increased exploration and putting "stuff" in their mouths, are at increased risk.

91% of foreign bodies aspirated by children (<8 years old) were organic in nature with peanuts accounting for 54% of that number. They also found that children did not have a significant difference between the foreign body being found in the right or left bronchial tree. (Children have symmetric bronchial angles until about 15 years of age.)

Tracheobronchial foreign bodies: presentation and management in children and adults. Chest. 1999 May;115(5):1357-62. Baharloo et. al. 

Foreign body aspiration has been described in 3 clinical phases. 

The first: occurs immediately following the incident. The patient will usually experience choking, gagging, coughing, wheezing, and/or stridor. There may also be an associated temporary cyanotic episode, usually perioral. The occurrence of death is very high during this first phase of aspiration.

The second: is the asymptomatic period that can last from minutes to months following the incident. The duration of this period depends on the location of the foreign body, the degree of airway obstruction, and the type of material aspirated. The ease with which the foreign body can change its location is also a factor in the duration of this period.

The third: is the renewed symptomatic period. Airway inflammation or infection from the foreign body will cause symptoms of cough, wheezing, fever, sputum production, and occasionally, hemoptysis.

Making this diagnosis is VERY DIFFICULT:  History lends to how suspicious you should be of a potential aspiration.

Unfortunately, history is often complicated by an unwitnessed event, witnessed by a person not present for history taking, or witnessed by an older sibling who may have had a role in the aspiration and chooses not to say anything.

(Nick Johnson...any thoughts?)





Final Points:

In the first phase the classic findings are cough, unilateral decreased breath sounds, and unilateral monophonic wheezing. If stridor (inspiratory and/or expiratory), aphonia, or hoarseness is present, the foreign body is most likely in the larynx or cervical trachea. 

In the third phase patients may present with signs and symptoms of pneumonia. Often a foreign body is not suspected and the foreign body remains untreated. These patients return with "recurrent pneumonia" which is actually a pneumonia or atelectasis which has never resolved because the foreign body is still there.

Complications arising from foreign body aspiration depend on the location and type of foreign body aspirated (organic vs. non-organic, sharp vs. dull), and the duration of time the foreign body remained in the airways. If the foreign body is successfully removed within 24 hours of the incident, the complication rate is very low. However, the longer the foreign body remains in the airways, the more likely inflammation and thus, complications will occur. Potential complications include: bronchial stenosis, bronchiectasis, lung abscess, tissue erosion/perforation, and pneumomediastinum or pneumothorax.

In the end...if you don't think about foreign body aspiration, you won't make the diagnosis.  Hope this helped to provoke some thoughts.  Keep up the good work!!!

Thanks to the Department of Pediatrics at the University of Hawaii for this case (from which I shamelessly pillaged and plagiarized.)

The Smoker:  Indonesian boy who started smoking at 18 months and was up to 40 heaters a day by the time this video was shot.

http://www.youtube.com/watch?v=x4c_wI6kQyE