A Deep "Seeded" Cough

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Written by: Laurie Nosbusch, MD (NUEM PGY-2) Edited by: Jon Andereck, MD, (NUEM PGY-4) Expert commentary by: Viren Kaul, MD


The Case

Chief Complaint: Cough for 3 weeks

History of Present Illness: An 18 month old male patient presents to the emergency department for a cough that has persisted for 3 weeks. He had a runny nose for one week, but the cough has persisted for two weeks beyond resolution of his congestion. The cough is non-productive and is worse at night when lying down. Parents deny fever, shortness of breath, wheezing, vomiting, choking, change in energy level, change in appetite, or weight loss.

Physical Exam:

Vitals: T 37.2, HR 103, BP 92/palp, RR 35, Sat 97% on room air

General: Well-appearing, interactive, sitting with parents

Pulmonary: Tachypneic but no signs of respiratory distress, no stridor, no accessory muscle use, no retractions, no tracheal tugging, no nasal flaring. Right lung is clear to auscultation. Left lung has decreased breath sounds at the base.

The rest of the physical exam is unremarkable.

 

Chest X- Ray [1]:

   
  
  
   
   
   
   
   
   
   
   
   
   
   
   
  
  
  
  
  
     Figure 1.  Radiology interpretation :  Hyperlucency of left lung with mediastinal shift to right

Figure 1. Radiology interpretation: Hyperlucency of left lung with mediastinal shift to right

Differential Diagnosis: Bronchial mass, congenital lobar emphysema, foreign body aspiration

Case Resolution: Bronchoscopy was performed and food debris (possibly a seed or popcorn) was removed from the left lower bronchus. The left mainstem bronchus was inflamed. The patient was treated for post-obstruction inflammation and pneumonia with steroids and antibiotics.

Final Diagnosis: Foreign body aspiration


Discussion:

Foreign Body Aspiration Causing Partial Airway Obstruction  

Epidemiology: Foreign body aspiration is a common presentation in the emergency department. Nearly 80% of these events occur in children younger than 3 years and they are more common in males. [2]

Presentation: These patients may have variable presentations depending on timing:

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Common Chest X-Ray Findings:

  • Visualization of radio-opaque foreign body
  • Normal chest x-ray (30%) [7,8]
  • Lower airway obstruction: hyperinflated lung, hyperlucent lung, atelectasis, mediastinal shift, pneumonia, abscess [7,9] (See Figure 1 Above)
  • Lower airway obstruction: hyperinflated lung, hyperlucent lung, atelectasis, mediastinal shift, pneumonia, abscess [7,9] (See Figure 1 Above)
  • Lateral decubitus films: air trapping due to foreign body in bronchus prevents collapse of affected lung [9] (Compare Figures 2 and 3 Below) 
  Figure 2. Left Lateral Decubitus Film [9]   Left lung collapses when in dependent position. This is normal and does not suggest foreign body or air trapping in left lung.

Figure 2. Left Lateral Decubitus Film [9]

Left lung collapses when in dependent position. This is normal and does not suggest foreign body or air trapping in left lung.

  Figure 3. Right Lateral Decubitus Film [9]   Right lung does not collapse when in dependent position. This is abnormal and suggests foreign body in right bronchus causing air trapping in right lung.

Figure 3. Right Lateral Decubitus Film [9]

Right lung does not collapse when in dependent position. This is abnormal and suggests foreign body in right bronchus causing air trapping in right lung.

Management:

  • Address the ABCs
  • Obtain a history, specifically asking about choking events
  • If the history is concerning for foreign body aspiration or if breath sounds are asymmetric, order x-ray
    • PA/lateral chest views
    • Consider expiratory phase chest x-ray (in cooperative patients) or bilateral decubitus chest x-rays (for younger, less cooperative patients) as these can enhance detection of unilateral air trapping [9]
    • If there is concern for laryngotracheal foreign body, obtain neck PA/lateral x-rays
    • If the x-rays are negative, order CT or proceed directly to bronchoscopy depending on clinical suspicion [9]
  • Bronchoscopy is performed to remove the foreign body
  • If there is evidence of inflammation or infection, give steroids and/or antibiotics
  • Initial empiric antibiotics should cover oral anaerobes, ex. ampicillin-sulbactam [10]

Key Points:

  • Consider foreign body aspiration for any pediatric patient with a respiratory complaint
  • The H&P is important for diagnosis because chest x-rays can be normal 30% of the time
  • Think about foreign body aspiration when you see an x-ray suggestive of air trapping

Expert Commentary

Thank you for the opportunity to review this well summarized article on partial tracheobronchial foreign body aspiration (FBA) in pediatric patients.

Here are my TOP TEN TIPS:

  1. Beware the unwitnessed FBA!
  2. Ask for presence of an older sibling, they often provide the foreign body (FB) to the younger sibling.
  3. > 60% FBs land on the right side and > 80% are organic.
  4. Having an iron will is a good thing. Having an iron pill in your airway: bad! Iron and potassium tablets dissolve in the airway, cause severe inflammation and result in stenosis.
  5. Smaller the child, smaller the airway, more likelihood of obstruction.
  6. Which FBs are most likely to cause obstruction and be fatal? MNEMONIC: They reach the RIBS!!
    1. Round
    2. Incompressible
    3. Don’t Break easily
    4. Smooth
  7. Peanuts are commonest single food item responsible for FBA.  
  8. DO NOT conduct blind sweeps of the mouth as it can lead to complete airway obstruction.
  9. What to do should the child stop speaking or coughing i.e. develop a complete central airway obstruction?
    1. Ask for help!
    2. Infants: Alternating back blows and compressions
    3. Older children/adults: Heimlich maneuver
    4. Follow the AHA guidelines
  10. Bronchoscopy is recommended in all cases where the suspicion for FBA is high. In children, rigid bronchoscopy is recommended. Flexible bronchoscopy can be used for diagnosis in uncertain situations but having a rigid bronchoscope in standby is strongly advised.
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Viren Kaul, MD

Fellow, Pulmonary and Critical Care Medicine

Mount Sinai School of Medicine at Elmhurst


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    How to cite this post

    [Peer-Reviewed, Web Publication]   Nosbusch L, Andereck J (2018, July 23). A deep "seeded" cough.  [NUEM Blog. Expert Commentary by Kaul V]. Retrieved from http://www.nuemblog.com/blog/pediatric-cough


    References:

    1. Case courtesy of Dr Jeremy Jones, <a href="https://radiopaedia.org/">Radiopaedia.org</a>. From the case <a href="https://radiopaedia.org/cases/26866">rID: 26866</a>
    2. Tan HK, Brown K, McGill T, et al. Airway foreign bodies (FB): a 10-year review. Int J Pediatr Otorhinolaryngol 2000; 56:91.
    3. Wiseman NE. The diagnosis of foreign body aspiration in childhood. J Pediatr Surg 1984; 19:531.
    4. Laks Y, Barzilay Z. Foreign body aspiration in childhood. Pediatr Emerg Care 1988; 4:102.
    5. Blazer S, Naveh Y, Friedman A. Foreign body in the airway. A review of 200 cases. Am J Dis Child 1980; 134:68.
    6. Mu L, He P, Sun D. The causes and complications of late diagnosis of foreign body aspiration in children. Report of 210 cases. Arch Otolaryngol Head Neck Surg 1991; 117:876.
    7. Sahin A, Meteroglu F, Eren S, Celik Y. Inhalation of foreign bodies in children: experience of 22 years. J Trauma Acute Care Surg 2013; 74:658.
    8. Svedstrom E, Puhakka H, Kero P. How accurate is chest radiography in the diagnosis of tracheobronchial foreign bodies in children? Pediatr Radiol 1989;19:520.
    9. Laya BF, Restrepo R, Lee EY. Practical imaging evaluation of foreign bodies in children: an update. Radiol Clin N Am 2017; 55:845
    10. Sandora TJ, Harper MB. Pneumonia in hospitalized children. Pediatr Clin North Am 2005; 52:1059.

    Posted on July 23, 2018 and filed under Pulmonary.