About Me

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I completed my medical school and background EM training from India (Christian Medical College, Vellore and Apollo Hospitals, Hyderabad) where I worked for 4 years. Following this, I devoted (with all my heart) about 1.5 years to do US Medical Licensing Exams. My stint towards an EM Residency in States did not work but it took me to places and it has been quite a journey. I then relocated to London, England to work as a Registrar (Non-Trainee) in A&E. This gave me an opportunity to better understand NHS, EM training pathways and more importantly the EM Mindsets in the United Kingdom. 

Currently, I am pursuing Higher Specialist Training in Emergency Medicine at South East Scotland Deanery where I have the honour and privilege of training under some of the most innovative brains in the field of Emergency Medicine. Over the past few years, I have realised that LEARNING and UNLEARNING (which can be challenging!) is equally important to deliver cutting edge care to our patients.And through this blog, I aspire to disseminate knowledge, assist trainees with exams and stay up to date with contemporary EM literature. I have always been an avid FOAMed supporter because FOAMed has always played an indispensable role during my training. 


Lakshay Chanana
ST4 EM Trainee 
Edinburgh, Scotland
drlakshayem@gmail.com

Monday, March 21, 2016

Foreign Body Aspiration masquerading as Pneumonia

Case

Two and a half year old boy presented to the ER with a seizure. Mother gave h/o cough cold, fever for the past one week and the child also had history of a choking spell one week back. Background h/o reactive airway disease (RAD) was positive.

O/E: Dehydrated , Comatose, Gasping


HR 60bpm, RR 50bpm , SpO2 60% RA, Temp 103F and bilateral silent chest .Vitals improved with BMV and he was treated on the lines of infective exacerbation of reactive airway disease. 



CXR on arrival

Eventually he was intubated following which SpO2 improved to 94%. CXR was suggestive of left consolidation /collapse. He was shifted to the ICU where due to a lack of response to treatment, he underwent bronchoscopy that revealed a peanut that caused collapse of the left lung and secondary infective exacerbation of RAD.


CXR after 2 days


Discussion

Foreign Body Aspiration (FBA) occurs commonly in children and it is frequently encountered by paediatric EM practitioners. It is more common in boys and frequently seen in kids less than 3 years of age. With classic acute and dramatic presentations, FBA is usually frequently diagnosed promptly but the diagnoses can get delayed with subtle of atypical presentations if a high index of suspicion is not maintained. 

Classic history comes as choking, coughing and cyanosis. Examination may reveal respiratory distress, asymmetrical chest expansion, localised wheeze or decreased breath sounds. If the size of the FB is small in relation to the airway, it can lead to partial airway obstruction and presentation may be delayed for days or weeks ultimately presenting as pneumonia. Majority of the FB aspirated are organic materials typically peanuts which can gradually absorb water and swell up over a period of time leading to complete obstruction. Inorganic FB like batteries, coins, toys are rare (unfortunately, the rare ones are easily seen on a CXR). 

Even with a FBA, CXR can be completely normal or it may show air trapping, infiltrates, consolidation. A later CXR may help in differentiating between airway and oesophageal FB. CT scans and bronchoscopy can further accurately localise the FB and aid removal . Whenever there is a high suspicion (based on history or poor response to treatment), further work up must be done. Rigid Bronchoscopy is used for the definitive management with occasional use of flexible bronchoscopes to reach sub segmental FBs


Take Home:
Aspirated foreign body is an important differential diagnosis for Asthma/Reactive Airway Disease and should also be considered in the child who has an exacerbation that does not respond to standard treatment. 


Further Reading
1. Rizk H, Rassi S. Foreign body inhalation in the pediatric population: lessons learned from 106 cases. Eur Ann Otorhinolaryngol Head Neck Dis 2011;128(4):169-174.
2. Asif M, Shah SA, Khan F, Ghani R. Analysis of tracheobronchial foreign bodies with respect to sex, age, type and presentation. J Ayub Med Coll Abbottabad 2007;19(1):13-15.
3. Saki N, Nikakhlagh S, Rahim F, Abshirini H. Foreign body aspirations in infancy: a 20-year experience. Int J Med Sci 2009 14;6(6):322- 328.
4. Fraga Ade M, Reis MC, Zambon MP, Toro IC, Ribeiro JD, Baracat EC. Foreign body aspiration in children: clinical aspects, radio- logical aspects and bronchoscopic treatment. J Bras Pneumol 2008;34(2):74-82.
5. Orji FT, Akpeh JO. Tracheobronchial foreign body aspiration in children: how reliable are clinical and radiological signs in the diagnosis? Clin Otolaryngol 2010;35(6):479-485.
6. Jung SY, Pae SY, Chung SM, Kim HS. Three-dimensional CT with vir- tual bronchoscopy: a useful modality for bronchial foreign bodies in pediatric patients. Eur Arch Otorhinolaryngol 2011;16. (Epub ahead of print)
7. Passàli D, Lauriello M, Bellussi L, Passali GC, Passali FM, Gregori D. Foreign body inhalation in children: an update. Acta Otorhinolaryn- gol Ital 2010;30(1):27-32.
8. Wu CT, Wang CJ. Alternate lung collapse in a 9-year-old boy with peanut aspiration. Pediatr Radiol 2006;36(12):1327. 
9. Zaupa, Paola, et al. "Management strategies in foreign-body aspiration." The Indian Journal of Pediatrics 76.2 (2009): 157-161.
10. Cohen, Shlomo, et al. "Suspected foreign body inhalation in children: what are the indications for bronchoscopy?." The Journal of pediatrics 155.2 (2009): 276-280.



Case contributed by Dr. Azharullah Khan, MRCEM (@Khan123Azhar)

2 comments:

  1. Thanks for sharing lakshay.very useful.
    Greetings
    Rachana

    ReplyDelete