Everything that wheezes… Late presentation of an aspirated foreign body as a cause of near fatal respiratory distress

IntroductionAspirated foreign bodies are a common cause of mortality in children. They can be difficult to diagnose if the aspiration is not witnessed or if the object is not radiopaque, as this case illustrates.Case reportA 4year old boy with a history of previous TB presented with respiratory distress after a week of fever and cough. No history of choking or foreign body was elicited. On examination the child was distressed, hypoxic and febrile. On auscultation bilateral coarse crackles and an expiratory wheeze were heard. The child was intubated, commenced on antibiotics and transferred to ICU. On arrival the child self extubated and was placed on nasal CPAP. Within hours he became distressed with a worsening wheeze and was given steroids and nebulised. X-ray at this point showed hyperinflation on the left and patchy opacification on the right. He continued to manage on CPAP until midnight, when he became restless with a marked prolonged expiratory wheeze. He was re-intubated and started on IVI salbutamol. On X-ray the right side now looked hyper-inflated. Ventilation was difficult, and high frequency oscillating ventilation commenced. Overnight he deteriorated, and developed a life threatening respiratory acidosis. Bronchoscopy was performed in the morning. It revealed a plastic foreign body in the right main bronchus which was successfully removed. The foreign body was possibly on the left initially, causing left sided hyperinflation, and was then coughed and re-aspirated into the right main bronchus causing acute deterioration. The child was extubated the next day and recovered well.DiscussionThis case illustrates the difficulty doctors may have when there is delayed presentation or unwitnessed aspiration of a foreign body. History, clinical symptoms and the X-ray findings may provide clues but are not diagnostic. In cases where a FB aspiration is suspected, bronchoscopy is both diagnostic and potentially curative