What's the Diagnosis? By Dr. Michael Tom

A 9 yo healthy F presents to the ED for coughing which started abruptly just prior to presenation. On exam, she is afebrile, nontoxic appearing, but does cough frequently. A CXR is done. What's the diagnosis? (scroll down for answer)




Answer: Foreign body aspiration- nail in R mainstem bronchus

  • Sudden onset of symptoms should raise suspicion
  • Patients may present with 'choking', may have history of unsupervised play; most commonly seen in ages 1-3
  • Classic teaching is that laryngotracheal FB causes stridor/hoarseness while bronchial FB causes unilateral wheeze and decreased breath sounds
  • If stable, plain radiograph is initial test of choice, but has poor sensitivity;  CT can help if suspicion is high for FB
  • If causing airway obstruction, asphyxiation or severe respiratory distress:
    • Involve anesthesia/ENT early
    • Check if FB can be visualized in the mouth-- blind finger sweep NOT recommended
    • Try back blows in infant, heimlich in older children
    • If unsuccessful may need RSI, can attempt removal w/ Magill forceps
    • If unable to remove w/ forceps, orotracheal intubation with dislodgment of the FB more distally, often to the R mainstem bronchus, may relieve complete obstruction and can be life saving
    • If ventilation cannot be provided w/ ET tube, may need cricothyrotomy/tracheostomy
  • Consultation with ENT or appropriate specialist for bronchoscopy provides definitive treatment



Mapelli E, Sabhaney V. Stridor and Drooling in Infants and Children. In: Tintinalli JE, Stapczynski J, Ma O, Yealy DM, Meckler GD, Cline DM. eds. Tintinalli’s Emergency Medicine: A Comprehensive Study Guide, 8e New York, NY: McGraw-Hill; 2016.