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

 References: 

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