A previously healthy 2-year-old black child has developed a chronic cough during the previous 6 weeks. He has been seen in different emergency rooms on two occasions during this period and has been placed on antibiotics for pneumonia. Upon auscultation, you hear normal breath sounds on the left. On the right side, you hear decreased air movement during inspiration but no air movement upon expiration. Inspiratory (A) and expiratory (B) radiographs of the chest are shown below. Which of the following is the most appropriate next step in making the diagnosis in this patient?
(b) Source: (Hay et al, pp 499-500. Kliegman et al, pp 1453-1454. McMillan et al, pp 693-694. Rudolph et al, pp 449-451.) Recurrent pneumonias in an otherwise healthy child should suggest the potential for anatomic blockage of an airway. In the patient in this question, the findings on clinical examination suggest a foreign body in the airway. Inspiratory and expiratory films can be helpful. Routine inspiratory films are likely to appear normal or near normal (as outlined in the question and noted in the first radiograph). Expiratory films will identify air trapping behind the foreign body (as noted on the second radiograph). It is uncommon for the foreign body to be visible on the plain radiograph; a high index of suspicion is necessary to make the diagnosis. Suspected foreign bodies in the airway are potentially diagnosed with fluoroscopy, but rigid bronchoscopy is not only diagnostic but also the treatment of choice for removal of the foreign body.
Measure the patient's sweat chloride.
Consult pediatric surgery for bronchoscopy.
Prescribe broad-spectrum oral antibiotics.
Initiate a trial of inhaled b-agonists.
Respiratory System