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A 24-month-old girl is brought to the emergency department after an episode of choking and coughing. The child was playing alone in another room when her mother heard her choking and gagging. En route to the hospital, the coughing resolved. She now appears calm. Oropharyngeal examination is normal. Expiratory wheezes are present over the right lower lobe of the lung. What is the most likely cause of the child's symptoms?

A. Epiglottitis

B. Tracheal foreign body

C. Lower airway foreign body

D. Lobar pneumonia

E. Status asthmaticus

Answer: C

The child's presentation is consistent with a foreign body aspiration into the lower airway. The aspiration event took place while she was at unobserved play, raising suspicion for aspiration of a small toy or part of a toy. The coughing and choking episode had a rapid onset and resolved spontaneously, and focal wheezing is now present over the right lower lobe of the lung. It is likely that the foreign body has lodged into a right-sided bronchus. Notably, most foreign bodies are radiolucent on chest radiography, but chest radiography may reveal other typical radiographic findings such as hyperinflation distal to the site of the foreign body. The hyperinflation is due to air trapping distal to the partially obstructive foreign body. The hyperinflation is best visualized during expiration. The foreign body can be removed via bronchoscopy.

Epiglottitis causes the acute onset of fever, toxic appearance, respiratory distress, stridor, and drooling. Its symptoms progress rapidly and do not self-resolve. Tracheal foreign bodies cause stridor and hoarseness, rather than wheezing, which is a sign of a lower airway obstruction. Lobar pneumonia can result in focal wheezing, but it would not explain the child's rapid onset of coughing and choking. Status asthmaticus results in wheezing, but the wheezing is typically diffuse rather than focal.

A 3-year-old girl is playing with friends at a birthday party when she suddenly begins coughing and choking. She is rushed to the emergency department, but her distress has resolved by the time of arrival. Wheezing is present over her right lower and middle lung fields, and hyperinflation is present over these areas on expiratory chest films. Which of the following is indicated?

A. Albuterol to relieve her lower airway obstruction

B. Amoxicillin to treat her community-acquired pneumonia

C. Broad-spectrum antibiotics for her epiglottitis

D. Parental reassurance about the benign nature of the episode

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