A 3-year-old child is brought to the emergency department with sudden onset choking followed by unilateral wheeze and decreased breath sounds on the right side. Chest X-ray shows mediastinal shift to the left on expiration. The most appropriate emergency management is:

• A Urgent lateral decubitus X-ray followed by physiotherapy
• B Rigid bronchoscopy under general anaesthesia for foreign body removal ✓
• C Flexible bronchoscopy under sedation with Fogarty catheter extraction
• D CT thorax followed by elective bronchoscopy within 24 hours

Explanation

The clinical picture — sudden onset unilateral wheeze and decreased breath sounds plus obstructive emphysema on expiration X-ray (ball-valve effect causing hyperinflation ipsilateral and mediastinal shift contralaterally on expiration) — is diagnostic of an endobronchial foreign body. Rigid bronchoscopy under general anaesthesia is the definitive standard-of-care procedure, allowing excellent visualisation, controlled airway, and use of appropriate grasping forceps. Flexible bronchoscopy is diagnostic but lacks the working channel for safe paediatric foreign body extraction.

Reference: Dhingra Diseases of Ear, Nose and Throat, 7th ed.

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Written and medically reviewed by the StethoPrep medical team.