All that wheezes is not asthma: a 6-year-old with foreign body aspiration and no suggestive history

Abstract

SummaryThe authors report the case of a 6-year-old girl, presenting with a 4-month history of wheeze associated with barking cough which frequently became wet requiring antibiotics. Her care was transferred to a paediatrician with specialist interest in paediatric respiratory medicine when she had continued symptoms despite bronchodilators and oral steroids for suspected asthma. Spirometry showed a forced expiratory volume 1 of 79% with no evidence of reversibility. The child was investigated for chronic wet cough. Immunoglobulins, sweat test and chest x-ray were all normal. There was no history suggestive of foreign body aspiration (FBA). Tracheomalacia was considered in view of the nature of the cough. The recurrence of an unusual inspiratory noise prompted referral for bronchoscopy. A small piece of plastic tube was removed from the bronchus intermedius. All symptoms resolved. The importance of clinical assessment to ascertain 'wheeze' when acutely unwell is emphasised. Current literature concerning FBA is reviewed.

Muddy clinical waters: a missed betel nut in the bronchus

“…If an organic FB (eg, betel nut, as in the present case) is left undetected for more than 30 days, bronchiectatic changes start developing 2. It is not uncommon for a child with an undiagnosed bronchial FB to be misdiagnosed in the initial stages as having bronchial asthma 11. The present case re-emphasises the caveat that ‘all that wheezes is not asthma’.…”

Chronic cough and uncontrolled asthma: Ending a three year clinical course with successful foreign body removal

“…However, in the case of chronic aspiration, bronchoscopy may show features of tissue reaction to the foreign body, by which object could be found incarcerated and difficult to be seen [6 , 7] . Granulation reactions could eventually lead to airway strictures, and subsequently airway distortion, which could present with unilateral wheezes in physical examination [8] . Aspiration of such FB is more common into the right lung, but they can occur in other scenarios, in the left lung [9] .…”

A 68-year-old man with haemoptysis and extensive ipsilateral lung infiltrates

“…FBA is a rarely occurs in young adults [ 5 ] but is very frequent in paediatric practice (80% of the cases) and quite common in the elderly population [ 6 ]; however, non-asphyxiating FBA is sometimes a delayed diagnosis, partly because it does not have a specific clinical manifestation unless the patient recalls an antecedent aspiration event [ 7 ]. Among paediatric patients, it is more common between the ages of 12 and 48 months owing to their tendency to put things into the mouth, poor chewing ability, lack of posterior dentition, and an impulse to have vigorous, uninhibited inspirations when coughing, laughing or feeling frightened [ 8 ]. The increased risk in elderly patient results from multiple factors including poor dentition, altered sensorium, poor coordination of deglutition mechanisms, and significant comorbidities such as degenerative neurological diseases ( e.g.…”