2. 2yo child. F/H bronchial asthma. 2 day ago viral uri. was playful
Nasal congestion.
Inspiratory and exiratory wheezing.
Do not jump to asthma.
CXR done showed hyperinflation of RLL.
Bronchodilator is contra- indicated because if it comes out it may lodge in carina.
Rigid bronchoscopy to be done.
The patient here has a family history of bronchial asthma but one notes here that the patient himself does not have asthma.
He has had an upper respiratory infection two days ago and inspite of that is extremely playful. So it is unlikely that this disease was causing much of an impact to the patient. The patient was having both inspiratory and expiratory wheezing subsequent to that. Inspit of this, his activity has not changed.
The patient is still being examined by the physician because of this wheezing as the family might be concerned about asthma. Since one hears inspiratory wheezing and expiratory wheezing, the key here would be the inspiratory wheezing which is usually not seen in asthma unless it is extremely severe and here we have a patient who is not severely unwell. Thus one should consider the posibility of a foreign body or an obstructive lesion inside one of the bronchi.
To jump to the conclusion of asthma in this case would be improper although it should still remain in the differential diagnosis. In child who cannot give the history of having swallowed or having inhaled something abnormal, one must get a chest x-ray as seen in this case, the x-ray does show hyperinflation of the right lower lobe indicating that there might be something in the right lower lobe bronchus which would be causing a ball valve action leading onto air entering the right lower lobe but not leaving it properly. This patient would need a bronchoscopy done although rigid bronchoscopy is the standard in treating patient with a foreign body.
In a case like this, one should first go in with a flexible bronchoscope and only if one finds something over there then one should insert a rigid bronchoscope. Rigid bronchosopes are not gentle on the anatomy of the lung and the procedure should be performed only if necessary. Bronchodilators in this case should not be used simply because one might open the bronchioles further and the foreign body may go deeper. Secondly, if one does manage to have the patient cough it out, the foreign body might come up and lodge in a spot which might be more critical and the patient might not be able to breath at all. For instance if it comes into the carina and lodges there, both bronchi might be in jeopardy.
Also note that viral infections are the commonest cause of fever. One should also point out that nasal sprays do have a side effect that as one inhales, it is a sniffing action which may lead to inhalation of the material into the lungs and thus cause chemical pneumonitis. It is also for this reason that most nasal steroids now are moving onto an aqueous-based medicine as opposed to fat or oil based medicine which is more prone to cause a pneumonitis due to aspiration.