Foreign-body aspiration — branching viva

Station opening

Examiner: "Define foreign-body aspiration and describe its three clinical phases." [1]

Strong candidate (must-hit)

• Defines aspiration as the inhalation of a solid or semi-solid object below the larynx into the trachea or bronchi; describes the acute phase of choking, coughing and gagging, the latent phase where the child settles and can be symptom-free for days or weeks, and the delayed phase of recurrent pneumonia, fixed wheeze and eventual bronchiectasis; and stresses that the latent phase is the trap that causes missed diagnoses because a well child can still harbour an object. [1]

Weak candidate

• "It is when a child swallows something and it goes down the wrong way, and we get an x-ray to look for it." [1]

Branch A — The toddler actively choking on a grape

Examiner: "A 2-year-old is brought in actively choking on a grape. Walk me through your immediate management." [6]

Strong

• Applies the choking algorithm starting with the effective-versus-ineffective cough judgement: if the cough is effective, encourages coughing and does not intervene; if ineffective but conscious in a child over one year, gives five back blows then five abdominal thrusts and repeats; avoids blind finger sweeps; and, if the child becomes unconscious, starts CPR, removes an object only if clearly visible, and calls the resuscitation team. [6] [1]

Weak

• "Put my fingers in and sweep the mouth, then lay the child down and wait." [6]

Branch B — The well toddler with a normal chest x-ray

Examiner: "A well 2-year-old had a witnessed choking episode on a peanut and now has a subtle right-sided wheeze. The chest x-ray is normal. What do you do?" [7]

Strong

• Diagnoses a probable inhaled foreign body on the choking history and the focal wheeze; explains that most objects are radiolucent so a normal film does not exclude aspiration, and that history, examination and imaging all have imperfect sensitivity; proceeds to rigid bronchoscopy under general anaesthesia, which is both diagnostic and therapeutic, justifying it on the strength of the history despite the normal radiograph. [7] [8]

Weak

• "The x-ray is normal, so I would reassure the parents and discharge." [7]

Branch C — Recurrent right-lower-lobe pneumonia

Examiner: "A 3-year-old has had three right-lower-lobe pneumonias in six months and a fixed monophonic wheeze not responding to bronchodilators. What is going on and what do you do?" [12]

Strong

• Recognises a retained bronchial foreign body from the recurrent same-lobe pneumonia and the fixed unresponsive wheeze; explains that a fixed monophonic wheeze is not typical asthma and same-lobe infection points to a fixed local cause; refers for rigid bronchoscopy to inspect and remove the object; and notes that a long-retained object causes granulation tissue, chronic infection and bronchiectasis, so removal should not be delayed. [12] [1]

Weak

• "Step up the asthma treatment and give another course of antibiotics." [1]

Branch D — The infant who chokes and goes limp

Examiner: "A 6-month-old chokes on a piece of food and becomes limp and unresponsive. What do you do, and how does it differ from the older child?" [6]

Strong

• Recognises a critical obstruction: if still conscious with an ineffective cough, gives five back blows then five chest thrusts (not abdominal thrusts, because of the visceral-injury risk in an infant), held head-down along the forearm; if unresponsive, starts infant CPR, looks for and removes a visible object only, and calls for help; and contrasts this with the older child who receives abdominal thrusts. [6] [1]

Weak

• "Give abdominal thrusts as for an adult." [6]

Close

Examiner: "Summarise your approach to the child with a suspected inhaled foreign body in one sentence." [1] [8]

Strong

• "Foreign-body aspiration is diagnosed by suspicion: I manage the acute choke by the effective-versus-ineffective cough algorithm with age-specific manoeuvres, I never let a normal chest radiograph reassure me because most objects are radiolucent, and I refer the stable child with a convincing choking history for rigid bronchoscopy, which is both the definitive diagnosis and the treatment." [1] [8]