Persistent wheeze in a toddler: is a foreign body still possible?
A 22-month-old boy is referred with a 4-week history of cough and wheeze. The illness began with a coryza, but the cough has persisted and is worse at night and after running. There was no witnessed choking. He has been treated with two courses of amoxicillin and a salbutamol inhaler with a spacer, with no improvement. Examination: respiratory rate 30, oxygen saturation 97% in air, temperature 36.8°C, reduced air entry and expiratory wheeze on the right, no crackles, no fever. Chest radiograph is reported as normal. He is thriving, has no eczema, and no family history of asthma. He attends nursery and has had no unwell contacts. You are the respiratory registrar in clinic.
1. What is your differential and what would you do next?
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The differential includes retained foreign body, viral-induced wheeze, asthma, and structural airway disease. The unilateral reduced air entry and wheeze after a 4-week illness that began with coryza is concerning: a foreign body can present without a choking history, and a normal chest radiograph does not exclude it because many vegetable bodies are radiolucent. I would examine for nasal obstruction, skin lesions, and growth, and review the radiograph myself rather than relying on the report.
Next I would refer urgently to paediatric respiratory for flexible bronchoscopy, with rigid bronchoscopy backup, and consider a chest CT if bronchoscopy is not immediately available. I would not start a further trial of asthma treatment without a clear rationale. If bronchoscopy is normal, I would reassess for asthma, reflux, and structural causes.
2. What are the dangers of a trial of asthma treatment in this child?
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Empirical asthma treatment is tempting because wheeze is common, but in this child it would delay diagnosis and could allow a foreign body to cause chronic obstructive changes, recurrent infection, or bronchiectasis. A 4-week history with unilateral signs is not typical asthma, and the lack of response to salbutamol is a warning sign. Repeated courses of steroids or antibiotics without a diagnosis waste time and may mask deterioration.
If I were unsure, I would set a short, clearly defined trial only after bronchoscopy has excluded a foreign body, and I would review within 2 weeks. The safer path is to investigate first, explain the uncertainty to the family, and involve the respiratory team early. The key judgement is to act on the possibility of a foreign body rather than wait for the classic history.