Acute Respiratory Distress in A 3-Year-Old at Daycare: (Enlarge Image)

- Acute Respiratory Distress in a 3-Year-
Old at Daycare
A 3-year-old white male developed stridor and respiratory distress while
eating lunch at his daycare facility. Upon admission to the emergency
room, direct laryngoscopy revealed a food bolus at the level of the posterior
pharynx that was easily removed with a rigid suction catheter. The patient's
stridor initially improved, but symptoms returned and transport to a tertiary
care facility was initiated. On arrival, the child was in severe respiratory
distress with signs of respiratory failure. According to his mother, the child
was developmentally normal and had been in good health recently.
The child had a tracheoesophageal fistula repaired when he was 2 days old
and underwent esophageal dilation and Nissen fundoplication secondary to
severe gastroesophageal reflux disease at the age of 9 months. Because
of a history of failure to thrive, a gastrostomy tube was also placed at this
time to allow continuous night feedings.
The child had a history of 2 previous hospitalizations, which included: (1)
treatment for pneumonia at 10 months of age, and (2) an admission
following "choking on food" 8 months ago. The child has a ventriculoseptal
defect that is nonsymptomatic.
Vital signs were as follows: rectal temperature 98.6° F, pulse 149,
respiratory rate 28/min, blood pressure 125/58 mm Hg, peripheral oxygen
saturation on high-flow oxygen by face mask 100%, weight 12 kg.
The patient was in severe respiratory distress prior to intubation.
Substernal and subcostal retractions and inspiratory stridor were present.
On auscultation, there was poor air movement bilaterally. Heart rate was
regular with III/VI systolic murmur; otherwise, patient exhibited
cardiovascular stability. A clean, dry, intact gastrostomy button was placed
at the left abdomen. The remainder of the physical exam was within normal
limits.
Peripheral blood examination showed a total white cell count of
15,700/mm3 with 74% polymorphonuclear leukocytes, 2% band forms, 19%
lymphocytes, 4% monocytes, hemoglobin 11.0 g/dL, and a platelet count of
266,000/mm3. A chemistry panel showed no electrolyte abnormalities.
(Enlarge Image)
A chest x-ray revealed a mild right middle lobe infiltrate. No other acute
process was noted.
The patient's respiratory status continued to deteriorate. He was sedated,
paralyzed, and mechanically ventilated. A bronchoscopy was performed.
An esophagogastroduodenoscopy (EGD) was performed.
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(Enlarge Image)
A bronchoscopy was also performed.
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Results revealed questionable tracheomalacia, but no foreign body.

Please click on the "continued" button on the bottom of the page for further
discussion.
Discussion
The diagnosis is esophageal meat impaction in a child with

esophageal dysmotility.
The differential diagnosis in this clinical scenario included aspiration
of foreign body, esophageal dysmotility with food impaction, and
other acute causes of respiratory failure. The impaction was moved
down the esophagus into the stomach using the endoscope. The
patient remained in the intensive care unit overnight and was
extubated in the morning without complication. Prophylactic
antibiotics were given prior to the procedures. After undergoing the
procedures, he received a 10-day course of antibiotics for
pneumonia noted on chest x-ray, which was completed on an
outpatient basis.
The child made a full recovery from this incident, but the underlying
esophageal dysmotility still poses a risk for this patient.
Review of Diagnosis
Q: What are the common symptoms of foreign body ingestion or

food impaction?
A: Choking, refusal to eat, vomiting, drooling, wheezing, stridor,
bloodstained saliva, and respiratory distress are all common
symptoms of foreign body ingestion or food impaction. Sudden
onset of cough without infectious symptoms is also sometimes seen
in association with these conditions.
Q: What is the typical outcome of a food bolus or foreign body
ingestion for a patient of this age (3 years)?
A: Roughly 80% to 90% of esophageal foreign body impactions or
foreign body ingestions that produce symptoms will pass
spontaneously in a patient of this age, but 10% to 20% will require
nonsurgical intervention. Less than 1% will require surgery. Experts
agree that in most cases, patients presenting with food impactions
often have underlying esophageal pathology directly responsible for
the impaction.[1] In the case presented here, esophageal dysmotility
was a contributing factor.
Q: Where are esophageal foreign body impactions most likely to
occur?
A: Esophageal impactions, perforations, and obstructions occur at
areas of angulation or physiologic narrowing. The level of the
cricopharyngeus muscle is the most common site for this type of
impaction.[1] A more distal nonphysiologic postoperative stricture
cannot be excluded in the case presented.
Q: Severe respiratory distress mandated the immediate removal of
the foreign body in the case presented above. What other
conditions require immediate endoscopic retrieval of ingested
foreign bodies?
A: The following conditions also require immediate intervention: (1)
ingestion of sharp objects or disk batteries, (2) patient's inability to
handle secretions, and (3) the presence of the ingested substance
for more than 24 hours.[1]
Q: What dietary advice should be provided to the caretaker(s) of a
child with esophageal dysmotility?
A: Caretakers should be instructed to cut all food into small pieces
and make sure that food is followed by copious amounts of liquid.
Avoid the following: unpeeled apples, dry or charcoal-grilled beef,
and fresh bread.[2]
Q: What is the relationship between tracheoesophageal fistula
(TEF) repair and esophageal dysmotility?
A: As many as 30% of children have dysmotility disorders after TEF
repair. Complications of this procedure include lodging of food
boluses just above the level of surgical anastomosis, esophagitis,
and Barrett's esophagus.[3] The Nissen fundoplication required for
management of the reflux disease frequently seen in these patients
may also contribute to food bolus impactions.
Q: Prior to endoscopy, what important premedication was indicated
by this patient's past medical history?
A: Prophylactic antibiotics (subacute bacterial endocarditis
prophylaxis) were indicated prior to endoscopy because of this
patient's ventricular septal defect. Ampicillin and gentamicin were
used in this case.

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- Acute Respiratory Distress in a 3-Year-

A bronchoscopy was also performed.

Results revealed questionable tracheomalacia, but no foreign body.

The diagnosis is esophageal meat impaction in a child with

Q: What are the common symptoms of foreign body ingestion or

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