What is the diagnostic value of flexible bronchoscopy in the initial investigation of children with suspected foreign body aspiration?

doi:10.1016/j.ijporl.2007.05.012

International Journal of Pediatric Otorhinolaryngology

Volume 71, Issue 9, September 2007, Pages 1383-1390

https://doi.org/10.1016/j.ijporl.2007.05.012 Get rights and content

Summary

Purpose of the study

The diagnosis and early bronchoscopic extraction of a foreign body (Fb) in children are life-saving measures. Many studies have described the manifestation of foreign body aspiration (FbA); however, only a few analyzed the role of flexible bronchoscopy in the diagnosis of FbA. The aim of this work is to define the indications of flexible bronchoscopy in the management algorithm of suspected FbA.

Setting

This study was conducted at a tertiary referral University Medical Center with an outpatient clinic and a 20-bed pediatric emergency unit.

Material and methods

Between January 2002 and July 2006 children referred with suspected FbA were included in this prospective study. Children with asphyxiating FbA requiring immediate rigid bronchoscopy, were excluded. If there was no convincing evidence of FbA, a diagnostic flexible bronchoscopy was performed under local anesthesia. In the case where a Fb was actually found, extraction was always performed by rigid bronchoscopy.

Results

Seventy cases (median age: 2 years, males: 44/females: 26) were analyzed. Among the 19 children who underwent flexible bronchoscopy first, 7 (37%) had a Fb. Among the 51 who underwent rigid bronchoscopy first, 43 had a Fb and 8 (16%) had a negative first rigid bronchoscopy. Predictive signs of a bronchial Fb were a radiopaque Fb, foreign body aspiration syndrome (FbAS) associated with unilaterally decreased breath sounds or localized wheezing and obstructive emphysema or atelectasis.

Conclusion

In case of suspected FbA in children, the following management algorithm is suggested: rigid bronchoscopy should be performed solely in case of asphyxia, finding of a radiopaque Fb, or in the presence FbAS associated with unilaterally decreased breath sounds, localized wheezing and obstructive radiological emphysema, or atelectasis. In all other cases, flexible bronchoscopy should be performed first for diagnostic purposes.

Introduction

New data on the incidence of FbA in the French pediatric population are not available. In 1980, Piquet and al. estimated the annual incidence of this pathology in France to be 4/10.000 (600 cases per year) [1]. The epidemiologic characteristics are similar regardless of countries; 55% of patients with a Fb in the airway are between 1 and 3 years of age and 7–10% of patients are less than 1 year of age [2], [3], [4], [5], [6], [7], [8], [9], [10], [11]. Inhalation of a Fb is a serious condition during childhood which may result in acute respiratory distress, chronic and irreversible lung injury, and death in case of mismanagement [6]. In the United States, 7% of all accidental deaths in children under 4 years of age in 1986 were caused by Fb aspiration, setting this pathology to the sixth row of accidental child death [12].

Thus, early diagnosis and extraction of Fbs are life-saving measures. Nevertheless, the positive diagnosis of a Fb in the airway before endoscopy is still difficult and requires tracheobronchial inspection even in the absence of clinical and/or radiographic changes. Usually, rigid bronchoscopy under general anesthesia is performed, for diagnostic and therapeutic purposes. However, a high rate of negative bronchoscopies is reported in the literature [12], [13], [14]. Unfortunately, Fiberoptic bronchoscopy cannot be considered a safe therapeutic procedure in young children [15] even if some authors report good results with this technique [16]. In other respect, the American Thoracic Society Task Force, in its 1992 report, has considered flexible bronchoscopy a cost-effective diagnostic procedure in cases of an equivocal tracheobronchial Fb, avoiding unnecessary rigid bronchoscopy and general anesthesia [17]. However, the role of flexible bronchoscopy as the initial diagnostic procedure in children with suspected FbA has rarely been evaluated prospectively [2]. Our goal was to define the indications of flexible bronchoscopy in the management of Fb aspiration.

Section snippets

Patients and methods

A prospective study was conducted in patients (age 15 or below) who presented or were referred to the University Hospital of Grenoble (France) with a history or suspicion of FbA between January 2002 and September 2006. All children were initially admitted to the pediatric emergency unit. Children with asphyxiating Fb aspiration, requiring immediate rigid bronchoscopy were excluded from the study.

For the included children, past and present history, symptoms and physical signs, and time between

Results

During the study period, 82 consecutive children were admitted to the pediatric emergency unit for a history or suspicion of FbA. Five required immediate rigid bronchoscopy, and seven patients had unreliably collected data. In the end, 70 children (median age: 24 months; 46 males and 24 females—sex ratio 1.9:1) were included in the study.

Twenty-three children were brought directly by their parents. Twenty-one children were referred secondarily by a hospital physician, and 26 children were

Discussion

The high risk of aspiration in young children has been attributed to a poor chewing ability due to: (1) tendency to put various objects into the mouth; (2) lack of posterior dentition; (3) frequent vigorous and uninhibited inspirations when laughing or crying [19]. The risk is also more important for patients with mental retardation with known difficulties in swallowing [11]. The male predominance of FbA seems to be in relation with the greater unruly behavior of boys in comparison with girls.

Conclusion

We suggest initial rigid bronchoscopy first in case of asphyxia due an obstructive Fb, a radiopaque Fb on chest-X-ray, association of unilaterally decreased breath sounds and obstructive radiological emphysema or atelectasis. In all other case, flexible bronchoscopy should be performed first for diagnostic purposes. If a Fb is found, rigid bronchoscopy must then be performed for extraction. The benefit–risk ratio of flexible bronchoscopy is highly in favor of its performance in the presence of

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The aims of this study were to describe our experience in the management of FB aspiration in children, focusing on the eventual association between delay in treatment and the development of complications, and to determine if the incidence of this emergency had decreased in the last 10 years.
Retrospective study of children with a diagnosis of FB aspiration managed between 1999 and 2019 at a tertiary care referral hospital. The following data were collected: demographics, clinical presentation, radiological findings, endoscopic technique, type of FB, time elapsed between the aspiration episode and treatment, and complications. Main outcome measures were the rate of complications (intraoperative and long-term) in the cohort of patients with delay in treatment (>72 h), and the incidence of FB aspiration in each of the two historical subgroups of the study.
The study included 130 patients, 66.2% male, with a median age of 24 months. Cough was the most frequent symptom (76.1%) and unilateral air trapping was the most common radiological finding (48.8%). Removal of FB was performed with rigid bronchoscopy in every case. The most common type of FB was organic (73%) and located in the right bronchial system (47.7%). The global rate of complications was 16.1%. Patients with a delay in treatment beyond 72 h from the aspiration episode showed a statistically significant risk of developing both intraoperative and postoperative complications. Additionally, we have stated that the incidence of FB aspiration in our community has decreased by 44.4% in the last 10 years.
The incidence of FB aspiration has remarkably decreased in our environment in the last decade. Delay in treatment placed our patients at a significant higher risk of developing complications both during the bronchoscopic procedure and in the long-term.
Foreign body aspiration in a tertiary Syrian centre: A 7-year retrospective study
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Paediatric foreign body aspiration constitutes significant lethal sequela worldwide. This is the first descriptive Syrian study that aims to describe the epidemiology of foreign body aspiration in a tertiary centre in Syria.
This is a retrospective cohort study conducted at the Children's University Hospital, Damascus, from 2011 to 2018 during the Syrian crisis. The children underwent rigid bronchoscopy at Al Mouwasat University hospital, the only properly equipped hospital to perform paediatric rigid bronchoscopy in Damascus. We included all cases with complete medical records of children under the age of 13 years with positive bronchoscopy findings of foreign body aspiration. The records of patients were examined, and data extracted included physical examination, CXR reports, bronchoscopy reports, and complications. Statistical package for social sciences 25.0 program for Windows was used to report frequencies, percentages, means, medians, and standard deviations.
Of 560 children diagnosed with foreign body aspiration, the peak incidence was at the age of 1–3 years 376 (67.2%). Most patients presented with an explicit history of inhalation 453 (80.9%). The most frequent clinical findings were dyspnoea 320 (57.1%), wheezing 308 (55%), and chest retraction 209 (37.35%). Hyperinflation 260 (46.4%) followed by pulmonary infiltration 197 (35.2%) were the most common abnormal radiological findings. Seeds 273 (48.8%) were the most frequent foreign body extracted by rigid bronchoscopy. The right main bronchus 255 (40.2%) was the most frequent site of foreign body lodgement. Lobar pneumonia 16 (2.8%) was the commonest complication of foreign body aspiration.
Foreign body aspiration is a major public health problem in Syria. The child's welfare must be our paramount concern. To prevent this accident, we should address a change in raising public health awareness with regards to appropriate food and eating habits. This would limit hazardous complications.
Aerodigestive Foreign Bodies and Caustic Ingestions
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Foreign body ingestion and aspiration is a common cause of morbidity and mortality in the pediatric population. Aerodigestive foreign bodies usually occur in toddler age children and are often exploratory in nature. Coins are the most commonly ingested object, whereas food impaction is more prevalent in older children and adults. Coins and button batteries show subtle differences on radiographic imaging (single vs. double-halo). The distinction is important as button batteries require urgent removal. A detailed history and physical and a high index of suspicion despite negative imaging are required. Chronic pulmonary symptoms, such as cough or wheezing that persists despite maximal medical therapy, may be the only sign of a foreign body. Often, a diagnostic endoscopy may be required to definitively investigate the upper aerodigestive tract. Noncaustic esophageal foreign bodies can be observed for a short period of time to see if they are able to pass into the stomach. Caustic substances such as detergent, button batteries, and household cleaners require urgent endoscopy for removal or evaluation of soft tissue injury. Airway foreign bodies require immediate removal in the operating room. A team-based approach with cooperation between the anesthetist, surgeon, and operating room staff is required during these procedures. Early intervention can prevent acute and chronic complications, which can be devastating. Early complications include partial mucosal erosion, perforation, airway edema or obstruction, respiratory failure, infections, and even death. Late complications include tracheoesophageal or vasculature fistulas, strictures, mature airway stenosis, emphysema, and persistent pneumonias.
New scoring system to predict foreign body aspiration in children
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To propose a new scoring system to predict foreign body aspiration (FBA) in children.
Children who underwent bronchoscopy for FBA were evaluated for age, sex, history of aspiration, physical examination, radiological findings and results of bronchoscopy retrospectively. A new proposed FBA scoring including statements about history, physical and radiological findings were applied to all patients to define a total score. The results of each statement and total FBA score were compared according to bronchoscopy findings. The sensitivity and specificity of FBA score and cut-off values of total FBA score to predict positive cases were evaluated.
Totally 720 patients with a male to female ratio of 227:133 were included. FBA was noted in 52.1% (n = 375) of cases. When the scoring system compared with the existence of foreign body (FB), the patient history had no statistical significance to predict positive cases (p > 0.05). The existence of FB was significantly associated with physical examination, radiological findings and total FBA score (p < 0.001). The revised scoring system without history parameters had range of total scores 0 to 5. The total scores were obtained by sum of physical findings and radiological parameters and the cut-off value of 2 had the highest diagnostic performance with sensitivity and specificity of 77.9% and 74.8% to predict FBA in children.
Our results suggest that the proposed scoring system can be utilized to predict FBA in children. The total score higher than 2 is predictive for FBA. Although, physical and radiologic findings are strong parameters for positive bronchoscopy, the history of FBA has no diagnostic utility.
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Ten years of paediatric airway foreign bodies in Western Australia
2020, International Journal of Pediatric Otorhinolaryngology
Whenever a paediatric airway foreign body (PAFB) is suspected, decisions may be difficult without a clearly defined or accepted treatment algorithm. History and examination are commonly non-diagnostic and the risks associated with either watchful waiting or proceeding to MLB are significant. This paper reviews a 10 year cohort of suspected PAFBs for the predictive utility of history, examination and investigations and subsequent positive findings at MLB.
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  To review cases of suspected PAFB undergoing MLB in Perth, Western Australia over 10 years
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  To examine the relative strengths of history, examination and imaging for predicting the presence of a foreign body, and their utility in treatment decision making
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  To characterise the epidemiology of our cohort and to Evaluate our complication rate
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The medical records of 127 children who underwent MLB for suspected PAFB between 2007 and 2016 were examined. The data was retrospectively reviewed for epidemiological details, history, examination, radiological findings and MLB outcomes.
Sensitivity for PAFB on MLB with all three; history, examination and imaging (x-ray) positive for PAFB was 87.7%. Of the patients who were both symptom and sign positive (n = 96), chest x-ray findings did not significantly alter the chance of finding a PAFB. Chest x-ray had a low specificity (17%) in symptom and sign positive patients. Conversely, sensitivity of chest x-ray was high (88%), for symptom and sign positive patients.
For a child with both signs and symptoms, xray is unlikely to assist in decision making around suspected PAFB. When only sign or symptom is present, positive imaging may significantly increase the chance that PAFB is the cause.For patients with a low suspicion of PAFB, consideration of a CT can be a helpful means of excluding a PAFB and avoiding an unnecessary general anaesthetic in this potentially high-risk group.A greater level of public awareness is needed with regards to appropriate food types for children and the importance of eating seated and supervised in order to reduce the risk of PAFB.
Foreign body aspiration in children with negative multi-detector Computed Tomography results: Own experience during 2011–2018
2019, International Journal of Pediatric Otorhinolaryngology
This study sought to summarize the clinical characteristics of foreign body aspiration(FBA) in children with negative multi-detector Computed Tomography(MDCT) results and to explore the essential points which determined the patients to undergo bronchoscopy.
The medical records of 48 pediatric patients admitted to the department of respiratory medicine in our hospital from January 2011 to October 2018 and diagnosed with foreign body aspiration and negative chest MDCT results were retrospectively analyzed. They were compared with the patients of FBA whose MDCT findings suggested indirect signs, such as atelectasis or emphysema.
Of the 48 patients, 33 were boys (68.8%) and 15 girls (31.2%), with a mean age of 35.3 months(range, 7–156 months). Cough (47 cases, 97.9%), fever (25 cases, 52.1%) and wheezing (23 cases,47.9%)were the main symptoms.39 patients (81.3%) had abnormal physical signs. None of the MDCT or three dimension(3D) images based on MDCT revealed foreign bodies in these children, while the results were: signs of lung infection without atelectasis or emphysema 52.1%(25 cases), increase of lung markings16.7%(8 cases),bronchiectasis 6.3%(3 cases), or normal 27.1%(13 cases). 41 Patients were successfully removed their foreign bodies(A further 5 had the FB removed from the tracheobronchial tree but it was then swallowed before retrieval. The remaining 2 cases had to be referred to another hospital for further management), most of which were organic. The shapes of foreign bodies were small granular (23 cases, 56.1%), sheet or powder (18 cases, 43.9%). The control group was 13 patients of FBA whose MDCT findings suggested indirect signs of atelectasis or emphysema during the same time. The result of comparison showed the clear history of FBA was statistically different between the two groups.
Foreign body aspiration could not be ruled out with negative MDCT in patients clinically suspected. Typical foreign body aspiration history and ineffective conservative treatment could provide important basis of performing bronchoscopy. Complicated with lung infection and the shape of foreign bodies may affect the false negative results of MDCT.

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What is the diagnostic value of flexible bronchoscopy in the initial investigation of children with suspected foreign body aspiration?

Summary

Purpose of the study

Setting

Material and methods

Results

Conclusion

Introduction

Section snippets

Patients and methods

Results

Discussion

Conclusion

Int. J. Pediatr. Otorhinolaryngol.

Clin. Radiol.

Int. J. Pediatr. Otorhinolaryngol.

J. Pediatr. Surg.

Am. J. Surg.

Pediatr. Clin. North Am.

Chest

Otolaryngol. Head Neck Surg.

Int. J. Pediatr. Otorhinolaryngol.

Int. J. Pediatr. Otorhinolaryngol.

J. Pediatr. Surg.

Epidémiologie et prévention des corps étrangers bronchiques

JFORL

Indications for flexible versus rigid bronchoscopy in children with suspected foreign-body aspiration

Am. J. Respir. Crit. Care Med.

Diagnostic evaluation of foreign body aspiration in children: a prospective study

J. Pediatr. Surg.