Use of decubitus radiographs in the diagnosis of foreign body aspiration in young children

Role of expiratory chest X-ray in pediatric foreign body aspiration

PURPOSE

Tracheobronchial foreign body aspiration is a common pediatric emergency and a leading cause of accidental deaths in children. The diagnosis remains sometimes difficult even with physical examination, medical history, and basic X-rays. This challenge necessitates the performance of endoscopy under general anesthesia, regardless of the potential for serious complications. The benefit of strategies like expiratory chest X-rays to reduce unnecessary endoscopies remains uncertain. We evaluated the effectiveness of expiratory chest X-rays in detecting airway foreign bodies to potentially reduce the need for endoscopies.

METHODS

We retrospectively studied children with suspected foreign body aspiration who had X-ray and endoscopy.

RESULTS

A total of 70 children were included in the study. Out of these, 19 cases (27.1 %) showed pathological findings on standard chest X-rays. However, when expiratory chest X-rays were added, the number of pathological radiographies increased to 37 cases (52.9 %). Out of the 36 foreign bodies that were present, only 2 were not detected. Furthermore, 3 chest X-rays displayed pathological results, while the endoscopies indicated normal findings. Consequently, the overall sensitivity, specificity, positive predictive value, and negative predictive value stood at 94.4 %, 91.1 %, 91.9 %, and 93.9 % respectively.

CONCLUSION

The remarkable sensitivity of expiratory chest radiography can eliminate the need for unnecessary endoscopy, but it should be limited to centers lacking access to MDCT. The performance of endoscopy should only be considered when persistent clinical symptoms are observed during auscultation.

Laryngeal Foreign Body Aspiration in Infancy: A Diagnostic Challenge

Foreign body aspiration (FBA) is a significant cause of accidental death among children, with laryngeal FBA being relatively rare but potentially fatal due to airway obstruction. This report highlights a case of laryngeal FBA in an 11-month-old child, initially misdiagnosed as viral croup. Otolaryngological evaluation, particularly in the case of laryngeal FBA, may facilitate management. An 11-month-old male was brought to the emergency department, presenting with inspiratory stridor following a choking episode. A chest radiograph and CT scan of the chest were read as normal. He was suspected of having croup and treated with dexamethasone and racemic nebulized epinephrine, which led to temporary clinical improvement.  The child returned with persistent stridor to the emergency department eight days after his initial visit, prompting an otolaryngological consultation. Flexible laryngoscopy ultimately identified a star-shaped sequin lodged in the glottis. The foreign body was successfully removed via direct laryngoscopy and bronchoscopy (DLB). Following the removal, the patient demonstrated significant improvement and eventually made a full recovery. This case emphasizes the difficulty in diagnosing laryngeal FBA due to its non-specific symptoms and the limitations of imaging techniques. The importance of a thorough clinical history, physical examination, and proper imaging combined with a high index of suspicion is crucial for early diagnosis and treatment. Additionally, the report discusses the potential for severe complications if diagnosis and treatment are delayed, highlighting the need for awareness and prompt intervention in suspected laryngeal FBA cases.

Rigid bronchoscopy: a consultant survey

INTRODUCTION

Inhalation of foreign bodies represents a potentially fatal emergency in both adults and children. Chest x-ray, in isolation, is neither sensitive nor specific. Rigid bronchoscopy represents the gold standard to diagnose and retrieve paediatric foreign bodies. Cases are encountered infrequently, creating anxieties about their management. Little is known about the confidence in, and maintenance of, rigid bronchoscopy skills by ear, nose and throat teams.

METHODS

A 15-question survey was completed by 50 practising otolaryngology consultants in England.

RESULTS

Results show that almost 40% of otolaryngology consultants covering rigid bronchoscopy have not performed bronchoscopy in more than 5 years. Consultants raised concerns about the anaesthetic support and the speed of equipment assembly. Questions on clinical practice showed disparities in practice in the same scenario.

CONCLUSIONS

The authors advocate addressing many of the issues raised by the study with a greater availability of simulation courses and regular scheduled intradepartmental teaching days for all professionals involved. National guidelines on criteria for transfer to tertiary centres would improve the consistency of practice.

Diagnostic clues for the identification of pediatric foreign body aspirations and consideration of novel imaging techniques

OBJECTIVE

To better understand the diagnosis of foreign body aspiration by elucidating key components of its clinical presentation.

METHODS

This is a retrospective cohort study of pediatric patients with suspected foreign body aspiration. We collected information regarding demographics, history, symptoms, physical exam, imaging, and operative findings for rigid bronchoscopies. An evaluation of these findings for an association with foreign body aspiration and the overall diagnostic algorithm was performed.

RESULTS

518 pediatric patients presented with 75.2 % presenting within one day of the inciting event. Identified history findings included wheeze (OR: 5.83, p < 0.0001) and multiple encounters (OR: 5.46, p < 0.0001). Oxygen saturation was lower in patients with foreign body aspiration (97.3 %, p < 0.001). Identified physical exam findings included wheeze (OR: 7.38, p < 0.001) and asymmetric breath sounds (OR: 5.48, p < 0.0001). The sensitivity and specificity of history findings was 86.7 % and 23.1 %, physical exam was 60.8 % and 88.4 %, and chest radiographs was 45.3 % and 88.0 %. 25 CT scans were performed with a sensitivity and specificity of 100 % and 85.7 %. Combining two components of the diagnostic algorithm yielded a high sensitivity and moderate specificity; the best combination was the history and physical exam. 186 rigid bronchoscopies were performed with 65.6 % positive for foreign body aspiration.

CONCLUSION

Accurate diagnosis of foreign body aspiration requires careful history taking and examination. Low-dose CT should be included in the diagnostic algorithm. The combination of any two components of the diagnostic algorithm is the most accurate for foreign body aspiration.

Comparison of chest X-ray interpretation by pediatric pulmonologists, pediatric radiologists, and pediatric residents in children with suspected foreign body aspiration-a retrospective cohort study

Chest X-ray (CXR) is an important tool in the assessment of children with suspected foreign body aspiration (FBA), although it can falsely be interpreted as normal in one-third of the cases. The aim of this study is to evaluate the positive predictive value of CXR in children hospitalized with suspected FBA, when interpreted by three disciplines: pediatric pulmonology, pediatric radiology, and pediatric residents. This is a retrospective study that included children aged 0-18 years, admitted with suspected FBA, between 2009 and 2020 in one tertiary center. All patients underwent CXR and a flexible/rigid bronchoscopy for the definitive diagnosis of FBA, up to 1 week apart. Two physicians from each discipline interpreted the CXR, independently. Intra-raters' and inter-raters' agreements were assessed. Sensitivity, specificity, and area under the curve (AUC) were calculated for each discipline. Four hundred seventy-three children were included in the study, 175 (37%) with FBA and 298 (63%) without FBA on flexible/rigid bronchoscopy. The most common radiological findings, as interpreted by a pediatric pulmonologist, were unilateral hyperinflation (47%), radiopaque FB (37.6%), lobar atelectasis (10.3%), unilateral hyperinflation with atelectasis (3.4%), and lobar consolidation (1.7%). Intra-raters' agreement ranged from 0.744 (p < 0.001) among pediatric pulmonologists to 0.326 (p < 0.001) among pediatric radiologists. AUC for predicting FBA based on a CXR was 0.81, 0.77, and 0.7 when interpreted by pediatric pulmonologists, pediatric residents, and radiologists, respectively (p < 0.001).

CONCLUSIONS

CXR has a high positive predictive value and independently predicts FBA in children; however, normal CXR should not rule out FBA. Predictability is variable among different disciplines.

WHAT IS KNOWN

• Chest X-ray is an important tool in the assessment of children with suspected foreign body aspiration (FBA). • Chest X-ray can be interpreted as normal in one-third of the cases.

WHAT IS NEW

• Chest X-ray independently predicts FBA in children, with a high positive predictive value. • The ability of chest x-ray to predict FBA in children differs between pediatric residents, pediatric radiologists, and pediatric pulmonologists.

Bronchoscopy for removal of foreign body: What's the big deal?

Foreign bodies of the airway are common occurrences in the pediatric population. Children requiring anesthesia for removal of airway foreign bodies can present many challenges. In this case, the patient required urgent removal of a foreign body while symptomatic with upper and lower respiratory symptoms. Circumstances such as these can result in higher intraoperative and postoperative complications. This presentation describes the clinical decision-making process and the discussion of common modalities for diagnosis, treatment, and anesthetic management.

The characteristics of foreign bodies aspirated by children across different continents: A comparative review

BACKGROUND

Foreign body aspiration (FBA) is a common issue in pediatric emergencies, with regional variations. Various cultures and foods, parents' and physicians' inadequate experience, and lack of bronchoscopy equipment are some attributable factors in the regional variation of FBA.

AIM

To more accurately represent the demographic characteristics of aspirated foreign bodies (FBs) across various continents, this review attempted to provide organized information based on the reviewed articles.

METHODOLOGY

A search was conducted in PubMed/PubMed Central, EMBASE, and google scholar. From the 36 included articles, information on age, gender, bronchoscopy type, type of FB, location, history of choking, and time elapsed between aspiration and admission were extracted.

RESULTS

A total of 14,469 cases were evaluated. According to the findings, children under two accounted for more than 75% of FBAs. Nuts and seeds were the most common FBs in most countries, whereas plastic and metal objects had higher rates in Brazil, and calcified objects were more prevalent in Thailand. The right bronchus was the most frequent location, and rigid bronchoscopy was the most often utilized type of bronchoscope. In addition, a significant percentage of patients were referred to the emergency rooms in the first 12-24 h following the aspiration incident. Moreover, Asian patients reported more choking history, and Europeans had fewer witnesses of FBA.

CONCLUSIONS

There is a lack of standardized reporting systems and organized guidelines in pediatric FBA. To select the ideal time for endoscopies and create educational programs, a collaboration between experienced researchers, pediatric pulmonologists, radiologists, and otolaryngologists is required.

May the first-line treatment for foreign body aspiration in childhood be flexible bronchoscopy?

INTRODUCTION:

Rigid bronchoscopy (RB) is the traditional treatment in foreign body (FB) aspiration in childhood but is a traumatic and invasive procedure. However, flexible optic bronchoscopy (FoB) is a noninvasive and nontraumatic respiratory intervention. The aim of this study was to evaluate FoB as a first-line treatment modality in pediatric cases presenting with a preliminary diagnosis of FB aspiration.

METHODS:

Subjects who underwent FoB under general anesthesia with the preliminary diagnosis of FB aspiration were enrolled in this cross-sectional study. Two cases were inherited from pediatric surgery because they were not removed with FoB. The demographic, clinical, and radiological findings at the presentation were recorded. Results of success rate and complications were recorded.

RESULTS:

Among the FB aspiration cases age range of 7 months to 16 years. FoB demonstrated a FB in the airways of 31 (62.2%) subjects. The duration of the symptoms in the subjects was 9.1 ± 8.8 days. Three of the cases were taken over from pediatric surgery because they were not removed with RB. Most commonly encountered FB's were organic materials (n = 20, 64%). FoB was successful in removing the FB from the proximal and also distal airways in 93% of the subjects. No significant complications and side effects were observed except post-FoB cough.

CONCLUSION:

This result has shown that FoB for the treatment of FB aspiration is successful in removing FB aspiration from both the proximal and distal airway that the RB cannot remove. Furthermore, FoB did not have any significant airway complication. FoB may be used as the first-line treatment modality for FB aspiration instead of RB in childhood the fact that noninvasive and nontraumatic respiratory intervention.

Tracheobronchial Tumors: Radiologic-Pathologic Correlation of Tumors and Mimics

Tracheobronchial masses encompass a broad spectrum of entities, ranging from benign and malignant neoplasms to infectious and inflammatory processes. This article reviews the cross-sectional findings of tracheal tumors and tumor-like entities, correlates imaging findings with histologic pathology, and discusses pearls and pitfalls in accurately diagnosing and classifying tracheal tumors and mimics.

Construction of an Anthropomorphic Phantom for Use in Evaluating Pediatric Airway Digital Tomosynthesis Protocols

Interpretation of radiolucent foreign bodies (FBs) is a common task charged to pediatric radiologists. The use of a motion compensated technique to decrease breathing motion on images would greatly decrease overall exposure to ionizing radiation and increase access to treatment yielding a great impact on clinical care. This study reports on the methodology and materials used to construct an in-house anthropomorphic phantom for investigating image quality in digital tomosynthesis protocols for volumetric imaging of the pediatric airway. Availability and cost of possible substitute materials were considered and simplifying assumptions were made. Two different modular phantoms were assembled in coronal slab layers using materials designed to approximate a one- and three-year-old thorax at diagnostic photon energies for use with digital tomosynthesis protocols such as those offered on GE's VolumeRAD application. Exposures were made using both phantoms with inserted food particles inside an oscillating airway. The goal of the phantom is to help evaluate (1) whether the currently used protocol is sufficient to image the airway despite breathing motion and (2) whether it is not, to find the optimal protocol by testing various commercially available protocols using this phantom. The affordable construction of the pediatric sized phantom aimed at optimizing GE's VolumeRAD protocol for airway foreign body imaging is demonstrated in this study which can be used to test VolumeRAD's ability to image the airways with and without a low-density foreign body within the airways.

Fifteen-minute consultation: An evidence-based approach to the child with preschool wheeze

Preschool wheeze is very common and its prevalence is increasing. It consumes considerable healthcare resources and has a major impact on children and their families due to significant morbidity associated with acute episodes.History taking is the main diagnostic instrument in the assessment of preschool wheeze. Diagnosis and management is complicated by a broad differential and associations with many other diseases and conditions that give rise to noisy breathing, which could be misinterpreted as wheeze. Several clinical phenotypes have been described but they have limitations and do not clearly inform therapeutic decisions. New insights in aetiopathogenesis modify treatment options and lay foundation for further research. An understanding of the approach and available evidence to assess and manage wheeze informs best patient care and use of resources.Our objective is to demonstrate a focused history, examination and management options in a preschool child with wheeze.

Review of tracheobronchial foreign body aspiration in the South African paediatric age group

Children, and in particular young children under the age of three, are the most vulnerable for aspiration and ingestion of foreign bodies (FBs). The Red Cross War Memorial Children's Hospital in Cape Town is the only children's hospital in South Africa and is unique in having a dedicated trauma unit for children under the age of 13 as part of its institution. Core activities of Childsafe South Africa (CSA), located at the hospital, are data accumulation and interpretation, development of educational programmes, health inculcation and advising in legislation involving child health. To achieve this task, CSA works in close co-operation with government, industry, non-governmental and community predicated organisations, community groups and individuals. A database of all children treated for trauma at CSA has been maintained since 1991; it currently contains detailed information of over 170,000 injuries in children under the age of 13. This review consists of a literature review combined with data from our database and aims to provide information on our experiences with tracheobronchial aspiration of FBs in children.

Airway foreign bodies: A critical review for a common pediatric emergency

BACKGROUND

Airway foreign bodies (AFBs) is an interdisciplinary area between emergency medicine, pediatrics and otolaryngology. It is a life-threatening condition that is not infrequently seen; however, it is poorly covered in medical literature. Accidental aspiration of an element into airways is a widespread clinical scenario among children under 3 years, predominantly males. Moreover, it is the leading cause of infantile deaths and the fourth one among preschool children.

DATA RESOURCES

A systemic search was conducted in July 2015 using PubMed/PubMed Central Database of The National Center for Biotechnology Information (NCBI) (http://www.ncbi.nlm.nih.gov/). A total of 1 767 articles were identified and most of them were meta-analyses, systematic reviews, and case series. Those thoroughly discussing assessment and management of AFBs were retrieved.

RESULTS

AFBs episodes may be either witnessed or missed. Presence of a witness for the inhalation is diagnostic. The later usually present with persistent active cough. A classical triad of paroxysmal cough, wheezing, and dyspnoea/decreased air entry was reported, though many presentations have inconsistent findings. Hence, diagnosis requires high index of clinical suspicion. Flexible fibro-optic bronchoscopy is the gold standard of diagnosis, whereas inhaled objects are best retrieved by rigid bronchoscopes.

CONCLUSIONS

Close supervision of pediatrics is the hallmark of prevention. Caregivers should ensure a safe surrounding milieu, including the toys their offspring play with. Immediate complications result from direct obstruction or injury by the inhaled object. Alternatively, prolonged lodging traps air and induces inflammatory response causing atelectesis and pneumonia, respectively.

Imaging Acute Airway Obstruction in Infants and Children

Acute airway obstruction is much more common in infants and children than in adults because of their unique anatomic and physiologic features. Even in young patients with partial airway occlusion, symptoms can be severe and potentially life-threatening. Factors that predispose children to airway compromise include the orientation of their larynx, the narrow caliber of their trachea, and their weak intercostal muscles. Because the clinical manifestations of acute airway obstruction are often nonspecific, clinicians often rely on the findings at imaging to establish a diagnosis. Several key anatomic features of the pediatric airway make it particularly susceptible to respiratory distress, and the imaging recommendations for children suspected of having acute airway obstruction are presented. Although cross-sectional imaging may be helpful, the diagnosis can often be established by using radiographs alone. Radiographs of the chest and upper airway should be routinely acquired; however, for the child who is in severe distress, a single lateral radiographic view may be all that is necessary. The purpose of this article is to provide an imaging approach to acquired causes of acute airway obstruction in children, including (a) abnormalities affecting the upper portion of the airway, such as croup, acute epiglottitis, retropharyngeal infection, and foreign bodies, and (b) abnormalities affecting the lower portion of the airway, such as asthma, bronchiolitis, and foreign bodies. It is essential that the radiologist recognize key imaging findings and understand the pathophysiologic features of acute airway obstruction because in most cases, when the cause is identified, the condition responds well to prompt management.

Endoscopic removal of an aspirated healing abutment and screwdriver under conscious sedation

PURPOSE

Aspiration of foreign bodies during dental treatment is a medical emergency that requires prompt removal. In this study, aspiration of screwdriver and healing abutment is reported with literature review.

MATERIALS AND METHODS

A 26-year-old male patient was referred from a local dental clinic with the suspicion of ingestion of a screwdriver and healing abutment during the second-stage surgery. The patient reported symptoms including dyspnea, cough, and foreign body sensation. On the chest radiograph, a radiopaque foreign body resembling the screwdriver and healing abutment was observed at the right mid lung.

RESULTS

Bronchoscopic examination using flexible cable was performed under conscious sedation, and microforceps were used to remove the instruments. Aspirated screwdriver and healing abutment were removed safely under intravenous sedation. The patient did not have any symptoms associated with lung aspiration after removal of the foreign body during follow-up periods.

CONCLUSION

Bronchoscopic removal is the most recommended procedure for removal of the aspirated foreign body. This can be performed under conscious sedation. Precautions, such as tethering the screwdriver, are recommended during implant procedures.

Tumors and tumorlike conditions of the large airways

OBJECTIVE

Large-airway tumors and tumorlike conditions are uncommon, but a systematic approach aids in narrowing the differential diagnosis. In this article, we describe an approach to dealing with large-airway lesions and discuss their imaging characteristics and clinical presentations.

CONCLUSION

We have found it useful to separate these entities into groups on the basis of the distribution pattern (focal vs diffuse) and location (trachea vs bronchi).

The utility of adding expiratory or decubitus chest radiographs to the radiographic evaluation of suspected pediatric airway foreign bodies

STUDY OBJECTIVE

This study aimed to compare test characteristics of standard (lateral and posteroanterior or anteroposterior) chest radiographs with and without special views (expiratory or bilateral decubitus) in the emergency department evaluation of children with suspected airway foreign bodies.

METHODS

From 1997 to 2008, 328 patients with a suspected airway foreign body had standard and special view chest radiographs: 192 with left and right decubitus views, 133 with expiratory views, and 3 with both. Patients were excluded for cardiorespiratory disease, chest wall deformity, visible airway foreign bodies on standard views, or spontaneously expelled airway foreign bodies. After blinded radiologist review, standard plus special view test characteristics were compared to standard views.

RESULTS

Nine upper airway and 70 tracheobronchial airway foreign bodies were identified by direct visualization or bronchoscopy, and the remainder were ruled out by bronchoscopy (50 patients) or clinically (199 patients). The sensitivity and specificity of the radiographs were, respectively, decubitus cohort, standard views, 56% and 79% and standard+decubitus views, 56% and 64%; expiratory radiograph cohort, standard views, 33% and 70% and standard+expiratory views, 62% and 72%. For standard plus decubitus views versus standard views alone, the relative sensitivity was 1.0 (0.56/0.56; 95% confidence interval [CI] 0.81 to 1.23) and the relative 1-specificity was 1.76 (0.36/0.21; 95% CI 1.3 to 2.37). For standard plus expiratory views versus standard views alone, the relative sensitivity was 1.87 (0.62/0.33; 95% CI 1.23 to 2.83) and the relative 1-specificity was 0.93 (0.28/0.3; 95% CI 0.6 to 1.44).

CONCLUSION

The addition of decubitus to standard views increases false positives without increasing true positives and lacks clinical benefit. The addition of expiratory to standard views increases true positives without increasing false positives, but test accuracy remains low and the clinical benefit is uncertain.

Foreign bodies in the airways: a meta-analysis of published papers

BACKGROUND

Very recently, some attempts have been made to start a systematic collection of foreign bodies (FB) in view of using them to characterize the risk of chocking in terms of size, shape and consistency of the FB. However, most of the epidemiologic evidence on foreign bodies in children comes from single-center retrospective studies, without any systematic geographical and temporal coverage. This paper is aimed at providing an estimate of the distribution of foreign body's injuries in children according to gender, age, type of FB, site of obstruction, clinical presentation, diagnostic/therapeutic procedures, complications, as emerging from a meta-analytic review of published papers.

METHODS

A free text search on PubMed database ((foreign bodies) OR (foreign body)) AND ((aspiration) OR (airways) OR (tracheobronchial) OR (nasal) OR (inhalation) OR (obstruction) OR (choking) OR (inhaled) OR (aspirations) OR (nose) OR (throat) OR (asphyxiation)) AND ((children) OR (child)) finalized to identify all English written articles referring to foreign body inhalation over a 30 years period (1978-2008) was performed. The target of the analysis has been defined as the proportion of injuries as reported in the studies, stratified according to children demographic characteristics, type of FB, site of obstruction. The pooled proportions of FB were calculated using the DerSimonian and Laird approach.

RESULTS

1699 papers were retrieved and 1063 were judged pertinent; 214 English written case series were identified, among them 174 articles were available and have been included in the analysis. Airway foreign body most commonly occurs in young children, almost 20% of children who have inhaled foreign bodies being between 0 and 3 years of age. Organic FB, particularly nuts, are the most documented objects while, among inorganic FBs, the greatest pooled proportion has been recorded for magnets, which can be particularly destructive in each location. Non specific symptoms or a complete absence of symptoms are not unusual, justifying mistaken or delayed diagnosis. Acute and chronic complications seem to occur in almost 15% of patients.

CONCLUSIONS

Even if an enormous heterogeneity among primary studies seems to exist and even if the absence of variables standardized definitions across case series, including class age definition and symptoms and signs descriptions, seriously impairs studies comparability, our results testify the relevant morbidity associated with foreign body inhalation in children, stressing the importance of preventive measures.

Questioning the legitimacy of rigid bronchoscopy as a tool for establishing the diagnosis of a bronchial foreign body

OBJECTIVES

Rigid bronchoscopy (RB) is the principal method used for the extraction of a tracheo-bronchial foreign body (FB), but its use as a diagnostic tool implies a certain rate of negative exams, exposing the child to the risk of procedure and anesthesia-related complications. Technological progress has improved the accuracy and availability of non-invasive modalities, such as CT scan and fluoroscopy. Our aim is to review our experience in the routine use of bronchoscopy for a suspected FB aspiration, and evaluate the adequacy of our current attitude in light of these alternatives.

METHODS

We performed a retrospective review of cases where bronchoscopy was used in the management of a suspected airway FB, and analysis of the correlation between the clinical and radiological data and the bronchoscopy's results. In addition we reviewed the literature concerning the use of RB and alternative means of diagnosis such as CT scan, fluoroscopy and flexible bronchoscopy.

RESULTS

Thirty-two patients underwent bronchoscopy to rule out a FB aspiration under general anesthesia. No FB was found in 8 cases (25%). Cough and a history of choking were the most sensitive parameters (sensitivity 100% and 80% respectively), but had a low specificity. Stridor was the most specific sign (88% specificity), but was not sensitive. Chest radiography had 25% sensitivity, and 62.5% specificity. Flexible bronchoscopy changed the management in 22% of cases, sparing RB.

CONCLUSIONS

Basing the decision to perform RB solely on the clinical findings and chest radiography entails a 25% rate or more of negative exams. CT scan appears to be the most accurate non-invasive tool for ruling out the presence of a FB but its use cannot be systematic due to its complexity and the risks of exposure to radiation. Digital substraction fluoroscopy is a safe and simple mean to confirm the presence of air trapping generated by a bronchial obstruction, but it is not sensitive enough to definitively rule out a FB. We propose a stepwise approach using fluoroscopy or possibly flexible bronchoscopy under sedation, in order to reduce the number of negative RBs while restricting the use of the CT scan.

The anesthetic considerations of tracheobronchial foreign bodies in children: a literature review of 12,979 cases

Asphyxiation by an inhaled foreign body is a leading cause of accidental death among children younger than 4 years. We analyzed the recent epidemiology of foreign body aspiration and reviewed the current trends in diagnosis and management. In this article, we discuss anesthetic management of bronchoscopy to remove objects. The reviewed articles total 12,979 pediatric bronchoscopies. Most aspirated foreign bodies are organic materials (81%, confidence interval [CI] = 77%-86%), nuts and seeds being the most common. The majority of foreign bodies (88%, CI = 85%-91%) lodge in the bronchial tree, with the remainder catching in the larynx or trachea. The incidence of right-sided foreign bodies (52%, CI = 48%-55%) is higher than that of left-sided foreign bodies (33%, CI = 30%-37%). A small number of objects fragment and lodge in different parts of the airways. Only 11% (CI = 8%-16%) of the foreign bodies were radio-opaque on radiograph, with chest radiographs being normal in 17% of children (CI = 13%-22%). Although rigid bronchoscopy is the traditional diagnostic "gold standard," the use of computerized tomography, virtual bronchoscopy, and flexible bronchoscopy is increasing. Reported mortality during bronchoscopy is 0.42%. Although asphyxia at presentation or initial emergency bronchoscopy causes some deaths, hypoxic cardiac arrest during retrieval of the object, bronchial rupture, and unspecified intraoperative complications in previously stable patients constitute the majority of in-hospital fatalities. Major complications include severe laryngeal edema or bronchospasm requiring tracheotomy or reintubation, pneumothorax, pneumomediastinum, cardiac arrest, tracheal or bronchial laceration, and hypoxic brain damage (0.96%). Aspiration of gastric contents is not reported. Preoperative assessment should determine where the aspirated foreign body has lodged, what was aspirated, and when the aspiration occurred ("what, where, when"). The choices of inhaled or IV induction, spontaneous or controlled ventilation, and inhaled or IV maintenance may be individualized to the circumstances. Although several anesthetic techniques are effective for managing children with foreign body aspiration, there is no consensus from the literature as to which technique is optimal. An induction that maintains spontaneous ventilation is commonly practiced to minimize the risk of converting a partial proximal obstruction to a complete obstruction. Controlled ventilation combined with IV drugs and paralysis allows for suitable rigid bronchoscopy conditions and a consistent level of anesthesia. Close communication between the anesthesiologist, bronchoscopist, and assistants is essential.