Bronchoscopic removal of aspirated foreign bodies in children

Role of Virtual Bronchoscopy in Evaluation of Suspected Foreign Body in Children's Tracheobronchial Tree

Introduction  The presence of foreign bodies in the airways remain a diagnostic challenge to healthcare professionals. They can become life threatening emergencies that require immediate intervention or go unnoticed for weeks and even months. Prevention is best but early recognition remains a critical factor in treatment of foreign body inhalation in children. Objective  To study the diagnostic advantages of virtual over rigid bronchoscopy in the evaluation of children with suspected foreign body in the tracheobronchial tree and plan for early management. Methods  A crossectional study conducted at a tertiary care hospital & medical college in India. A total 24 patients (0-12-years-old) who presented with complaints of sudden onset of coughing, choking, and breathing difficulty were included during the 2-year duration, from January 2018 to December 2019. All patients underwent virtual and rigid bronchoscopy. Results  In 8 patients, foreign bodies detected by virtual bronchoscopy were confirmed by rigid bronchoscopy. There was one case in which virtual bronchoscopy showed no foreign body, but rigid bronchoscopy detected it. In 15 cases virtual and rigid bronchoscopy did not show foreign bodies. The sensitivity, specificity, positive and negative predictive value of virtual bronchoscopy were 88.88, 100, 100, and 93.75%, respectively. Conclusions  Virtual bronchoscopy is less invasive and does not require general anesthesia but cost and availability are limitations. It can be used as method of investigation in children with suspected foreign body aspiration.

Foreign Bodies in Pediatric Otorhinolaryngology: A Review

Foreign bodies (FBs) in pediatric otorhinolaryngology represent up to 10% of cases in emergency departments (ED) and are primarily present in children under five years old. They are probably the result of children's curiosity and tendency to explore the environment. Aural and nasal FBs are the most common and accessible, and the removal methods differ depending on the exact location and type of FB, which can be organic or inorganic. A fish bone stuck in one of the palatine tonsils is the most common pharyngeal FB. Laryngopharyngeal FBs can obstruct the upper respiratory tract and thus become acutely life-threatening, requiring an urgent response. Aspiration of FBs is common in children between 1 and 4 years old. A history of coughing and choking is an indication of diagnostic and therapeutic methods to rule out or confirm a tracheobronchial FB. Regardless of the availability of radiological diagnostics, rigid bronchoscopy is the diagnostic and therapeutic method of choice in symptomatic cases. Radiological diagnostics are more significant in treating esophageal FBs since most are radiopaque. Flexible or rigid esophagoscopy is a successful method of removal. A delayed diagnosis, as with tracheobronchial FBs, can lead to fatal consequences.

A Foreign Body Aspiration Leading to Pneumothorax: A Case of Airway Emergency

Foreign body (FB) aspiration is a matter that should not be taken lightly. The presence of a foreign object might lead to hazardous complications, particularly in the pediatric population. These complications depend on the type and location of the aspirated object as the tracheobronchial tree has a very small diameter, and foreign bodies become stuck in the upper airways of children, causing stridor and sudden difficulty in breathing. Impaction of a foreign body in the right bronchial tree is more frequent due to the relatively straighter alignment of the right mainstem of the trachea, as opposed to the left side. Herein, we present a 10-year-old Malay boy who accidentally aspirated a pencil cap. An urgent computed tomography (CT) of the thorax revealed a suspicious intraluminal FB in the bronchus leading to pneumothorax and pneumomediastinum. He underwent a right bronchoscopy and a successful FB removal.

Foreign body aspiration score (FOBAS)-a prospectively validated algorithm for the management and prediction of foreign body aspiration in children

Foreign body aspiration (FBA) is a common cause of pediatric morbidity, but a standardized protocol to guide decision-making about bronchoscopy is lacking. We aimed to validate a new Foreign body aspiration score (FOBAS) for the pediatric emergency department (ED). Patients aged 0-18 years referred to the ED for suspected FBA were prospectively enrolled. FOBAS was calculated according to clinical features of a choking episode, sudden cough, exposure to nuts, absence of fever and rhinitis, stridor, and unilateral auscultatory and radiological findings. FBA risk was evaluated based on the total score (low, 1-3; moderate, 4-6; high, 7-10). Low-risk children were discharged from the ED and followed clinically. Moderate-risk children were hospitalized and evaluated by a pediatric pulmonologist, and high-risk children were referred directly for therapeutic bronchoscopy. Among the 100 enrolled children (59% males; median age 20 [interquartile range 11-39] months), a foreign body was diagnosed in 1/49 (2%), 14/41 (34.1%), and 9/10 (90%) with low, moderate, and high FOBAS, respectively (P < .001). Logistic regression indicated a higher risk for FBA with higher scores. The odds ratio for each additional point was 2.75 (95% confidence interval 1.78-4.24), and FOBAS showed a high predictive value for FBA (area under the curve 0.89). FOBAS implementation significantly reduced the rate of negative bronchoscopies, from 67.4% annually during 2016-2019 to 50% in 2020 (P = .042).

CONCLUSION

FOBAS reliably predicts FBA in cases of suspected FBA and improves management and in-hospital decision-making.

WHAT IS KNOWN

• Foreign body aspiration is a major cause of pediatric morbidity and mortality. • Currently, there is no unified protocol for children referred to the emergency department for suspected FBA, therefore, a well-defined algorithm is needed to improve the decision-making process.

WHAT IS NEW

• The pediatric Foreign body aspiration score (FOBAS) is a new, prospectively validated clinical score that shows high sensitivity and specificity for the presence of FBA in children. • FOBAS reduces unnecessary admissions and invasive procedures and leads to better clinical outcomes.

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.

The Role of CT Scan in Pediatric Airway Foreign Bodies

Objective

We aim to determine the utility of CT scan as a method to accurately confirm pediatric airway foreign bodies (AFBs), the current gold standard of which is chest X-ray as the primary imaging modality in the investigation screening of AFBs with progression to microlaryngobronchoscopy.

Methods

A retrospective cohort study of children diagnosed with suspected AFBs between July 2019 and June 2020 was conducted. The primary outcome of missed AFBs from radiologic investigations was recorded.

Results

A total of 226 children with an average age of 1.94 years were included in this study. One hundred and two children were eventually admitted to the hospital for microlaryngobronchoscopy. A total of 89 cases were initially examined by chest X-ray with the diagnosis confirmed in 26 cases. The initial examination was chest CT scan in 105 cases, of which the diagnosis was confirmed in 46 cases. The initial examination was chest CT scan with airway reconstruction in 32 cases, and the diagnosis was confirmed in 17 cases. Patients with negative chest CT scan with airway reconstruction were observed to have resolution of symptoms with no further need for bronchoscopy.

Conclusion

Chest CT scan with airway reconstruction had the highest rate of confirmed diagnosis of pediatric AFBs on initial scanning, followed by chest CT scan, and finally chest X-ray with fluoroscopy; there was no missed diagnosis in chest CT scan with airway reconstruction. Chest CT scan with airway reconstruction can accurately and quickly detect AFBs and reduce unnecessary bronchoscopy.

Parental Knowledge and Practices Related to Foreign Body Aspiration in Children in Makkah, Saudi Arabia

Background Foreign body aspiration (FBA) is a life-threatening event and one of the most common causes of mortality in children. As it has different clinical presentations, parental knowledge is essential for early management to prevent complications. Objectives This study was designed to assess the knowledge and practices relating to FBA in children among parents living in Makkah city, Saudi Arabia. Methods An online questionnaire was designed using Google Forms (Google LLC, Mountain View, California, United States) and distributed in October 2022 among parents living in Makkah city. After data collection, an appropriate statistical analysis was conducted. Results A total of 1087 parents enrolled in this study; 63.9% were women and the majority were married 93%. Additionally, 52% of the parents had at least three children. Moreover, 17.6% had an experience of a child having aspirated a foreign body once. The Internet was the most popular source of information on FBA (43.5%). Furthermore, the parents had poor levels of knowledge and practices related to FBA (65.4% and 78.6%, respectively). Conclusion This study reported that parental levels of knowledge of FBA and FBA practices were inadequate. There is a need to increase awareness, which will lead to better outcomes.

Management of Foreign Bodies in the Ear, Nose and Throat in Pediatric Patients: Real-Life Experience in a Large Tertiary Hospital

BACKGROUND

Foreign body (FB) injuries occur frequently in children. The aim of this paper is to provide an update on the experience of the Department of Otolaryngology, San Camillo Forlanini Hospital in Rome concerning the management of FB injuries in children.

METHODOLOGY

This study was carried out by collecting data from the medical reports of our Pediatric Emergency Room stored between 2007 and 2021. Inclusion criteria were diagnosis of FB in pediatric patients based on the ENT evaluation. Pediatric patients included children and preteens ranging from six months to 15 years.

RESULTS

Between 2007 and 2021, 1,623 cases of FBs in young patients (840 males, 783 females, mean age: 5.5 years) were observed at the Pediatric Emergency Room and treated by the ENT Department. The ear was the most frequently involved site (700 patients), followed by the nose (517 cases), pharynx (319 cases), mouth (76 patients) and airways (11 cases). The most common management strategy was FBs' removal in the emergency room and home discharge (1,409 patients), 99 cases required outpatient discharge, 64 patients moved away from the Emergency Care refusing treatment, 35 patients were hospitalized, 10 patients refused hospitalization, five were transferred to the pediatric hospital and one died in the emergency room.

CONCLUSIONS

A quick diagnosis of FB followed by an effective removal is crucial to avoid injuries and complications. Surveillance registries have a key role in the prevention and management of FB injuries. Moreover, it is necessary to train medical and nursing staff of emergency, pediatric and otolaryngologist departments to best recognize and manage FB injuries.

A new scoring system and clinical algorithm for the management of suspected foreign body aspiration in children: a retrospective cohort study

BACKGROUND

Cases of foreign body aspiration in children may be encountered in emergency departments. A suggestive history is important in diagnosing aspirated foreign body owing to the difficulty in making a diagnosis on the basis of an abnormal physical examination or chest radiography alone. The aim of this study was to examine the sensitivity and specificity of the presenting symptoms, physical examination, and radiologic findings as predictors of foreign body aspiration in children. In addition, a feasible simple algorithm with a scoring system was generated to indicate bronchoscopic investigation.

METHODS

In a retrospective cohort, medical records of patients aged less than 16 years with suspected foreign body aspiration who underwent flexible or rigid bronchoscopy were included. Data including age, sex, symptoms, physical examination findings, radiological features, nature and location of the foreign body, and outcome of the bronchoscopy were collected, and multivariable binary logistic regression analysis was employed for prediction of foreign body aspiration.

RESULTS

A total of 203 children were included, and the model showed excellent discrimination power for positive foreign body aspiration (area under the curve = 0.911) with an accuracy, sensitivity, and specificity of 86.2, 90.6, and 76.6%, respectively. The total weighted risk score at a cut-off > 2 showed a significant good power of discrimination (area under the curve = 0.879), with a sensitivity of 79.9% and specificity of 84.4%. Accordingly, a clinical algorithm was recommended.

CONCLUSIONS

The proposed scoring system and clinical algorithm might help in decision making with regard to the need and type of bronchoscopy in children presenting with potential foreign body aspiration. However, further prospective multicenter studies should be conducted to validate this scoring system.

Foreign Body Aspiration in Egyptian Children Clinical, Radiological and Bronchoscopic Findings

Purpose

Foreign body aspiration (FBA) is a frequent cause of childhood morbidity and mortality. Diagnosis of FBA is challenging in the absence of a witnessed aspiration event. The aim of this study was to determine the accuracy of presenting symptoms as well as physical and radiologic findings as predictors of FBA in children. Thus, indications for bronchoscopy could be determined in such cases.

Methods

This retrospective cohort study was conducted in the ENT department, Kafr-elsheikh University Hospital. The medical records of patients younger than 16 years old who underwent rigid bronchoscopy for suspected FBA were included. Data including age, gender, symptoms, physical examination findings, radiological features, nature and location of foreign body, and outcome of the bronchoscopy were collected.

Results

This study included 130 patients, 105 (80.8%) patients were positive for the presence of a foreign body in their airways. Foreign bodies were most frequently (43.8%) lodged in the right main bronchus, and nuts (66.7%), were the most commonly retrieved. Multivariate regression analysis identified the presence of suggestive signs or symptoms as independent predictors of FBA on rigid bronchoscopy.

Conclusion

Objective finding of clinical signs eg unilateral wheezes on chest examination in the presence of symptoms such as a sudden cough, dyspnea, and hoarseness could predict FBA and help physicians in deciding bronchoscopy.

Aspiration of the dental crown in an elderly patient

The aspiration of objects and foreign bodies requires quick and systematic care. During emergent orotracheal intubation, accidental dental crown release can cause a threat to the patient's life. This paper aimed to report a case of foreign body (dental prosthetic crown) aspiration and its management and discuss alternative approaches. An 81-year-old male patient, who was admitted to the hospital's intensive care unit (ICU) for meningitis, presented with altered consciousness, and decreased oxygen saturation. He underwent emergent orotracheal intubation. After intubation, chest radiography was performed to check for proper orotracheal tube positioning and lung expansion. The resultant images revealed the presence of a foreign body within the right lower lobe bronchus in the shape of a dental crown. The foreign body, intubation cannula and basket clamp were successfully removed, followed by reintubation of the patient. The foreign body was a prosthetic upper premolar dental crown (24). While care should be taken to avoid complications, if a foreign body is aspirated during emergent orotracheal intubation, endoscopic removal appears safe and effective. Careful creation, placement, maintenance, and preservation of prosthetic crowns are critically important in elderly patients.

Butyryl-cholinesterase deficiency: A case report of delayed recovery after general anaesthesia

•

Suggestive presentation of foreign body aspiration needs emergency bronchoscopy.

•

Meticulous history and high index of suspicion is needed to diagnose butyryl-cholinesterase deficiency.

•

Succinylcholine apnoea is treated by ventilation and recombinant enzyme could be the specific antidote.

•

Genetic testing is needed to confirm the diagnosis of butyryl-cholinesterase deficiency.

•

Succinylcholine apnoea patient and their family should be well-informed about the situation.

Background

Apnoea and prolonged paralysis after succinylcholine administration is not uncommon occurrence in anaesthetic practice. It occurs due to inherited or acquired deficiency of butyrylcholinesterase.

Case report

Here we report a case of succinylcholine apnoea for 2 h in a 5 years old girl who was anaesthetized for bronchoscopic extraction of a foreign body. She was subsequently kept on assisted ventilation. She recovered few minutes after I.V. atropine and naloxone. Laboratory investigation revealed low cholinesterase activity. Thus the girl was given 150 mL fresh frozen plasma. She has been discharged the next day after complete recovery.

Conclusion

As the genetic analysis was not available to confirm the diagnosis of atypical variant of cholinesterase. The family was advised to submit serum samples for assessment of cholinesterase activity and avoid exposure to cholinesterase inhibitors. Moreover, clear instructions were given to the family so they can warn the anaesthetists in case any family member undergoes general anesthesia for any reason in the future. Furthermore, they must be strongly advised to avoid exposure to anticholinesterases as they might have heightened sensitivity to these agents. It should be emphasized that Naloxone and atropine could help speed up recovery in such cases.

Eighteen years lasting bronchial foreign body: A case report in Cameroon, sub-Sahara Africa

INTRODUCTION

Foreign body aspiration represents an important cause of morbidity and mortality during childhood. A neglected aspirated foreign body can last for years, leading to complications that are sometimes difficult to manage, dramatically affecting the quality of life of the patient.

CASE REPORT

We report the case of a 29-year-old female who presented with eighteen-year history of recurrent cough, choking, and respiratory infections following a foreign body aspiration. The course was complicated by a chronic secondary lung abscess, successfully managed by combined medical and surgical treatment.

DISCUSSION

In low-income countries like ours, foreign body aspiration is often misdiagnosed. The often delayed management due to low socioeconomic status can lead to serious complications. To the best of our knowledge, it is the longest period of bronchial foreign body retention reported in the medical literature in Africa.

CONCLUSION

Foreign body aspiration is common in childhood and requires early recognition and treatment, in order to avoid complications that can be very serious or even fatal.

Value of multi-slice spiral computed tomography for diagnosis of tracheobronchial foreign body aspiration in children: 5-year retrospective study

BACKGROUND

Tracheobronchial foreign body (TFB) aspiration is a significant cause of respiratory problems in children. The timely diagnosis of TFB is important to decrease the mortality rate and the incidence of complications. Advances in radiology have led multi-slice spiral computed tomography (MSCT) to become the best technique for diagnosing TFB.

METHODS

We performed a retrospective study over 5 years from July 2008 to June 2013. We collected information on children who were diagnosed with a TFB by bronchoscopy, and analyzed age, sex, location, type of foreign body, and various MSCT manifestations.

RESULTS

A total of 382 children were included and 68.6% of them were aged 1 to <2 years. The majority (95.8%) of aspirated foreign bodies were vegetation items, and nearly half (47.6%) of them were peanut kernels, followed by sunflower seeds (26.2%). A total of 4.7% of TFBs were in the trachea, 51.0% were in the left main bronchus, and 44.2% were in the right main bronchus. Among the TFBs, 359 (95.5%) showed a high-density shadow in the tracheal / bronchial lumen using MSCT, which could establish the presence of a foreign body directly. Emphysema, localized obstruction and pneumonia were more commonly detected in the 7-21 days and ≥21 days group compared with those in the <7 days group (all P < 0.01). Bronchiectasis was found in two children who were diagnosed at least 21 days after aspiration.

CONCLUSIONS

Multi-slice spiral computed tomography is very sensitive to TFBs. Timely diagnosis and treatment of TFB is important to prevent long-term sequelae in children.

Flat sticker as a mobile airway foreign body: A case report and review of the literature

Diagnosis of an airway foreign body in the setting of an unwitnessed aspiration event remains a challenge for physicians in the emergency setting. We describe a case of a 2-year-old male who presented to the emergency department with atypical symptoms resulting from ingestion and aspiration of a large, flat sticker. The airway foreign body remained in place for over 24 hours despite obtaining appropriate airway imaging, and the object was later removed without complication via rigid bronchoscopy in the operating room. Further review of this case and the current literature highlighted multiple lessons. Initial evaluations should combine a rigorous history and physical with strict guidelines on usage of multiple imaging modalities (eg, plain radiographs and CT). Imaging should be obtained with the patient devoid of all obstructive materials in multiple positions (eg, upright, supine, lateral) in order to maximize the physician's ability to positively diagnose airway foreign bodies prior to definitive treatment with rigid bronchoscopy.

Comparison of direct vision and video imaging during bronchoscopy for pediatric airway foreign bodies

Rigid ventilation bronchoscopy is a most useful means of detecting and removing foreign bodies in the airway. We performed a retrospective study of 114 children who had undergone such a procedure during a 12-year period. During bronchoscopy, 48 of these patients had been examined under direct vision and 66 by videotape recording. We found that the positive rate on first-look direct vision was 93.8% and the positive rate on first-look video imaging was 89.4%. The lower positive rate during the first-look examination by video imaging might be attributable to the facts that it is safer and that it provides a better visual field, which can encourage operators to choose video ventilation bronchoscopy, either as a diagnostic or therapeutic tool. In addition, three foreign-body-negative patients in the direct-vision group underwent a second procedure, and a foreign body was found in all three. Only one of the video-imaging patients underwent a second procedure, and no foreign body was found. The difference in the positive rates after the second procedure was statistically significant (p<0.05). This might be attributable to the higher success rate with video imaging following the first procedure, which significantly reduced the need for a second look and the possibility of overlooked or residual foreign bodies. The condition of the mucosa postprocedurally was described in every case after video imaging but after only 41.7% of the direct-vision cases—a statistically significant difference (p<0.001). Video imaging provides the physician with a clear, magnified view of the area under examination. It allows for later review of the videotape when necessary, and it reduces the risk that residual foreign-body material will remain in the airway.

Utility of bronchoscopy combined with surgery in the treatment and outcomes of dogs with intrathoracic disease secondary to plant awn migration

OBJECTIVE

To evaluate the diagnostic and therapeutic utility of bronchoscopy in dogs undergoing computed tomography (CT) and surgery for intrathoracic disease (pyothorax and pneumothorax) secondary to migrating plant awns (MPA) and to report outcomes in dogs that did and did not undergo bronchoscopy in addition to CT and surgery.

STUDY DESIGN

Retrospective case series.

ANIMALS

Thirty-seven client-owned dogs.

METHODS

Medical records from 2008 to 2017 were reviewed for dogs with documented MPA in the thoracic cavity treated with CT and surgery with or without bronchoscopy. Information regarding diagnostics, treatments, complications, and outcomes relating to hospitalization was evaluated.

RESULTS

At least one abnormal lung lobe was identified by CT in all dogs. Bronchial abnormalities were identified with bronchoscopy in 21 of 22 dogs (95.4%) with available reports. Agreement between CT and bronchoscopy findings ranged from 50% to 81.8%, depending on lung lobe. Thirty-six dogs had one or more lung lobes surgically removed. Thirty-seven MPA were retrieved via bronchoscopy in 10 of 27 (37%) dogs, and 39 MPA were retrieved at surgery in 26 of 37 (70.3%) dogs. Actinomyces spp. were cultured from surgical samples in 7 of 33 (21.2%) dogs. Thirty-five of 37 (94.6%) dogs survived to discharge.

CONCLUSION

Migrating plant awns were successfully retrieved via bronchoscopy. Agreement between CT findings and bronchoscopy was inconsistent, so there may be roles for both modalities. Short- and long-term survival was excellent in this cohort.

CLINICAL SIGNIFICANCE

Bronchoscopy may allow for diagnostic and therapeutic advantages compared with CT in dogs with endobronchial MPA. Actinomyces spp appear to be variably present in surgically acquired bacterial cultures in dogs with MPA.

Inhaled Foreign Body Impaction: A Review of Literature in Malaysian Children

Foreign body aspiration in children is a problem that can lead to several complications, including death. In this retrospective publication review from 1970 to 2015, there were altogether 42 Malaysian children below the age of 15 y reported with foreign body (FB) ingestion. There were 31 boys and 11 girls between 2 and 177 mo of age. The incidence of FB ingestion in children varied with dietary practices. Peanut was the most common food-related substance inhaled followed by watermelon seed and coconut kernel. The most common non-food related substances were metal objects (toys, springs, hair clips) and plastic objects (ballpoint tips, pencil caps and whistles). Successful removal of FB by bronchoscopy is achieved in the vast majority of cases except for a case of impacted whistle inhalation and a neglected laryngeal FB which required a tracheostomy. One child required thoracotomy for the removal of a peanut in the right bronchus. The incidence of food-related substance inhalation was more common than non-food related substance (30:7). From this review, the key messages are two: first, prevention can be achieved by educating parents not to allow access to small objects or dangerous foods to children below 3 y age; Second, emergency first aid home measures, in the combination form of back blows in the head down position and chest or abdominal thrusts, should be early performed according to the pediatric age group and can be quite effective.

Bronchoscopy for Pediatric Airway Foreign Body: Thirty-Day Adverse Outcomes in the ACS NSQIP-P

OBJECTIVES

(1) Describe outcomes of bronchoscopy with foreign body removal among children on the basis of a large standardized multi-institutional data set. (2) Identify factors associated with 30-day adverse events.

STUDY DESIGN

Cross-sectional analysis of a US national database.

SETTING

Public data set from the ACS NSQIP-P (American College of Surgeons National Surgical Quality Improvement Program-Pediatric) from 2012 to 2015.

SUBJECTS AND METHODS

Children <18 years old who underwent bronchoscopy with removal of foreign body were identified. Patient demographics, comorbidities, hospitalization factors, surgical characteristics, and 30-day postoperative adverse events, including complication and readmission, were analyzed. Multivariate logistic regression identified predictive factors for postoperative complications and prolonged length of stay.

RESULTS

A total of 275 children underwent bronchoscopic foreign body removal (n = 165 male, 60%; n = 75 nonwhite and/or Hispanic, 27%; mean age, 3.5 years [range, 0.63-17.9; median, 2.0]). Adverse events occurred among 10 children (4%). Seven had pulmonary-related complications, and 1 patient died. Three patients were readmitted; there were no reoperations. On multivariate analysis, preoperative pulmonary disease or need for pulmonary support (odds ratio [OR], 6.42; P = .04) predicted postoperative complications. Preoperative pulmonary compromise (OR, 8.10; P < .01), American Society of Anesthesiologists class 3 or 4 (OR, 4.13; P < .01), and prolonged operative time (OR, 3.05; P = .01) were associated with prolonged hospital stay.

CONCLUSION

Bronchoscopy for retrieval of foreign body among children has an overall low incidence of 30-day adverse events. Children with preoperative pulmonary compromise have a significantly higher risk of postoperative complications. These findings may be applied to optimize perioperative care and counsel parents and families.

Clinical experience in the treatment of children who swallowed multiple magnetic foreign bodies: A report of five cases

BACKGROUND

Several clinical reports have been published on complications resulting from swallowing multiple magnetic foreign bodies. This study aimed to summarize the clinical experience of managing children who swallowed multiple magnetic foreign bodies.

METHODS

We reviewed the clinical records of five children who swallowed multiple magnetic foreign bodies and were admitted to our hospital during June 2012 to June 2014. Details of the patients' presentation, imaging studies, complications and treatment were recorded.

RESULTS

All five children suffered from gastrointestinal perforation and intestinal obstruction. The magnetic foreign bodies caused local bowel wall tissue ischemia necrosis and perforation as well as other complications associated with fistula formation. The magnets were finally removed by laparotomy surgery.

CONCLUSION

If magnetic foreign bodies cannot be removed by endoscopy, an operation is suggested as soon as possible to avoid serious complications.

A new clinical algorithm scoring for management of suspected foreign body aspiration in children

Background

Foreign Body Aspiration (FBA) is a serious problem in children and delays in diagnosis and management can be devastating. The history is often vague, with subtle physical and chest radiograph abnormalities. This study aims to determine the indications for bronchoscopy in children with suspected FBA and evaluate the key clinical and statistically significant predictors of FBA, based on the patients’ historical, physical and radiological findings at presentation.

Methods

This is a retrospective observational study, including patients who were admitted between January 2001 to January 2011 with suspected FBA. Their presenting history, physical exam, radiological and bronchoscopic findings were analyzed.

Results

Three hundred children with a mean age of 2.1 ± 1.7 years were included. In children with both abnormal physical and radiological findings, 47.2% had proven FBA. If either was abnormal, the likelihood reduced to 32–33.3%; if both were normal, only 7.4% had a FB. Witnessed choking (adjusted OR 2.1, 95% CI 1.03–4.3; P = 0.041), noisy breathing/stridor/dysphonia (adjusted OR 2.7, 95% CI 1.2–6.2; P = 0.015), new onset/recurrent /persistent wheeze (adjusted OR 4.6, 95% CI 1.8–11.8; P = 0.002), abnormal radiological findings (adjusted OR 4.0, 95% CI 1.9–8.5; P < 0.001), and unilateral reduced air entry (adjusted OR 2.9, 95% CI 1.5–5.5; P = 0.001) were significant predictors of FBA (P < 0.05). When three or more risk factors were present, the cumulative proportion of children with proven FBA increased significantly. The discriminative ability of the model was found to be good; the area under the ROC curve value was 0.76 (95% CI 0.70, 0.82). The predicted cutoff score derived using ROC analysis was found to co-relate well with known clinically significant predictors of FBA. This supports our algorithm and scoring system.

Conclusions

A high index of suspicion is required in diagnosing airway FB. Our proposed clinical algorithm and scoring system hopes to empower physicians to accurately predict patients with a high likelihood of FBA.

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.

Incidental intraoperative diagnosis of retained foreign body lung misdiagnosed as pulmonary tuberculosis

Tracheobronchial foreign body aspiration (FBA) is a very common and lethal problem among children. It can easily be diagnosed with a typical history of choking crisis. Clinical examination and radiology play a secondary role in diagnosis. Acute choking episode may lead to death or else to serious sequels such as bronchiectasis, atelectasis, and recurrent pneumonia. Here, we report an interesting case of bronchiectasis in a young female initially thought to be a consequence of pulmonary tuberculosis, who was subsequently found to have retained foreign body in the left lower lobe lung which was the actual cause of her symptoms.

Foreign Bodies in Trachea: A 25-years of Experience

OBJECTIVE

Tracheobronchial foreign body aspirations may cause cardiopulmonary arrest and sudden death. The incidence in children is higher than in adults. Rapid diagnosis and treatment is live saving. In this paper, we aimed to present our experience in tracheal foreign body aspirations and rigid bronchoscopy for 25-years.

MATERIALS AND METHODS

From January 1990 to January 2015, 805 patients with suspected tracheobronchial foreign body aspiration were admitted to our department. Hundred and twelve patients with tracheal foreign body were included in this study. We evaluated patients' records, retrospectively. Age, gender, clinical symptoms, physical examination findings, radiological evidences, type of foreign body and intervention types were noted.

RESULTS

Sixty-five of the patients were female (58%) and 47 patients were male (42%), and mean age was 8.1 years (8 month-58 years). Coughing was the main symptom (n=112, 100%). Other symptoms and findings included dyspnoea and bilateral decreased lung sounds (n=73, 65.1%), bilateral rhonchi (n=68, 60.7%) and cyanosis (n=41, 36.6%). Rigid bronchoscopy was performed in all patients. The most common foreign body was nuts (n=75, 67%). The main radiologic finding was radiopaque image of the related foreign body in 27 patients (n=27, 24.1%). Cardio-pulmonary arrest occurred in 11 patients and two of them died.

CONCLUSION

Tracheobronchial aspirations of foreign bodies are life-threatening events. If not diagnosed and treated rapidly, distressful results can be seen. Warning people by skilled persons on this topic will reduce the incidence of foreign body aspirations.

Thorough documentation of the accidental aspiration and ingestion of foreign objects during dental procedure is necessary: review and analysis of 617 cases

OBJECTIVES

To review the cases of accidental aspiration and ingestion of foreign objects during dental procedure, and to emphasize the importance of thorough documentation of the accidents.

METHODS

A comprehensive search on (dental procedure/treatment/practice), (aspiration/inhalation), and (ingestion/swallow) was performed for all years before 1st October 2014 available. The statistic analysis was made on the variables including journals and reported year, patients' age, gender, general conditions, dental procedure and location for procedure, foreign objects, site of involvement, possible causes, anesthesia during procedure and treatment, symptoms, treatment time and treatment modality, follow-up, and so on.

RESULTS

A total of 617 cases reported by 45 articles from 37 kinds of journals were included and analyzed. Most reports made detailed record. While some important variables were recorded incompletely, including patient's general conditions, location for procedure, clinical experience of the involving dentists, tooth position of procedure, possible causes, and anesthesia during procedure and treatment for the accident.

CONCLUSIONS

Aspiration and ingestion of foreign objects are rare and risky complication during dental procedure. Each accident should have thorough documentation so as to provide enough information for the treatment and prevention.

Point-Of-Care Ultrasound Findings Associated With Foreign Body Aspiration in the Pediatric Emergency Department

Point-of-care ultrasound (POCUS) continues to generate new and interesting clinical findings as its use expands in the pediatric emergency department. This case report describes the novel findings identified during a POCUS focused lung examination of a pediatric patient with suspected foreign body aspiration.

Inhaled Foreign Bodies: Presentation, Management and Value of History and Plain Chest Radiography in Delayed Presentation

OBJECTIVES: To assess the clinical and management aspects of tracheobronchial foreign body (FB) in children and adults; to judge the influence of the operator's experience on the outcome of the procedure and to evaluate the factors associated with delayed diagnosis of FB aspiration (FBA) in children; and to compare clinical, radiologic and bronchoscopic findings in the patients with suspected FB inhalation (FBI).

STUDY DESIGN AND SETTING: Retrospective review of a 10-year experience (from 1995 to 2005), involving a 1512-bed Mansoura university hospital and a 184-bed Mansoura emergency hospital.

MATERIAL AND METHODS: Three thousand three hundred patients underwent rigid bronchoscopy for suspected FBI between 1995 and 2005 in Mansoura, Egypt. The data were analyzed in 3 groups: the patients with negative bronchoscopy for FBI (group 1), early (group 2), and delayed diagnosis (group 3). Foreign body was removed using the rigid bronchoscope with or without using the extracting forceps (Egyptian novel technique; Sersar technique).

RESULTS: The penetration syndrome and decreased breath sounds were determined in a significantly higher number of the patients with FBI. The plain chest radiography revealed radiopaque foreign bodies (FBs) in 23.56% of all patients with FBI. Pneumonia and atelectasis were more common in the groups with negative bronchoscopy and with delayed diagnosis ( P < 0.01). The FBs were mostly of vegetable origin, such as seeds and peanuts. The Egyptian novel (Sersar) technique was used since 2004 April in 100 cases (4.62%) with a history of FBI (pins and or small rounded materials). It was successful in 73 cases of nonimpacted inhaled pins.

CONCLUSIONS: Bronchoscopy is indicated on appropriate history and on suspicion. To prevent delayed diagnosis, characteristic symptoms, and clinical and radiologic signs of FBI should be checked in all suspected cases. Because clinical and radiologic findings of FBI in delayed cases may mimic other disorders, the clinician must be aware of the likelihood of FBI.

EBM rating: C-4

A case control study of the factors associated with occurrence of aerodigestive foreign bodies in children in a regional referral hospital in South Western Uganda

Background

Aerodigestive foreign bodies (ADFB) in children are a common emergency in ENT clinics globally. The aim of this study was to determine the prevalence and common types of ADFB’s presenting to a referral hospital in South Western Uganda, and to review clinical presentation and factors that influence their occurrence among children under 12 years of age.

Methods

We conducted a case control study comprising 40 cases and 80 unmatched controls. Consecutive and random sampling were used for the cases and controls respectively. A questionnaire was used to collect data. Clinic records were reviewed to calculate prevalence.

Results

Prevalence was 6.6 % of all paediatric cases seen in the ENT department that year. The most common symptoms included: history of choking [45 %], sudden cough [72.5 %], stridor [60 %] and failure to swallow [35 %]. The most common location for an airway foreign body was the right main bronchus [40 %] and the upper one third of the oesophagus [32.5 %] for digestive tract foreign bodies. Seeds and coins were most frequently removed. Children from upper level SES had a significantly lower risk of foreign body occurrence [OR = 0.29, p = 0.02] compared to those from a low SES. Also significantly, most cases were referrals from other government health centres [p = <0.01]. The male to female ratio among cases was 2:1. Children of older mothers were less likely to have an ADFB.

Conclusion

Prevalence of ADFB’s is relatively high. The most common symptoms are a history of choking, cough and failure to swallow. Age under 5 years, male sex, younger maternal age and low socioeconomic status increased odds of ADFBs.

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.

Crowning achievement: a case of dental aspiration

Aspiration of foreign bodies during dental procedures is a rare but potentially serious complication. We present a case of a 75-year-old man who aspirated a dental crown requiring flexible bronchoscopic retrieval. We discuss the risk factors for aspiration, the radiographic features of diagnosis, and the techniques for management and retrieval.

Subcutaneous emphysema: Unique presentation of a foreign body in the airway

Foreign body airway (FBA) is a common problem among the children. Variable presentation makes it difficult to diagnose a case of FBA, particularly, when no definite history of aspiration is available. Subcutaneous emphysema (SCE) and pneumomediastinum are rare presentations. We report a case of FBA who presented with SCE without any history of aspiration. A 3-year-old female child was admitted with respiratory distress, fever and SCE over the right side of chest, neck and face. Initially, she was diagnosed as a case of pneumonitis with barotrauma. X-ray of the chest revealed SCE with pneumomediastinum without pneumothorax. Diagnostic bronchoscopy with rigid ventilating bronchoscope was done under general anesthesia. A plastic foreign body with sharp projections embedded in the mucosa was detected and retrieved from right main bronchus. Postoperatively SCE regressed gradually.

Foreign body aspiration - Sometimes a tough nut to crack

Foreign body aspiration (FBA) is a dangerous and potentially life-threatening event. We report the case of a 24-month old boy, who was initially presented with an episode of obstructive bronchitis to the family pediatrician. Then, while being treated with empiric antibiotics, he aspirated a peanut. Although resulting in a coughing episode, the mother did initially not ascribe any relevancy to it. Since the diagnosis of obstructive bronchitis had already been established, only an in-depth history taking session with the mother could help figure out, why the boy's symptoms got worse instead of better. This article underlines the importance of accurate history taking and clinical examination.

Management of accidental swallowing in implant dentistry

This report describes a protocol for managing the accidental swallowing of dental instruments in implant dentistry, illustrated by a patient who accidentally swallowed a hexagonal wrench. The first step was to refer the patient to the medical emergency hospital service for radiographic and clinical evaluation. The hexagonal wrench was located in the stomach and was immediately removed with an endoscopic procedure. The gastric mucosa was sampled via biopsy and the sample submitted to the urease test, which was positive for Helicobacter pylori. Triple treatment was instituted for gastritis caused by H pylori to avoid exposing the patient to unnecessary risk. Removal of a foreign body by means of an endoscopic procedure constitutes a safe and effective treatment.

Food choking hazards in children

OBJECTIVES

To review the literature on pediatric food choking risks, with the long-term goal of supporting legislation regulating the production, labeling, and distribution of high-risk foods.

METHODS

A PubMed search (Keywords: choking, obstruction, asphyxiation, foreign body, food) was conducted in July-September 2010 with publication dates ranging from 1966 to 2010.

STUDY SELECTION

Articles related to pediatric foreign body aspiration (FBA) were selected by three independent reviewers. 1145 articles were initially identified. Abstracts were then screened utilizing a tool designed to isolate relevant pediatric choking events; this tool helped to only select abstracts which presented data on patients younger than 18 years of age who had choked on food items. Through this, a total of 72 pertinent articles were isolated (55 observational studies, 17 case reports/series).

DATA EXTRACTION

For each study, patient age, sex, foreign body location, presenting signs and symptoms, utility of radiographic studies, and type of foreign body detected in the majority of study participants were determined. A "majority" of patients for each study was predetermined arbitrarily to be 2/3 of the studied population.

RESULTS

The majority of patients in each observational study was determined to be: male (87% of all studies) and age <5 years (95% of all studies). Aspirated foreign bodies were mostly detected in the right main bronchus foreign body (72% of all studies), and there were abnormal radiographic signs (81% of all studies) at the time of evaluation. Food-object foreign bodies were the most frequent factors associated with choking (94% of all studies).

CONCLUSION

Childhood aspiration of food-objects is a significant public health issue. Although there is substantial legislation regulating non-food items that pose a choking hazard, equivalent guidelines do not exist for high-risk foods. Our study identifies and confirms several risk factors for pediatric FBA events. In doing so, it echoes the concerns and suggestions of various groups in supporting the development of legislation which may reduce the incidence of food-object aspiration.

The internet, adolescent males, and homemade blowgun darts: a recipe for foreign body aspiration

We describe our experience with blowgun dart aspiration via an illustrative case series and review the resources available to teach children how to construct these objects. A 15-year-old boy presented with cough, wheeze, and eventually admitted to aspiration of a homemade blowgun dart. This instance heightened the awareness of our experience with blowgun dart aspiration as 3 cases presented within a 3-month period. Patients uniformly presented with cough and reported aspiration, and wheezing was noted in 2 of the 3. Although all ultimately admitted their behavior, 2 were initially reluctant to admit aspirating the blowgun dart. Radiographic findings of a needle-shaped metallic airway foreign body were consistent in all patients. Each admitted to finding instructions for blowgun dart construction on the Internet. Emergent rigid bronchoscopy with blowgun dart removal resulted in symptom resolution in all without complication. This represents the largest series of blowgun dart aspiration to date. During deep inhalation, when preparing to propel a blowgun dart, the vocal folds maximally abduct, leading to increased risk for aspiration. Twenty websites were identified providing instructions for the construction of homemade blowgun darts. With the accessibility of the Internet and number of instructional websites, this clinical entity may become more common in the future. Unfortunately, only a few of the websites provide any safety warnings. Certainly, prompt treatment can result in good outcomes; however, serious potential complications, including death, could occur especially given the hesitance our patients showed in divulging the truth of the inciting event.

3D images based on MDCT in evaluation of patients with suspected foreign body aspiration

To evaluate the value of 3D images based on multi-detect computer tomography (MDCT) for the diagnosis and management of patients with suspected foreign bodies aspiration, and report our experience about diagnosis and management of the aforementioned patients using the 3D images, as well as detail our protocol for the management of those patients. Forty-four patients (37 children, 7 adults) with suspected foreign bodies aspiration who accepted pre-surgical examination and bronchoscopy in our hospital were included in this study. All the patients' pre-surgical 3D images based on MDCT were reconstructed and analyzed. After that all the results were compared with observations in the surgeries. Among the 37 pediatrics, 34 patients were detected with FB in their tracheobronchial system by the 3D images based on MDCT, and 3 cases were detected negative. The sensitivity of 3D images is 100 %, and the specificity is 75 %.In the adult group, all the 7 cases of FB in the tracheobronchial tree were detected by 3D images and proved by bronchoscopy. 3D images based on MDCT were proved to be a valuable method for the diagnosis of the patients with suspected FB aspiration. In the diagnosis and management of those patients, we considered that both the typical FB aspiration history and the intractable symptoms of cough should be taken as the criteria and the first step for selecting those suspected patients; then 3D images based on MDCT could be taken as the second step and as the selective criteria for those patients who should accept the rigid bronchoscopy.

Tracheobronchial aspiration of foreign bodies and rigid bronchoscopy in children

BACKGROUND

A significant proportion of cases of tracheobronchial foreign body aspiration due to life-threatening condition is observed during childhood. The aim of the present study was to describe our experience with the diagnosis and treatment of foreign body aspirations during childhood and review published literature.

METHODS

One hundred and eighty-four patients under 16 years of age with a tentative diagnosis of foreign body aspiration were retrospectively evaluated according to age, sex, patient delay symptoms at presentation, foreign body type, localization and the diagnostic and therapeutic methods used.

RESULTS

The most frequently aspirated objects were shelled nuts and seeds such as sunflower seeds, pistachio and hazelnuts. The chief symptom was cough. On physical examination, the most frequent findings were unilateral decrease of respiratory sound on the affected side with coarsening and bronchi. While 51% of cases presented a radiological finding, chest X-ray was normal in the other. All patients underwent rigid bronchoscopy under general anesthesia and a foreign body was identified in 137 (74.3%). The rigid bronchoscopy intervention was used in some cases, especially in the presence of tracheal foreign bodies of organic origin.

CONCLUSIONS

Tracheobronchial foreign body aspiration is a significant cause of childhood morbidity and mortality. Early diagnosis and treatment is of utmost importance. Rigid bronchoscopy under general anesthesia should be performed in all patients suspected of foreign body aspiration, which could minimize mortality and morbidity if performed by experienced personnel with safe methods.