Foreign body aspirations in children and adults

Cluster analysis of symptoms and assessment of caregiver reports in pediatric foreign bodies

Foreign body (FB) ingestion and aspiration are frequent causes of pediatric emergency room visits, with significant morbidity and mortality risks. This cross-sectional study analyzed 1,052 pediatric patients admitted for suspected FB events at a single institution between 2008 and 2015, including 886 cases of suspected ingestion and 166 cases of suspected aspiration. Cluster analysis identified three distinct clusters for both groups, with respiratory symptoms being predominant in clusters with worse outcomes. The respiratory clusters were associated with increased complication rates (13.0% for aspiration, 3.6% for ingestion) and all mortalities (three in aspiration and two in ingestion). In ingestion cases, Respiratory Cluster patients showed increased complications, prolonged hospital stays (mean 55.1 h), and accounted for all mortalities, a relationship not previously reported. Caregiver-reported certainty of event occurrence showed moderate sensitivity (72.5%) and low specificity (45.4%) for aspiration, and higher sensitivity (86.8%) with lower specificity (19.8%) for ingestion. Decision Curve Analysis revealed a net benefit in utilizing caregiver certainty for clinical decision-making. Confirmatory radiographic findings were commonly observed in ingestion cases (84.2%) than in aspiration cases (37.7%), likely due to the higher incidence of metal ingestions compared to mostly organic aspirations. Endoscopic management had high success rates (97.6%), and low mortality, highlighting its central role in FB treatment. These findings underscore the importance of assessing respiratory symptom severity within the broad clinical spectrum of FBs to identify patients at risk of worse clinical outcomes, which helps prioritize resources when necessary. Caregiver-reported information has been shown to be valuable in guiding diagnostic decisions.

The characteristics of occult foreign body aspiration and predicting factors in children

OBJECTIVE

To summarize the clinical characteristics and risk factors of occult foreign body aspiration (FBA) in children, which can help with early diagnosis and timely intervention, potentially preventing further exacerbations.

METHODS

We retrospectively analyzed the clinical data of the children with a final diagnosis of FBA by flexible bronchoscopy in our hospital from 2017 to 2023. The patients were divided into occult and typical groups, and two groups were compared. Multivariate binary logistic regression analysis was employed to identify risk factors associated with the occurrence of occult FBA.

RESULTS

Among 1031 patients, the incidence of occult FBA was 4.3 % (44 cases). Compared to the typical group, children in the occult group had higher odds of ventilator management (P = .006) and longer postoperative hospitalization time (P < .001). Risk factors for predicting occult FBA were identified as age greater than 3 years old [OR: 6. 918; 95%CI (3.150-15.191)], fever [OR: 2.323; 95%CI (1.092-4.939)], inspiratory laryngeal stridor [OR: 6.514; 95%CI (1.863-22.781)], atelectasis [OR: 3.372; 95%CI (1.418-8.020)], and infiltration [OR: 2.749; 95%CI (1.195-6.323)].

CONCLUSIONS

Unlike typical FBA, the diagnosis of occult FBA is far more challenging, and occult foreign bodies are linked to a further exacerbation. This study identifies a few risk factors that have the potential to facilitate an early diagnosis of occult FBA in children. Further multicenter studies should be conducted to validate the findings.

Capsule endoscopy aspiration and respiratory physician's treatment insights: a case report and literature review

Background

Capsule endoscopy (CE) is widely used for intestinal examination; however, capsule aspiration into the airway is a serious complication that requires urgent intervention. We present a management case report and review 39 cases from 2003 to 2023, providing insights into the prevention and treatment of capsule aspiration.

Case presentation

A 69-year-old man with chronic bronchitis and emphysema presented with 7 months of intermittent melena. After swallowing a capsule endoscope (PillCam™ SB 3), he had a brief cough and chest tightness. Imaging confirmed aspiration in the right intermediate bronchus, and non-invasive removal procedures were unsuccessful.

Methods

Real-time imaging confirmed the lodged capsule. Non-invasive methods, such as coughing and chest percussion, were unsuccessful. Therefore, flexible bronchoscopy was performed under general anesthesia to retrieve the capsule using a snare, which was then placed into the duodenum using a gastroscope.

Results

The capsule was successfully retrieved, and the patient recovered well, completing the endoscopy without further issues.

Conclusion

Our case study and literature review highlight the need for careful attention to high-risk groups in CE, including the elderly and individuals with neurological or swallowing difficulties. A thorough history review and real-time monitoring are essential for preventing complications. Bronchoscopy is preferred for CE retrieval due to its advantages. Manufacturers are urged to improve CE safety, with respiratory physicians helping internists in managing this potentially life-threatening complication.

The Impact of Deep Learning on Determining the Necessity of Bronchoscopy in Pediatric Foreign Body Aspiration: Can Negative Bronchoscopy Rates Be Reduced?

INTRODUCTION

This study aimed to evaluate the role of deep learning methods in diagnosing foreign body aspiration (FBA) to reduce the frequency of negative bronchoscopy and minimize potential complications.

METHODS

We retrospectively analysed data and radiographs from 47 pediatric patients who presented to our hospital with suspected FBA between 2019 and 2023. A control group of 63 healthy children provided a total of 110 PA CXR images, which were analysed using both convolutional neural network (CNN)-based deep learning methods and multiple logistic regression (MLR).

RESULTS

CNN-deep learning method correctly predicted 16 out of 17 bronchoscopy-positive images, while the MLR model correctly predicted 13. The CNN method misclassified one positive image as negative and two negative images as positive. The MLR model misclassified four positive images as negative and two negative images as positive. The sensitivity of the CNN predictor was 94.1 %, specificity was 97.8 %, accuracy was 97.3 %, and the F1 score was 0.914. The sensitivity of the MLR predictor was 76.5 %, specificity was 97.8 %, accuracy was 94.5 %, and the F1 score was 0.812.

CONCLUSION

The CNN-deep learning method demonstrated high accuracy in determining the necessity for bronchoscopy in children with suspected FBA, significantly reducing the rate of negative bronchoscopies. This reduction may contribute to fewer unnecessary bronchoscopy procedures and complications. However, considering the risk of missing a positive case, this method should be used in conjunction with clinical evaluations. To overcome the limitations of our study, future research with larger multi-center datasets is needed to validate and enhance the findings.

TYPE OF STUDY

Original article.

LEVEL OF EVIDENCE

III.

Progress in the Application of Bronchoscopic Cryotherapy in Pediatric Pulmonary Diseases

Cryotherapy in interventional bronchoscopy is a new treatment modality which has recently been made available for the pediatric airway. Lack of experience and safety concerns have led to hesitant adaptation. The aim of this work was to elaborate on the application progress of cryotherapy in pediatric pulmonary diseases and also to assess indications, success rates, and complications of airway cryotherapy in children. In summary, cryotherapy via flexible bronchoscopy is a safe and feasible method. The application scope in pediatrics is similar to that in adults, and it is mainly used in airway obstructive diseases. However, it is primarily caused by benign conditions, and the interventional treatment mainly seeks to provide long-lasting symptomatic alleviation. Thus, prevention, treatment, and prognosis of long-term complications are issues that should be carefully considered in pediatric applications.

Fatal Iron Tablet Aspiration: Importance of Early Diagnosis and Forensic Pathologist Awareness

ABSTRACT

Pill aspiration is a significant source of foreign body aspiration in the United States and can occur without swallowing dysfunction or illness. Consequences depend on various factors, such as the pill's chemical composition, size, and diagnostic delay. Aspiration of iron tablets poses a higher risk because of hydroxyl radical formation and subsequent caustic burns, inflammation, obstruction, and/or necrosis. We present a case of a middle-aged obese woman who died 3 weeks after aspirating an iron tablet. Autopsy revealed morbid obesity, a necrotic focus in the right middle lobe of the lung, bronchiolar granulation tissue with iron staining foreign matter, extending into an adjacent arteriole, and mural perforation of the hilar right middle lobe. Despite seeking medical attention twice, the patient was only accurately diagnosed postmortem. This case highlights the importance of accurate and timely diagnosis in preventing fatal outcomes. To enhance diagnostic accuracy and reduce morbidity and mortality associated with pill aspiration, clinicians should maintain a high level of suspicion for foreign body aspiration in patients with persistent or worsening respiratory symptoms. Furthermore, it is crucial for forensic pathologists to have a high index of suspicion about the potential for lethal pill aspiration and complications days after the acute event.

Clinical characteristics and removal approaches of tracheal and bronchial foreign bodies in elders

The symptoms of tracheobronchial foreign body in the elderly are not typical, so they are often missed or misdiagnosed. This study aims to depict the clinical characteristics of tracheobronchial foreign body inhalation in the elderly. We retrospectively analysed the clinical data of elder patients (age ≥ 65 years) diagnosed with tracheal and bronchial foreign bodies. The data included age, sex, clinical symptoms, type and location of foreign bodies, prehospital duration, Chest CT, bronchoscopic findings, and frequencies and tools for removing these elderly patients' tracheal and bronchial foreign bodies. All patients were followed up for a half year. Fifty-nine cases were included, of which only 32.2% had a definite aspiration history. Disease duration > 30 days accounted for 27.1% of the patients. 27.1% of the patients had a history of stroke, and 23.8% had Alzheimer's Disease. Regarding clinical symptoms, patients mainly experience cough and expectoration. The most common CT findings were abnormal density shadow (37.3%) and pulmonary infiltration (22.0%). Under bronchoscopy, purulent secretions were observed in 52.5% of patients, and granulation tissue hyperplasia was observed in 45.8%. Food (55.9%) was the most common foreign object, including seafood shells (5.1%), bones (20.3%), dentures (18.6%), and tablets (20.3%). The success rate of foreign body removal under a bronchoscope was 96.7%, 28.8% of the foreign bodies were on the left and 69.5% on the right. 5.1% of the elderly patients required rigid bronchoscopy, and 6.8% required two bronchoscopies. In elderly cohorts, tracheal foreign bodies are obscured by nonspecific clinical presentations and a paucity of aspiration history, challenging timely diagnosis. Predominantly constituted by food particles, with a notable predilection for the left bronchial tree, these cases demand skilled bronchoscopic management, occasionally requiring sophisticated approaches for successful extraction.

Lung function responses to cold water ingestion: A randomised controlled crossover trial

This study tested the hypothesis that cold water ingestion would reduce lung function and thereby confound its measurement in a way that is mediated by both temperature and volume. In a randomised crossover trial, 10 healthy adults performed spirometry before and 5, 10, 15, and 30-minutes after consuming one-of-four drinks: 500 mL or 1000 mL refrigerated water (∼2 °C); identical water volumes at ambient temperature (∼18 °C). Ingesting 1000 mL cold water significantly reduced forced vital capacity (FVC) for at least 10 min (mean difference =0.28 L, p < 0.05, d=1.19) and forced expiratory volume in 1 s (FEV1) for at least 15 min (0.20-0.30 L, p < 0.05, d=1.01). Ingesting 500 mL cold water reduced FEV1 for 5 min (0.09 L, p < 0.05, d=1.05). Room-temperature water had no influence on lung function. To avoid confounding the measurement of lung function, we conclude that individuals should avoid drinking cold water, especially in large volumes, immediately prior to a given test.

Foreign Body Aspiration in Children-Retrospective Study and Management Novelties

Foreign body aspiration (FBA) is a frequent diagnosis in children. In the absence of other lung conditions, such as asthma or chronic pulmonary infections, this manifests as a sudden onset of cough, dyspnea, and wheezing. The differential diagnosis is based on a scoring system which takes into account the clinical picture as well as the radiologic aspects. The treatment that is considered the gold-standard for FBA in children remains to be rigid fibronchoscopy, however it comes with several potentially crucial local complications such as airway edema, bleeding, and bronchospasm, along inherent issues due to general anesthesia. Material and methods: Our study is a retrospective study analyzing the medical files of the cases from our hospital over the span of 9 years. The study group consisted of 242 patients aged 0-16 years diagnosed with foreign body aspiration in the Emergency Clinical Hospital for Children "Sfânta Maria" Iași, between January 2010-January 2018. Clinical and imaging data were extracted from the patients' observation sheets. Results: In our cohort, the distribution of children with foreign body aspiration was uneven, with the highest incidence being reported in children from rural areas (70% of cases), whereas the most affected age group was 1-3 years, amounting to 79% of all cases. The main symptoms which led to emergency admittance were coughing (33%) and dyspnea (22%). The most important factors that determined the unequal distribution were socio-economic status, which relates to a lack of adequate supervision by parents, as well as the consumption of food inappropriate for their age. Conclusions: Foreign body aspiration is a major medical emergency that may be associated with dramatic clinical manifestations. Several scoring algorithms designed to establish the need for bronchoscopy have been proposed, taking into account both the clinical and radiological results. The issue with asymptomatic or mild symptomatic cases, as well as difficulties managing cases with radiolucent foreign bodies, remains a challenge.

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.

A Case of Occult Pistachio-Shell Endobronchial Foreign Body Causing Recurrent Pneumonia

Endobronchial foreign body aspiration is a rare occurrence in adults, with a higher incidence in children. However, the possibility of such foreign body aspiration should not be overlooked in adult patients presenting with recurrent pneumonia symptoms, particularly when antibiotic treatment is ineffective. The diagnosis of occult endobronchial foreign body aspiration is challenging and requires a high degree of clinical suspicion, as it may not be associated with a history of aspiration. In this report, we present a case of recurrent pneumonia persisting for over two years, which was eventually diagnosed as an endobronchial foreign body due to occult pistachio shell aspiration. The foreign body was successfully removed through bronchoscopy. The diagnostic workup for recurrent pneumonia, including imaging and bronchoscopy, and the therapeutic management of endobronchial foreign body aspiration are discussed in detail. This case highlights the importance of considering endobronchial foreign body aspiration as a potential diagnosis in adult patients presenting with recurrent pneumonia, even in the absence of a history of aspiration. Early recognition and prompt intervention can prevent potential complications, including bronchiectasis, atelectasis, and respiratory failure.

Foreign Body Aspiration Mimicking an Endobronchial Neoplasm: A Case Report and Review of the Literature

Foreign body aspiration (FBA) is infrequently encountered in the adult population, with major risk factors including advancing age, intoxication, and disorders of the central nervous system. Here, we present a case of FBA in an adult undergoing routine lung cancer screening to review imaging findings and highlight potential pitfalls for the practicing radiologist. A low-dose chest computed tomography (CT) scan was performed for lung cancer screening in a 57-year-old male with a one-month history of worsening dyspnea and cough. An endobronchial lesion was identified in the right bronchus intermedius. A follow-up 18F-fluorodeoxyglucose positron emission tomography-computed tomography (18F-FDG PET-CT) revealed hypermetabolic activity in the region of interest, raising concern for malignancy. Bronchoscopy was performed, revealing a nodular mass adjacent to a foreign body in the bronchus intermedius. Histopathologic analysis of the tissue sample revealed the presence of an aspirated foreign body with squamous metaplasia of the respiratory epithelium. Adult FBA is an uncommon clinical entity that may be incidentally observed on a screening chest CT. Relevant multimodality imaging findings are discussed here, along with a review of the accompanying pathologic changes seen with chronic airway impaction.

Risk factors associated with radiolucent foreign body inhalation in adults: a 10-year retrospective cohort study

BACKGROUND

Foreign body aspiration (FBA) is a serious condition with high morbidity and mortality rates. Although chest radiography is generally the first radiologic modality used in diagnosis, a substantial percentage of foreign bodies are radiolucent in adults with diagnosis challenging.

METHODS

Retrospective review of adult patients with FBA diagnosed by flexible electronic bronchoscopy from 2012 to 2022 collecting demographics, history, hospital presentation, radiographic, and operative details. Risk factors associated with radiolucent foreign body inhalation in adults were explored using appropriate statistical methods.

RESULTS

Between 1 January 2012 and 1 January 2022, 114 adult patients diagnosed with FBA were enrolled. The median age of participants was 65 years (IQR 52-74). Multidetector computed tomography (MDCT) examinations identified 28 cases (25%) showing direct visualization of the foreign body (defined as the radiopaque group) and 86 cases (75%) in the radiolucent group. Multivariable stepwise linear regression analysis showed increased odds of radiolucent foreign body inhalation in adults associated with pneumonic patches in MDCT (OR 6.99; 95% CI 1.80-27.22; P = 0.005) and plants/meat foreign bodies (OR 6.17; 95% CI 1.12-33.96; P = 0.04). A witnessed choking history (OR 0.02; 95% CI 0-0.14; P < 0.001) was a protective factor of radiolucent foreign body inhalation in adults.

CONCLUSIONS

Unlike radiopaque FBA, in those presenting with a suspected radiolucent foreign body aspiration, the diagnosis is far more challenging. Risk factors such as lacking a choking history, non-resolving pneumonia (pneumonic patches) in MDCT findings, and plants/meat foreign bodies may help in the early diagnosis of radiolucent foreign body inhalation in adults. Further prospective multicenter studies should be conducted to validate the findings.