Utility of multidetector CT and virtual bronchoscopy in tracheobronchial obstruction in children

Diagnostic utility of MDCT in evaluation of persistent stridor in children: Large airway causes and benefit of additional findings

OBJECTIVES

To assess the diagnostic utility of MDCT in the evaluation of persistent stridor in children for the underlying large airway causes and benefit of additional findings.

METHODS

All consecutive pediatric patients who underwent MDCT for the evaluation of persistent stridor from December 2018 to February 2020 were included. Two pediatric radiologists independently reviewed MDCT studies for the presence of abnormalities at six large airway levels: (1) nasopharynx, (2) oropharynx, (3) glottis, (4) subglottis, (5) trachea, and (6) mainstem bronchi. In addition, studies were evaluated for the presence of non-airway abnormalities. Interobserver agreement between two reviewers was evaluated with kappa statistics.

RESULTS

There were a total of 40 pediatric patients (age range: 1 day-4 years. MDCT detected large airway abnormalities in 20 (50%) out of 40 patients, including 4 (20%) in nasopharynx, 4 (20%) in glottis, 4 (20%) in trachea, 3 (15%) in subglottis, 3 (15%) in mainstem bronchi, and 2 (10%) in oropharynx. Non-airway abnormalities were seen in 13 (32.5%) children, including 9 (69%) in the lungs, 3 (23%) in the soft tissue, and 1 (8%) in the bone. The remaining 7 (17.5%) studies were normal. There was excellent interobserver agreement seen for detecting large airway and non-airway abnormalities (k > 0.90).

CONCLUSION

MDCT has high diagnostic utility in diagnosing large airway causes of persistent stridor in children. It can also provide additional information regarding non-airway abnormalities. Therefore, MDCT has the potential to be utilized as a noninvasive problem-solving imaging modality in pediatric patients with persistent stridor.

Avoiding unnecessary bronchoscopy in children with suspected foreign body aspiration using computed tomography

BACKGROUND

Bronchoscopy is the standard of care for diagnosis and treatment of foreign body aspiration (FBA). Drawbacks of this approach include its invasiveness, the potential for exacerbation of reactive airway disease, and the need for general anesthesia. Computed tomography (CT) can potentially identify patients with FBA, thereby avoiding unnecessary bronchoscopies in patients with at-risk reactive airways.

METHODS

A retrospective review was performed to identify patients who underwent CT and/or bronchoscopy for suspected foreign body aspiration (FBA) from June 2012 to September 2018. Variables included clinical history, exam findings, radiographic findings, and operative findings. A telephone survey was performed for patients who had a CT without bronchoscopy. Three radiologists performed rereads of all CTs.

RESULTS

A total of 133 patients were evaluated for FBA, and 84 were treated with bronchoscopy. For those with a CT demonstrating a foreign body, findings were confirmed on bronchoscopy in 17/18 (94.4%). For those with bronchoscopy alone, 39/64 (60.9%) were found to have a foreign body (p < 0.01). CT excluded FBA in 49 patients. Sensitivity was 100%, specificity was 98%, and interobserver reliability was excellent (κ = 0.88).

CONCLUSION

CT is an accurate and reliable diagnostic tool in the evaluation of FBA that can increase the rate of positive bronchoscopy.

TYPE OF STUDY

Retrospective comparative study.

LEVEL OF EVIDENCE

Level III.

A comparison of virtual bronchoscopy versus flexible bronchoscopy in the diagnosis of tracheobronchomalacia in children

INTRODUCTION

Flexible bronchoscopy (FB) is the current gold standard for diagnosing tracheobronchomalacia. However, it is not always feasible and virtual bronchoscopy (VB), acquired from chest multi-detector CT (MDCT) scan is an alternative diagnostic tool. We determined the sensitivity, specificity, and positive and negative predictive values of VB compared to FB in diagnosing tracheobronchomalacia.

METHODS

Children aged <18-years scheduled for FB and MDCT were recruited. FB and MDCT were undertaken within 30-min to 7-days of each other. Tracheobronchomalacia (mild, moderate, severe, very severe) diagnosed on FB were independently scored by two pediatric pulmonologists; VB was independently scored by two pairs (each pair = pediatric pulmonologist and radiologist), in a blinded manner.

RESULTS

In 53 children (median age = 2.5 years, range 0.8-14.3) evaluated for airway abnormalities, tracheomalacia was detected in 37 (70%) children at FB. Of these, VB detected tracheomalacia in 20 children, with a sensitivity of 54.1% (95%CI 37.1-70.2), specificity = 87.5% (95%CI 60.4-97.8), and positive predictive value = 90.9% (95%CI 69.4-98.4). The agreement between pediatric pulmonologists for diagnosing tracheomalacia by FB was excellent, weighted κ = 0.8 (95%CI 0.64-0.97); but only fair between the pairs of pediatric pulmonologists/radiologists for VB, weighted κ = 0.47 (95%CI 0.23-0.71). There were 42 cases of bronchomalacia detected on FB. VB had a sensitivity = 45.2% (95%CI 30.2-61.2), specificity = 95.5% (95%CI 94.2-96.5), and positive predictive value = 23.2 (95%CI 14.9-34.0) compared to FB in detecting bronchomalacia.

CONCLUSION

VB cannot replace FB as the gold standard for detecting tracheobronchomalacia in children. However, VB could be considered as an alternative diagnostic modality in children with symptoms suggestive of tracheobronchomalacia where FB is unavailable. Pediatr Pulmonol. 2017;52:480-486. © 2016 Wiley Periodicals, Inc.

Recurrent Pneumonia in Children: A Reasoned Diagnostic Approach and a Single Centre Experience

Recurrent pneumonia (RP), i.e., at least two episodes of pneumonia in one year or three episodes ever with intercritical radiographic clearing of densities, occurs in 7.7%–9% of children with community-acquired pneumonia. In RP, the challenge is to discriminate between children with self-limiting or minor problems, that do not require a diagnostic work-up, and those with an underlying disease. The aim of the current review is to discuss a reasoned diagnostic approach to RP in childhood. Particular emphasis has been placed on which children should undergo a diagnostic work-up and which tests should be performed. A pediatric case series is also presented, in order to document a single centre experience of RP. A management algorithm for the approach to children with RP, based on the evidence from a literature review, is proposed. Like all algorithms, it is not meant to replace clinical judgment, but it should drive physicians to adopt a systematic approach to pediatric RP and provide a useful guide to the clinician.

Application of the Virtual Bronchoscopy in Children with Suspected Aspiration of the Foreign Body - Case Report

In diagnosing the aspiration of the foreign body (AFB) in children most important are: medical history, clinical signs and positive radiography of the lungs. Common dilemmas in the diff erential diagnosis are life-threatening asthma attacks or difficult pneumonia. Conventional rigid bronchoscopy (RB) is not recommended as a routine method. Virtual bronchoscopy (VB) can be a diagnostic tool for solving dilemmas. Fiber-optic bronchoscopy (FOB) has a therapeutic stake in severe cases. Herein, we describe a girl, at the age of 6, who was hospitalized due to rapid bronchoconstriction and based on the anamnesis, clinical symptoms and physical fi ndings the suspicion was that she aspirated the foreign body. Due to the poor general condition and possible sequel, the idea of RB was dropped out. Multidetector computed tomography of the chest and VB was performed and AFB was not found. Due to positive epidemiological situation, virus H1N1 was excluded. FOB established that the foreign body does not exist in the airways. During bronchoscopy numerous castings are aspirated from the peripheral airways which lead to faster final recovery. With additional procedures, the diagnosis of asthma was confirmed and for girl that was the first attack. Along with inhaled corticosteroids as prevention she feels well.

Virtual bronchoscopy can be successfully used as a valid diagnostic procedure in suspected foreign body in the children’s lungs, but fiber-optic bronchoscopy remains most important diagnostic and therapeutic method.

Role of Computed Tomography in Pediatric Chest Conditions

CT is the preferred cross-sectional imaging modality for detailed evaluation of anatomy and pathology of the lung and tracheobronchial tree, and plays a complimentary role in the evaluation of certain chest wall, mediastinal, and cardiac abnormalities. The article provides an overview of indications and different types of CT chest, findings in common clinical conditions, and briefly touches upon the role of each team member in optimizing and thus reducing radiation dose.

Reducing the number of rigid bronchoscopies performed in suspected foreign body aspiration cases via the use of chest computed tomography: is it safe? A literature review

BACKGROUND

Foreign body aspiration is common and potentially life threatening. Although rigid bronchoscopy has the potential for serious complications, it is the 'gold standard' of diagnosis. It is used frequently in light of the inaccuracy of clinical examination and chest radiography. Computed tomography is proposed as a non-invasive alternative to rigid bronchoscopy.

OBJECTIVE

This study aimed to evaluate the accuracy and safety of computed tomography used in the diagnosis of suspected foreign body aspiration, and compare this with the current gold standard, in order to examine the possibility of using computed tomography to reduce the number of diagnostic rigid bronchoscopies performed.

METHOD

The study comprised a review of literature published from 1970 to 2013, using the PubMed, Scopus, Web of Knowledge, Embase and Medline electronic databases.

RESULTS

The sensitivity for computed tomography ranged between 90 and 100 per cent, with four studies demonstrating 100 per cent sensitivity. Specificity was between 75 and 100 per cent. Radiation exposure doses averaged 2.16 mSv.

CONCLUSION

Computed tomography is a sensitive and specific modality in the diagnosis of foreign body aspiration, and its future use will reduce the number of unnecessary rigid bronchoscopies.

What all physicians should know about the potential radiation risk that computed tomography poses for paediatric patients

The repeated use of CT imaging raises a child's radiation exposure, overall radiation accrual and future cancer risks. However, our review suggests that these risks can be considerably reduced by physicians, radiologists and academic bodies, through proper justification, optimisation and dose limitation.

CONCLUSION

Computed tomography poses a potential risk of radiation-induced cancer in children. The physician must weigh up the overall risks and benefits of CT before referring a child for imaging.

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).

Virtual bronchoscopy in the era of multi-detector computed tomography: Is there any reality?

Virtual bronchoscopy, in conjunction with axial and MPR MDCT images, can enhance diagnostic accuracy of tracheo-bronchial endoluminal pathologies. We describe a few cases highlighting the utility of virtual bronchoscopy in the diagnosis of varied tracheo-bronchial pathologies encountered in the setting of a tertiary care Armed Forces Hospital of India.

Technical developments in postprocessing of paediatric airway imaging

CT postprocessing allows more scan information to be viewed at one time allowing an accurate diagnosis to be made more efficiently, and is particularly important in paediatric practice where invasive clinical diagnostic tools can be replaced or at least assisted by modern postprocessing techniques. Four visualization techniques in clinical use are described in this paper including the advantages and disadvantages of each: multiplanar reformation, maximum and minimum intensity projections, shaded surface display and volume rendering. Volume-rendered internal visualization in the form of virtual endoscopy is also discussed. In addition, the clinical usefulness in paediatric practice of demonstrating airway compression and its causes are discussed. Advanced postprocessing techniques that must still find their way from the biomedical research environment into clinical use are introduced with specific reference to computer-aided diagnosis.

Recurrent lower respiratory tract infections in children: a practical approach to diagnosis

Many children are affected by recurrent lower respiratory tract infections (LRTIs), but the majority of them do not suffer from serious lung or extrapulmonary disease. The challenge for clinicians is to distinguish the recurrent RTIs with self-limiting or minor problems from those with underlying disease. The aim of this review is to describe a practical approach to children with recurrent LRTIs that limits unnecessary, expensive and time-consuming investigations. The children can be divided into three groups on the basis of their personal and family history and clinical findings: 1) otherwise healthy children who do not need further investigations; 2) those with risk factors for respiratory infections for whom a wait-and-see approach can be recommended; and 3) those in whom further investigations are mandatory. However, regardless of the origin of the recurrent LRTIs, it is important to remember that prevention by means of vaccines against respiratory pathogens (i.e. type b Haemophilus influenzae, pertussis, pneumococcal and influenza vaccines) can play a key role.

Diagnosis and treatment of tracheobronchial foreign bodies in 1024 children

OBJECTIVE

This study sought to summarize the experience of diagnosis and treatment of tracheobronchial foreign bodies in children to effectively reduce complications and mortality.

METHODS

The medical records of 1024 pediatric patients admitted to our hospital from January 1997 to September 2011 and diagnosed with clinically suspected tracheobronchial foreign body aspiration were retrospectively analyzed.

RESULTS

Of the 1024 children patients, 674 were boys (65.8%) and 350 girls (34.2%). Two died of respiratory and circulatory failure (foreign bodies detected upon bronchoscopy but not retrieved) before surgery, 65 patients underwent direct bronchoscopic removal of foreign bodies due to their critical status, and 957 received chest radiographs and chest fluoroscopy or multidetector spiral computed tomographic scans (941 positive). Foreign bodies were expectorated before surgery in 3 cases. There were 953 cases of bronchoscopically proven airway foreign body aspiration, with a diagnostic accuracy of 94.5%. Ninety-eight foreign bodies were lodged in the main bronchus and/or bilateral bronchi, 506 in the right main bronchus, and 349 in the left main bronchus. Atelectasis was noted in 42 patients, including 11 with pulmonary consolidation, whose lungs were re-expanded by endobronchial lavage and sputum aspiration. In 3 patients with bronchiectasis, conservative treatment following foreign body removal was followed by no improvement, and pulmonary lobectomy was performed. Foreign bodies were successfully extracted at the first bronchoscopic attempt in 948 cases, accounting for 99.7% of the total. However, 3 patients had to undergo another bronchoscopy to remove the foreign bodies. The most common types of foreign bodies were peanuts, melon seeds, and beans.

CONCLUSIONS

Timely accurate diagnosis and treatment of tracheobronchial foreign bodies in children can avoid delay in treatment and effectively reduce complications and mortality.

Multi detector CT Imaging of Abdominal and Diaphragmatic Hernias: Pictorial Essay

Diagnosis of abdominal wall hernia is often a clinical problem, especially in occult or in obese patients. Multidetector CT is an accurate method of detecting various types of abdominal and diaphragmatic hernias. It clearly demonstrates the anatomical sites of hernial sac, its contents and possible complications.

The value of preoperative CT scan in newborns with type C esophageal atresia

PURPOSE

This study was designed to evaluate the accuracy of preoperative CT scan in depicting the structure of type C esophageal atresia (EA) and determine its role in planning the surgical strategy by digitally measuring the interpouch distance.

METHODS

Thirty-five neonates (20 males, 15 females) born with type C EA were enrolled in this study. A helical CT scan was performed after chest radiographs of the neonates with a coiled oroesophageal tube in the upper esophageal pouch. The interpouch distances measured on CT images were compared with the findings at surgery.

RESULTS

With the use of helical CT scan, the structure of EA-TEF was accurately depicted; the origins of the fistula and the interpouch distance were defined. The interpouch distance detected by CT scan correlated well with the findings at surgery. Statistical analysis demonstrated no significant difference (R = 0.99, P < 0.001). CT scan findings were crucial in planning the surgical strategy in 14 patients (40%).

CONCLUSION

Preoperative CT scan could provide more accurate information about the origin of the fistula and the interpouch distance in type C EA and played a crucial role in planning the surgical strategy.

Multidetector computed tomography of pediatric large airway diseases: state-of-the-art

Advances in multidetector computed tomography (MDCT) technology have given rise to improvements in the noninvasive and comprehensive assessment of the large airways in pediatric patients. Superb two-dimensional and three-dimensional reconstruction MDCT images have revolutionized the display of large airways and enhanced the ability to diagnose large airway diseases in children. The 320-MDCT scanner, which provides combined detailed anatomic and dynamic functional information assessment of the large airways, is promising for the assessment of dynamic large airway disease such as tracheobronchomalacia. This article discusses imaging techniques and clinical applications of MDCT for assessing large airway diseases in pediatric patients.