Safely Decreasing Rigid Bronchoscopies for Foreign-Body Aspiration in Children: An Algorithm for the Emergency Department

Abstract

Introduction Rigid bronchoscopy was traditionally performed in the management of foreign-body aspiration (FBA). More recently, since development of a less invasive method, flexible bronchoscopy has been proposed in some centers for the management of FBA. For the past few years, we have applied a decisional algorithm, privileging flexible bronchoscopy for diagnosis and, in some cases, for extraction of foreign body (FB). Our aims are first to analyze our current management of FBA and second to examine the bronchoscopic findings and complications.

Materials and Methods Retrospective medical chart review of all patients with clinical suspicion of FBA who underwent bronchoscopy (flexible and/or rigid) from 2009 through 2014.

Results An FB was found in 23 (33%) of the 70 patients included in the study (45 boys, 25 girls; median age: 21.5 months). Diagnosis of FBA was made on first intention in 22/23 (96%) and extraction was performed in 7/23 (30%) by flexible bronchoscopy. Rigid bronchoscopy was necessary for the extraction of the 16/23 (70%) remaining FBs. The rigid procedure was performed as first intention in only two (3%) patients, and one of the two was negative. Among the clinical signs of FBA, none were > 90% specific except for apnea (100%), but which was poorly sensitive (22%). Seven clinical and radiologic signs were found to be significantly different between FB+ and FB− groups: sudden choking, cyanosis, apnea, decreased breath sounds, atelectasis, mediastinal shift, and air trapping. Conversely, when none of these symptoms or signs and no clear history of sudden choking were present (in 15/70 patients), no FB was found. No life-threatening complications or death were observed.

Conclusion Our current management of FBA allows us to avoid almost all negative rigid bronchoscopies. In addition, we identified some symptoms and clinical and radiologic signs whose absence was highly predictive of negative bronchoscopy. We propose a novel algorithm for management of FBA that will help decrease the number of negative bronchoscopies.

Keywords

child - foreign body - aspiration - management - flexible bronchoscopy

• References

• 1 From the Centers for Disease Control and Prevention. Nonfatal choking-related episodes among children—United States, 2001. JAMA 2002; 288 (19) 2400-2402
• 2 Korlacki W, Korecka K, Dzielicki J. Foreign body aspiration in children: diagnostic and therapeutic role of bronchoscopy. Pediatr Surg Int 2011; 27 (08) 833-837
• 3 Fidkowski CW, Zheng H, Firth PG. The anesthetic considerations of tracheobronchial foreign bodies in children: a literature review of 12,979 cases. Anesth Analg 2010; 111 (04) 1016-1025
• 4 Righini CA, Morel N, Karkas A. , et al. What is the diagnostic value of flexible bronchoscopy in the initial investigation of children with suspected foreign body aspiration?. Int J Pediatr Otorhinolaryngol 2007; 71 (09) 1383-1390
• 5 Kiyan G, Gocmen B, Tugtepe H, Karakoc F, Dagli E, Dagli TE. Foreign body aspiration in children: the value of diagnostic criteria. Int J Pediatr Otorhinolaryngol 2009; 73 (07) 963-967
• 6 Orji FT, Akpeh JO. Tracheobronchial foreign body aspiration in children: how reliable are clinical and radiological signs in the diagnosis?. Clin Otolaryngol 2010; 35 (06) 479-485
• 7 Heyer CM, Bollmeier ME, Rossler L. , et al. Evaluation of clinical, radiologic, and laboratory prebronchoscopy findings in children with suspected foreign body aspiration. J Pediatr Surg 2006; 41 (11) 1882-1888
• 8 Cohen S, Avital A, Godfrey S, Gross M, Kerem E, Springer C. Suspected foreign body inhalation in children: what are the indications for bronchoscopy?. J Pediatr 2009; 155 (02) 276-280
• 9 Ayed AK, Jafar AM, Owayed A. Foreign body aspiration in children: diagnosis and treatment. Pediatr Surg Int 2003; 19 (06) 485-488
• 10 Oncel M, Sunam GS, Ceran S. Tracheobronchial aspiration of foreign bodies and rigid bronchoscopy in children. Pediatr Int 2012; 54 (04) 532-535
• 11 Black RE, Johnson DG, Matlak ME. Bronchoscopic removal of aspirated foreign bodies in children. J Pediatr Surg 1994; 29 (05) 682-684
• 12 Cavel O, Bergeron M, Garel L, Arcand P, Froehlich P. Questioning the legitimacy of rigid bronchoscopy as a tool for establishing the diagnosis of a bronchial foreign body. Int J Pediatr Otorhinolaryngol 2012; 76 (02) 194-201
• 13 Swanson KL, Prakash UBS, Midthun DE. , et al. Flexible bronchoscopic management of airway foreign bodies in children. Chest 2002; 121 (05) 1695-1700
• 14 Martinot A, Closset M, Marquette CH. , et al. Indications for flexible versus rigid bronchoscopy in children with suspected foreign-body aspiration. Am J Respir Crit Care Med 1997; 155 (05) 1676-1679
• 15 Tang LF, Xu YC, Wang YS. , et al. Airway foreign body removal by flexible bronchoscopy: experience with 1027 children during 2000–2008. World J Pediatr 2009; 5 (03) 191-195
• 16 Skoulakis CE, Doxas PG, Papadakis CE. , et al. Bronchoscopy for foreign body removal in children. A review and analysis of 210 cases. Int J Pediatr Otorhinolaryngol 2000; 53 (02) 143-148
• 17 Ciftci AO, Bingöl-Koloğlu M, Şenocak ME, Tanyel FC, Büyükpamukçu N. Bronchoscopy for evaluation of foreign body aspiration in children. J Pediatr Surg 2003; 38 (08) 1170-1176
• 18 Pinzoni F, Boniotti C, Molinaro SM, Baraldi A, Berlucchi M. Inhaled foreign bodies in pediatric patients: review of personal experience. Int J Pediatr Otorhinolaryngol 2007; 71 (12) 1897-1903
• 19 Tokar B, Ozkan R, Ilhan H. Tracheobronchial foreign bodies in children: importance of accurate history and plain chest radiography in delayed presentation. Clin Radiol 2004; 59 (07) 609-615
• 20 Kadmon G, Stern Y, Bron-Harlev E, Nahum E, Battat E, Schonfeld T. Computerized scoring system for the diagnosis of foreign body aspiration in children. Ann Otol Rhinol Laryngol 2008; 117 (11) 839-843
• 21 Hitter A, Karkas A, Schmerber S, Righini CA. Rigid bronchoscopy. Progr Respir Res 2010; 38: 83-94