Cent. Eur. J. Med. • 9(5) • 2014 • 648-652 DOI: 10.2478/s11536-013-0337-4

Central European Journal of Medicine

Diagnosis of paediatric airway foreign body: is it easy? Research Article

Beata Rybojad*1,2, Grażyna Niedzielska3, Ewa Rudnicka-Drożak2 1 Department of Anaesthesiology and Intensive Care, Children’s University Hospital of Lublin, 20-093 Lublin, Poland; 2 Department of Expert Medical Assistance with Emergency Medicine Unit, Medical University of Lublin 20-081 Lublin, Poland 3 Chair and Department of Paediatric Otorhinolaryngology, Phoniatrics and Audiology, Medical University of Lublin, 20-093 Lublin, Poland.

Received 11 June 2013; Accepted 6 December 2013

Abstract:  Foreign-body aspiration in children results in diagnostic problems, mainly because of nonspecific signs. Therefore, in this study, we  placed particular stress on false-positive and -negative predictors.  Charts of 139 consecutive paediatric patients aged 6.0 months  to 15.5 years who underwent bronchoscopy for a suspected foreign body aspiration were analysed retrospectively. A foreign body  was found in 95 cases (68%). The anamnesis was positive in 91%. Cough was the most common clinical symptom (91%) with a  sensitivity and specificity of 94% and 23%, respectively. There were no significant correlations between clinical symptoms and the  locations of foreign bodies. The majority of focal hyperinflation (24%) and atelectasis (15%) were seen in chest radiographs, with a  sensitivity and specificity of 33% and 89% (hyperinflation) and 15% and 82% (atelectasis), respectively. Chest X-rays were normal in  46 cases; however, an object was removed in 25. Persistent infiltrates were present in 14 X-rays, and a foreign body was extracted  during bronchoscopy in 4. A highly significant correlation between the type of foreign body and radiological signs was noted (p  = 0.00001). Anamnesis, clinical symptoms, and radiological findings are helpful in confirming aspiration, but can be misleading.  Chronic or recurrent pneumonia should prompt further bronchoscopic diagnosis.  Keywords: Aspiration • Bronchoscopy • Chest radiographs • Children • Clinical symptoms • Foreign body  

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1. Introduction Foreign-body aspiration (FBA) can be a life-threatening problem. Suspicion of FBA should be high when there is a history of sudden choking and coughing or when the patient has chronic pulmonary infections or symptoms. In such cases, bronchoscopy should be performed to search for a FB [1]. Poor coordination between swallowing and closing the glottis in children under 3 years of age causes frequent aspiration in this age group [2]. A choking event is sometimes not witnessed by any adults. This results in obtaining an unclear history from

parents, especially in the absence of clinical symptoms and radiological signs. Objects made of plastic, wood, rubber, and organic materials do not absorb X-rays and therefore are not visible during common diagnostic procedures; their presence must be concluded from indirect findings. Plain anteroposterior chest X-rays (CXR) and neck X-rays should be ordered in any case of suspected FBA. In doubtful cases, lateral projection and inspiration and expiration projections of the chest should be performed. In uncooperative children, it is easier to perform an X-ray in the supine position on the right and left sides with horizontal rays. During this procedure, the lower lung is forced to exhale. Sometimes CXR performed * E-mail: [email protected]

648

B Rybojad et al

in the exhalation phase shows one lung with focal hyperinflation, which indirectly indicates the possibility of a FB on that side (air trapping due to ball-valve effect of FB with respiration). This problem concerns ~30% of patients [3]. In this study, we analysed predictors of FBA with particular stress on false-positives and -negatives, which may mislead clinicians during diagnosis of FB in the tracheobronchial tree.

2. Materials and methods This study was approved by the Ethics Committee of the Medical University of Lublin (KE-0254/194/2009). Data were collected in accordance with the International Statistical Classification of Diseases and Related Health Problems (ICD-10) from the medical records of the patients treated at Children’s University Hospital of Lublin (a tertiary referral centre in southeast Poland). Our retrospective study involved 139 children with a history suggestive of suspected FBA who were referred for rigid bronchoscopy. The study protocol included anamnesis, age and sex, type and location of FB, clinical symptoms, and radiological evaluation.

3. Statistical methods The results were analysed statistically using simple proportions, Pearson’s χ2 test, and Fisher’s exact test, where appropriate. The sensitivity and specificity of the studied parameters were calculated. Statistical significance was set at p < 0.05. Multivariable tables were drawn. Statistica 8.0 PL (StatSoft, Inc.) was used for all statistical calculations. Table 1.

4. Results In total, 139 children aged 6.0 months to 15.5 years (mean age, 3.8 years) were enrolled in the study. The clinical history was positive in 127 children (91%); however, an exogenous object was removed bronchoscopically in 95 cases (68%). The sensitivity and specificity of witnessed aspiration were 96% and 18%, respectively. Fourteen patients included in the survey underwent a procedure despite a negative anamnesis because of chronic or recurrent pneumonia confirmed by CXR, and a FB was extracted in four of these cases. Three children underwent four consecutive bronchoscopy procedures, and a nut-like mass of residual purulent exudate was removed each time. The most common clinical symptom was cough (126 patients, 91%) followed by stridor (79 patients, 57%). Pain was reported in only eight cases, and in six, a FB was not found. The most frequent clinical symptoms according to the location of the FBs are presented in Table 1. We found no statistically significant correlations between clinical symptoms and FB location. In the assessed population, suspicion of organic FBs (mostly parts of nuts) predominated (106 patients, 76%); however, such FBs were removed bronchoscopically in only 70 patients (50%). The presence of a radiolucent FB in the respiratory tract may result in indirect signs in CXR such as atelectasis, focal hyperinflation, side-shift of the mediastinum, and pulmonary infiltration. These sometimes appeared separately, and sometimes all of the above indirect findings were observed (Figures 1, 2). In our study, CXR showed no aberrations in 48 patients (35%); however, a FB was successfully removed from the bronchial tree in 5 patients. A radiopaque object

Most frequent clinical symptoms of suspected FBA according to location

Location

Trachea

Cough

Stridor

Dyspnea

Wheezing

No*

No

No

No

9

5

6

2

R bronchus

50

30

21

22

L bronchus

27

22

15

13

R+L

9

4

7

3

Nasopharynx

1

0

1

0 6

Not found

33

18

16

Altogether (%)**

126 (91)

79 (57)

66 (47)

46 (33)

Sensitivity (%)

94

97

51

44

Specificity (%)

23

5

63

83

χ2 p

5.27 0.384021

8.68 0.122307

9.41 0.093696

10.98 0.051796

No=number; ** Percent of all children undergoing bronchoscopy (No 139)

*

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Foreign body aspiration in children

We noted a very highly significant correlation between the type of FB and the radiological signs (p = 0.00001). No organic object was radiopaque. Inorganic FBs were visible more often at CXR (10 of 37 suspected). Among patients with suspicion of organic FBA, CXRs were described as normal in 20 of 70 (29%).

5. Discussion

Figure 1.

Left-sided shift of mediastinum, focal hyperinflation of left lung, and uprising of the right hemidiaphragm, suggesting the presence of a foreign body in the left bronchus.

Figure 2. Recurrent bronchopneumonia in a 10-month-old

intubated patient (an orange petiole was removed during bronchoscopy).

was visible on CXR in only 10 patients (7%). Indirect manifestations were seen in the remaining 81 CXRs (58%). Organic FBs (mostly nuts) appeared more often as indirect radiological findings or normal CXR findings (Table 2). Table 2.

Relationship between type of FB and radiological signs.

Radiological signs

Kind of a suspected FB Organic

Inorganic

FB Not found

Sensitivity (%) / Specificity (%)

Focal hyperinflation

27

3

4

33/89

Atelectasis

11

3

7

15/82

Pulmonary infiltrate

4

2

8

6/80

Hypervascularity

5

1

4

6/90

Shift of mediastinum

3

1

0

4/100

Visible FB

0

10

0

11/-

Normal CXR

20

5

21

26/51

Altogether

70

25

44

Number of patients

*

650

In this study, we evaluated the diagnostic criteria taken into account before the decision to perform rigid bronchoscopy for FB removal. A suggestive history is important for the diagnosis because in many cases, no one observes a choking child. Children may inhale objects without adult supervision. We demonstrated that even witnessed aspiration had a very high sensitivity (96%) but a low specificity (18%), which is in accordance with previous reports [4,5]. The percentage of removed FBs (68%) was comparable with some studies [6,7], but other researchers noted lower or higher rates (57.0%, 59.1%, and 91.3%) [2,8,9]. During bronchoscopy, objects were found most often in the right main stem bronchus followed by the left, as in most surveys [7-9,10-16]. An exception was found in two studies in which patients under 3 years of age inhaled FBs into the left bronchus slightly more frequently (51.4% and 55.0%) [17,18]. The authors explained this finding by the fact that they were carrying their child in the left arm while trying to assist them. In this position, the toddler was involuntarily tilted slightly toward the left. Coughing occurred in 126 patients (91%); other symptoms by frequency of occurrence were stridor, dyspnoea, and wheezing as reported by other authors [8]. Schmidt and Manegold reported fever as the predominant clinical symptom of a FB (46%), followed by pneumonia (39%) and coughing (29%) [13]. The clinical

B Rybojad et al

picture varies depending on how long the FB has been lodged. Patients in our study had fever only with accompanying pneumonia. Brkić noted that the presence of a FB in the airways is characterised by a triad of symptoms: coughing, wheezing, and decreased breath [8]. In our study, wheezing was heard without auscultation in 33% of patients, but in 58% of patients, there were auscultatory findings only. The sensitivity and specificity of the listed clinical symptoms in our study varied from those reported by other researchers. Cough and stridor had very high sensitivities (94% and 97%, respectively), whereas the specificities were low (23% and 5%, respectively). No parameters were found to be both sensitive and specific; similar results were reported by Cavel et al. [5]. CXR in the posteroanterior (in younger children: anteroposterior) and lateral projections is a basic radiological examination [1,14,20]. It assists with identification of radiopaque metallic objects (pins, coins, batteries, etc.). FBs were clearly visible on 10 CXRs (7%). In 81 cases, only indirect signs suggested the presence of a FB: mostly atelectasis, focal hyperinflation, and pulmonary infiltration [7]. Zerella et al. analysed the presence of FBs in the respiratory tract before bronchoscopy. They stated that abnormalities were visible in only 122 of 232 plain CXRs [20]. In other surveys, focal hyperinflation or atelectasis was the most frequently appearing indirect radiological finding [16-18]. Shifting of the mediastinum and a raised dome of the hemidiaphragm are signs secondary to air trapping. When we evaluated the radiological findings, the sensitivity of so-called normal CXRs was low (26%), which has been confirmed by other studies (28.2%). This indicates that more than 70% of the patients with normal CXRs had a FB in their airways [5,19]. This is also why pulmonologists or paediatricians

do not often suspect FBA even in chronic or recurrent bronchitis or pneumonias. We observed similar results in cases of pulmonary infiltrates (6.0% and 4.3%, respectively). In our survey, the sensitivity of the other radiological signs, focal hyperinflation and atelectasis, equalled 33% and 15%, respectively, while other authors reported 63.8% and 8.0%, respectively [20]. The specificity of all radiological signs listed in Table 2 was high and the sensitivity was quite low, which was confirmed by other studies [5,6]. In some centres, computed tomography is undertaken to confirm (or exclude) the presence of a FB [5]. Because of its higher X-ray dose, we do not use it unless there is an urgent need. According to our findings, a lack of clinical symptoms should not prevent further radiological diagnosing (CXR) and bronchoscopy. We noted that amongst 48 CXRs with no trace of pathology, we also found false-negative results: in 5 children, FBs were eventually removed during bronchoscopy. Similar experiences have been reported in the literature [21]. When organic FBA is suspected, indirect CXR findings may help in the diagnostic process. A chest radiograph with no trace of pathology does not preclude the possibility of a FB lodged in the bronchial tree, especially when a chronic or recurrent infection of the lower respiratory tract is present. We recommend rigid bronchoscopy as a golden standard in all paediatric patients with a suspicion of FBA, especially when accompanied by at least one of the following symptoms: witnessed choking, wheezing, persistent cough, chronic or recurrent bronchopneumonia, or positive radiological findings suggesting a FB.

Conflict of interest statement Authors state no conflict of interest.

References [1] Tan H.K.K., Brown K., McGill T., Kenna M.A., Lund D.P., Healy G.B., Airway foreign bodies (FB): a 10-year review, Int. J. Pediatr. Otorhinolaryngol., 2000, 56, 91-99 [2] Even L., Heno N., Talmon Y., Samet E., Zonis Z., Kugelman A, Diagnostic evaluation of foreign body aspiration in children: a prospective study, J. Ped. Surg., 2005, 40, 1122-1127 [3] Corporate Author: Advanced Life Support Group, Advanced Paediatric Life Support: The Practical Approach, 5th ed., John Wiley & Sons, 2011 [4] Zawadzka-Głos L., Chmielik M., Gabryszewska A., Zając B., Badelek-Izdebska M., Analysis of indications for bronchoscopy In the Department of

Paediatric Otolaryngology in Warsaw from 1998 to 2003, Borgis-New Medicine, 2003, 2, 4-11 [5] 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, 194-201 [6] Kiyan G., Gocmen B., Tugtepe H., Karakoc F., Dagli E., Dagli T.E., Foreign body aspiration in children: The value of diagnostic criteria, Int. J. Pediatr. Otorhinolaryngol., 2009, 73, 963-967 [7] Kalyanappagol V.T., Kulkarni N.H., Bidri L.H., Management of tracheobronchial foreign body aspirations in paediatric age group- a 10 year 651

Foreign body aspiration in children

retrospective analysis, Indian. J. Anaesth., 2007, 51, 20-23 [8] Brkić F., Delibegović-Dedić S., Hajdarović D., Bronchoscopic removal of foreign bodies from children in Bosnia and Herzegovina: experience with 230 patients, Int. J. Pediatr. Otorhinolaryngol., 2001, 60, 193-196 [9] Oguzkaya F., Akçali Y., Kahraman C., Bilgin M., Sahin A., Trachoebronchial foreign body aspirations in childchood: a 10-year experience, Eur. J. Cardiothorac. Surg., 1998, 14, 388- 382 [10] Brkić F., Umihanić Š., Tracheobronchial foreign bodies in children Experience at ORL clinic Tuzla, 1954-2004, Int. J. Pediatr. Otorhinolaryngol., 2007, 71, 909-915 [11] Lederman H.M., Airway Foreign Body Imaging. eMedicine Radiology, 2011, http://emedicine.medscape.com/article/405994-overview [12] Pinzoni F., Boniotti C., Molinaro S.M., Baraldi A., Berlucchi M., Inhaled foreign bodies in pediatric patients: Review of personal experience, Int. J. Pediatr. Otorhinolaryngol., 2007, 71, 1897-1903 [13] Schmidt H., Manegold B.C., Foreign body aspiration in children, Surg. Endosc., 2000, 14, 644-648 [14] Skoulakis C.E., Doxas P.G., Papadakis C.E., Proimos E., Christodoulou P., Bizakis J.G., et al., Bronchoscopy for foreign body removal in children. A review and analysis of 210 cases, Int. J. Pediatr. Otorhinolaryngol. 2000, 53, 143-148

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[15] Tahir N., Ramsdem W.H., Stringer M.D., Tracheobronchial anatomy and distribution of inhaled foreign bodies in children, Eur. J. Pediatr. 2009, 168, 289-295 [16] Tomaske M., Gerber A.C., Stocker S., Weiss M., Tracheobronchial foreign body aspiration in children-diagnostic value of symptoms and signs, Swiss Med. Wkly. 2006, 136, 533-538 [17] Kula Ö., Gürkan S., Alunöz H., Yazici Ö., Ocakli Ö., Dülger S.,U., et al. Foreign Body Aspiration in Infants and Children, Turk. Resp. J., 2003, 2, 76-78 [18] Van Looij M.A.J., Rood P.P.M., Hoeve R.L.J., Borgstein J.A., Aspirated foreign bodies in children: why are they more commonly found on the left? Clin. Otolaryngol., 2003, 28, 364-367 [19] Aydoğan L.B., Tuncer U., Soylu L/, Kiroğlu M., Ozsahinoglu C., Rigid bronchoscopy for the Suspicion of foreign body in the airway. Int. J. Pediatr. Otorhinolaryngol. 2006, 70, 823-828 [20] Zerella J.T., Dimler M., McGill L., Pippus K.J., Foreign Body Aspiration in Children: Value of Radiography and Complications of Bronchoscopy. J. Pediatr. Surg., 1998, 33, 1651-1654 [21] De Sousa S.T., Ribeiro V.S., de Mezesez Filho J.M., et al., Foreign body aspiration in children and adolescents: experience of a Brazilian referral center. J. Bras. Pneumol., 2009, 35, 653-659