Abstract
Background
Foreign body aspiration is common in children, but there are no clinical clues that can determine or rule out the diagnosis before entering the operating room for bronchoscopy. The purposes of our study were to define the clinical characteristics of foreign body aspiration in the pediatric population and to evaluate the significance of delay in its diagnosis and treatment.
Methods and results
The study used a retrospective review of 136 charts of children up to the age of 16 who underwent bronchoscopy for foreign body removal for 10 years in Ha’Emek Medical Center (Afula, Israel). An adult witness of an aspiration episode (most frequent presenting symptom), a child younger than 2 years, and an abnormal plain chest radiography were found to be significant predictors of foreign body aspiration. Estimated risk for foreign body aspiration was significantly higher in children who were younger than 2 years with an eyewitness for the aspiration episode and abnormal chest radiography (odds ratio, 5.6, with confidence interval from 2.0 to 15.6). The rate of complication was 2-fold higher in patients who arrived at the hospital 2 days or more after the aspiration compared with patients who arrived earlier. The rate of complication was 2-fold higher in patients who underwent bronchoscopy 24 hours or more after arrival at the emergency department compared with patients who underwent bronchoscopy within the first 24 hours.
Conclusion
Delayed arrival of a child with a suspected foreign body aspiration at the hospital and delayed bronchoscopy were found to be related to a higher rate of complication.
1
Introduction
Foreign body aspiration is common in the pediatric population. It was estimated as a rate of 29.9/100 000 population and was responsible for the death of 160 children in the United States in 2000 . In our region, the rate of bronchoscopies is 11/100 000 children per year . Many foreign body aspiration events are preventable. The public health education program can help to reduce up to 35% of the incidences of foreign body aspiration but cannot eliminate it . Foreign body aspiration leads to significant complications, and the rate of these complications increases with delay in diagnosis and treatment . Although many comprehensive studies have dealt with the clinical presentation, diagnosis, and outcome of foreign body aspiration, there are no clearly defined clinical and radiologic characteristics that can determine the diagnosis. This uncertainty causes delay in diagnosis and treatment in clinical practice .
We reviewed our experience in the treatment of pediatric foreign body aspiration for 10 years. The aims of this retrospective study were (1) to define the clinical and radiologic features of aspirated foreign body and (2) to evaluate the consequences of delayed diagnosis and treatment of foreign body aspiration.
2
Methods
A retrospective review of all bronchoscopies performed in Ha’Emek Medical Center, Afula, Israel, between January 1994 and December 2004 was undertaken. The patients consisted of 136 children up to the age of 16 years who underwent bronchoscopy for foreign body removal. Data were collected for patient age and sex, duration of symptoms, time of diagnosis, history of aspiration events, physical examination in the emergency department (ED), and results of radiographic studies (plain chest radiography and fluoroscopy). Details of the bronchoscopy included the time of procedure, nature, and location of foreign body in the bronchial tree and complications. All bronchoscopies were performed under general anesthesia in an operating room. A rigid bronchoscope was used in most of the cases. In a minority of cases, a flexible bronchoscope was used at the beginning, and if a foreign body was found, the procedure was followed by rigid bronchoscope. Additional information includes complications relevant to bronchoscopy or aspiration such as recurrent bronchoscopies or chronic pulmonary disorders such as recurrent pneumonia with hospitalizations.
Statistical analysis was performed using the statistical software SPSS (SPSS Inc, Chicago, IL). The correlation between evidence of foreign body aspiration and clinical data was evaluated by χ 2 test. P values less than .05 were considered as statistically significant. Sensitivity and specificity were calculated for symptoms, physical examination, and radiologic findings. A multivariant model with logical regression comparing clinical data was created, and odds ratios in confidence interval 95% were calculated.
2
Methods
A retrospective review of all bronchoscopies performed in Ha’Emek Medical Center, Afula, Israel, between January 1994 and December 2004 was undertaken. The patients consisted of 136 children up to the age of 16 years who underwent bronchoscopy for foreign body removal. Data were collected for patient age and sex, duration of symptoms, time of diagnosis, history of aspiration events, physical examination in the emergency department (ED), and results of radiographic studies (plain chest radiography and fluoroscopy). Details of the bronchoscopy included the time of procedure, nature, and location of foreign body in the bronchial tree and complications. All bronchoscopies were performed under general anesthesia in an operating room. A rigid bronchoscope was used in most of the cases. In a minority of cases, a flexible bronchoscope was used at the beginning, and if a foreign body was found, the procedure was followed by rigid bronchoscope. Additional information includes complications relevant to bronchoscopy or aspiration such as recurrent bronchoscopies or chronic pulmonary disorders such as recurrent pneumonia with hospitalizations.
Statistical analysis was performed using the statistical software SPSS (SPSS Inc, Chicago, IL). The correlation between evidence of foreign body aspiration and clinical data was evaluated by χ 2 test. P values less than .05 were considered as statistically significant. Sensitivity and specificity were calculated for symptoms, physical examination, and radiologic findings. A multivariant model with logical regression comparing clinical data was created, and odds ratios in confidence interval 95% were calculated.
3
Results
3.1
Epidemiology
Of the 136 patients, 86 (63.2%) children were male, and 50 (36.8%) were female. The mean age was 33 ± 34.7 months (range, 5–180 months). Most children (64%) were younger than 2 years.
A foreign body was found in 99 patients (72.8%). Positive bronchoscopies were significantly more frequent in children younger than 2 years than older children (83% and 57%, respectively; P = .001). Positive bronchoscopies were little more frequent in boys than girls (77.6% and 66%, respectively).
3.2
History and physical examination
A clear history of aspiration (choking event) was the most frequent presenting symptom and found in 106 children (78%). Younger patients were observed by caretakers to have foreign body particles in their mouths. Older children were able to report by themselves on the foreign body aspiration. There was no difference in the frequency of a history of aspiration between children who were younger than 2 years and older children. Coughing, acute dyspnea, and pneumonia were additional symptoms leading to bronchoscopy ( Table 1 ).
| Symptoms | Frequency | Specificity | Sensitivity | P |
|---|---|---|---|---|
| Witness to aspiration episode | 78.5% | 33.3% | 82.8% | .04 |
| Coughing | 74% | 25% | 73.7% | NS |
| Acute dyspnea | 36.6% | 80% | 43.2% | .012 |
| Pneumonia | 10.7% | 83% | 8.4% | NS |
The mean duration of symptoms before arriving at the hospital was 10.6 days with median of 1 day. Nineteen children (14%) arrived at the ED a week or more after the onset of symptoms ( Fig. 1 ). There was no difference in duration of symptoms between children younger than 2 years and older children.
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