Indian Pediatrics 1999; 36:386-389 

Role of Flexible Fiberoptic Bronchoscopy in the Diagnosis of Tracheobronchial Foreign Bodies in Children

Airway aspiration of foreign body remains a common problem that accounts for a large number of accidental deaths in children(1). Missed or a delayed diagnosis of a foreign body can result in respiratory difficulties ranging from life threatening airway obstruction to recurrent or chronic wheezing and recurrent pneumonia. Early diagnosis and extraction of foreign bodies must therefore be achieved. Usually rigid bronchoscopy under general anesthesia is performed allowing both diagnosis and extraction of foreign bodies in children. To prevent the morbidity resulting from neglected foreign bodies this procedure is performed in a large number of cases with negative results and hence may be unnecessary(2). Flexible fiberoptic bronchoscopy. (FFB) is performed under conscious sedation and has the advantage of reaching more distal airways permitting more cost effective diagnostic evaluation. One of the main indications for bronchoscopy in children is localized hyperinflation or atelectasis on chest radio- graphs with or without history of foreign body inhalation or a choking episode. A common clinical situation is when a patient has a negative or an equivocal history of foreign body but a clinical or a radiological finding suggesting intrabroncial obstruction. There may be circumstances when there is a past history of foreign. body inhalation but no localizing finding either physical or radiological. Commonly, this occurs in patients with a history of persistent cough, mild fever without evidence of atelectasis or localized hyperinflation on the chest radiograph. Subjecting all these patients to rigid bronchoscopy means exposure to the risk of general anesthesia even to those where FB may not be detected. We are presenting our experience after electively doing flexible fiberoptic bronchoscopies in cases where suspected foreign body aspiration was one of the differential diagnoses and followed with rigid bronchoscopy only the ones in whom foreign bodies were located.

Subjects and Methods

Patients were taken up for FFB in the. bronchoscopy room. of the Department of Pediatrics if they had: (i) A persistent localized pulmonary collapse or hyperinflation on clinical and radiological examination seen on more than two occasions more than six weeks apart in presence or absence of recurrent respiratory symptoms like cough or. wheezing; (ii) History bf a choking episode in the child with/without direct observation by the parent; (iii) Recurrent hemoptysis irrespective of presence or absence of radiological findings; (iv) History of recurrent cough or wheezing with single documentation of local radiological signs.

The patients were recruited from either the Pediatric Outpatient Department or as referrals from Pediatric Surgery and Otorhinolaryngology Departments. All these patients were without acute respiratory distress. A careful clinical evaluation was done prior to the procedure including' discussion with radiologist about the need for noninvasive investigations like chest radiography and CT scan. After obtaining informed parental consent, flexible bronchoscopy was performed with Olympus pediatric broncho-fiberscope (Olympus BF 3C 20, outer diamter 3.5 mm) under conscious sedation using intravenous Diazepam or Midazolam(3). Ketamine was used (1-2 mg/Kg) in. patients where it was not possible to sedate the child with benzodiazapines alone. Topical analgesia was used with 2% Xylocaine solution. In patients with history of wheezing, nebulized Salbutamol was administered before the procedure. Heart rate and oxygen saturation were monitored throughout the procedure. Patients were administered oxygen with a nasal catheter. Prior consultation was taken from pediatric surgeons arid information sent for a Possible need for a rigid bronchoscopy which was done in all cases where foreign body was detected with an appropriate sized Karl Storz bronchoscope under general anesthesia.

Results

A total of 22 patients underwent flexible bronchoscopy for suspected foreign body (FB). The mean age of patients was 4.86 ± 4.26 years (range' 3 months to 11 years). The duration of symptoms was 4.6 ± 2.6 months. Table I lists the bronchoscopic findings and the relation to the clinical findings. Localized finding in the form of persistent collapse or unilateral hyperinflation was seen in 13 patients. Five patients presented with history of hemoptysis. Amongst these cases, two patients had nonhomogenous pulmonary infiltrates, one patient had a rounded opacity which was confirmed to be an A V malformation post bronchoscopically by a CT scali. Other two patients did not have any significant radio- logical finding. In these patients, neglected foreign body was. considered as one of the pre-procedure diagnosis acting as an intrabronchial lesion in the form of a FB granuloma. Four children presented with recurrent lower respiratory symptom like cough and wheezing. History in these subjects had suggested that patients had exposure to objects (e.g., taking peanuts) which could act as foreign bodies. All four patients had a documented upper lobe coIlapse.

Flexible bronchoscopy was performed in a total' of 22 patients and only 6' had foreign body obstruction; 4 patients were detected to have mucus plugging, 6 had granulomatous obstruction (three turned out to be positive for Mycobacterium tuberculosis on culture of bronchial aspirate), one patient had an H type tracheo-esophageal fistula and one was found to have extrinsic compression which was que to an A V malformation picked up by a CT scan done afterthebronchoscopy. No abnormal finding was found in two cases. There were seven patients in total in whom history of sudden choking could be elicited. Five. of these patients had foreign bodies.

Inpatients with FB 'obstruction who underwent a rigid broochoscopy, foreign bodies removed included peanuts(2), Bengal gram (n=2), tamarind seed (n=1),and ball pen cap (n=1). Radio-opaque foreign bodies were not seen in any of our cases. In one patient with chronic left sided hyperinflation, granulomatous obstruction was seen. Following flexible bronchoscopy, this child developed a bout of cough leading to shifting of radiological signs on the other side as evidenced by collapse suggesting displacement of a FB. Tbis patient was taken up for urgent rigid bronchoscopy under general anesthesia and a pen cap was removed. The patient recovered uneventfully.
 

TABLE I

Bronchoscopy Findings in Patients with Suspected Foreign Body
 

Discussion

The indications of flexible bronchoscopy in children with suspected non asphyxiating foreign bodies are not clearly defined(2,4). Although flexible bronchoscopy has been found useful for foreign body removal in adults and adolescents(5), we believe that open tube extraction remains the procedure .of choice in children with a definite history ofFB inhalation. The rigid instrument enables ventilation of very narrow air passages and permits easy removal of foreign bodies. Parez and Wood suggested that if rigid bronchoscopy did not reveal a foreign body but there was still a high degree of suspicion of its presence, flexible bronchoscopy should be performed since it allows more distal inspection of air- ways(2). Wood and Gauderer proposed that diagnostic flexible bronchoscopy should be used as a first procedure in all cases if there was no clear cut evidence of FB on physical or radiological findings(4). Physical findings have been reported to be absent in upto 39% of patients with FB(6) and radiographs are normal in 7 to 21 % of cases(7,8). In the studies by Hoeve and colleagues(7) and Francois and coworkers(8) this led to high rate of negative rigid bronchoscopic findings (26% and 46%, respectively) and these were considered as unjustified instances of general anesthesia. In our study if rigid bronchoscopy had been performed in all the cases at the first instance then the negative finding rate would be to the tune of 16/22.

This data demonstrates the importance of diagnostic FFB in the management of children suspected of foreign bodies in bronchus. In a typical case of foreign body aspiration there is history of a child playing with objects which can act as foreign bodies or there is a history of a child suddenly choking while eating or playing with small objects. However, a large number of cases present with recurrent respiratory symptoms and atelectasis or hyperinflation of a localized segment of the lung without this history. Rigid bronchoscopy. should not be the first choice in all these cases because it is a procedure performed under general anesthesia associated with a significant risk. Flexible bronchoscopy becomes useful in such situations and helps in selecting cases for rigid bronchoscopy. In our study also, a larger proportion of patients were found to have obstruction due to mucus plugging or inflammatory masses who would have been taken up for unnecessary rigid bronchoscopy under general anesthesia.

Flexible bronchoscopy is a safe and cost saving diagnostic procedure. The dislodgment of foreign body due to FFB as observed by Wood and Gauderer(4) was seen in one of our patients, without an adverse outcome. However, prior information to the pediatric surgeons and a joint approach were particularly beneficial in treating this child. The cost of fiberoptic bronchoscopy in our institution is Rs. 100/- per procedure whereas rigid bronchoscopy costs Rs. 300/- to the patients because of the additional cost of operative room time and general anesthesia.

Hence it is proposed that if there is a definite history of foreign body inhalation in a child, a choking episode or when he presents with asphyxial features he should be taken up straight for rigid therapeutic bronchoscopy. However, if a history is not forthcoming then even in the presence of localizing signs doing a diagnostic FFB can be rewarding.



 

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