Once in a while you’ll see a child with a chronic cough. Even in the absence of a compelling history – and let’s face it, the history cupboard is often bare – it is important to consider the possibility of an inhaled foreign body. Thinking about the possibility of a bronchial foreign body got me thinking about the indications for bronchoscopy. Previously I figured that the indications were if a foreign body is present then bronch. Let’s see if good ‘ole intuition was correct.
Cohen et al in J. Peds from 2009 examined a cohort of 142 children with suspected foreign bodies. The authors noted that all of the the patients had a suggestive history; either a witnessed report of an acute episode of choking (n = 106) or an acute persistent cough (n = 36). The median age was 20 months.
Important symptoms n their cohort included cough, dyspnea, labored breathing, drooling, dysphagia, vomiting, and fever. The abnormal physical exam findings were cough, fever, tachypnea, hypoxemia, decreased lung sounds, wheezes, and crackles. Abnormal radiologic findings included air-trapping, atelectasis, infiltration, mediastinal shift, and radioopaque foreign body. All patients underwent bronchoscopy within 24 hours of admission. Overall 43% had a foreign body (61/142). When they were subdivided into 5 groups, the proportion having a foreign body on bronchoscopy was:
- 42/63 (67%) children with both abnormal exam and XRays
- 14/22 (64%) children with abnormal exam but normal XRays
- 3/10 (30%) children with normal exam but abnormal XRays
- 2/31 (6%) children with a normal exam and XRays – but persistent cough/abnormal symptoms
- 0/16 (0%)children with normal exam, normal XRays and no symptoms
The children without foreign body were compared to those with one. Note that kids with a FB were more likely to have had a witnessed choking event, have persistent cough, have sats <94%, have localized decreased breath sounds, and localized air trapping or mediastinal shift on Chest XRay.
OK, so this wasn’t a randomized controlled trial. But would an IRB approve such an investigation? Anyway, this did help me better understand why a bronchoscopist would be less likely to take an asymptomatic child with a normal exam and normal films to the OR. I’d go so far as to say that such children can probably be discharged home without a consult in the first place.
