Critical

Comments
Pediatric Otorhinolaryngology

DR. BIKASH GURUNG

2ND YEAR RESIDENT
GMSMA OF ENT HNS
MMC, TUTH, IOM
Tracheobronchial foreign body aspiration in infants
& children: Diagnostic utility of multidetector CT
with emphasis on virtual bronchoscopy

Ehab Ali Abd-ElGawad a,*, Mohammed Ahmed Ibrahim a,

Yasser Shaban Mubarak b

https://doi.org/10.1016/j.ejrnm.2014.07.003

Citation: 2
IF: 0.32
Received 30 January 2014; accepted 14 July 2014
Available online 4 August 2014
 Tracheobronchial foreign body aspiration in infants & children:
Title Diagnostic utility of multidetector CT with emphasis on virtual
bronchoscopy
• Well defined, descriptive and nominal

• Contains abbreviation

• 18 words

• Authors' names, affiliations : Stated

Corresponding author. Tel.: +20 0862342505;

• Address of correspondence: Stated fax: +20 0862366743
E-mail address: abdelgawadehab@yahoo.com
• Academic degree : Not stated
Alternate title

Efficacy of virtual bronchoscopy using multi detector CT scan in

detecting foreign body airway in infants and children
Abstract

Well Structured (four-point structured )

183 words (150-250 words)
Concrete information about study
Each section – outlined clearly
Keywords mentioned: 4 in number (3-10)
Level of evidence

Hospital based prospective study

Introduction
• Background for research: mentioned

• Rationale: Well elaborated

• Objective: mentioned

• Justification for current study: mentioned

Introduction
• Early diagnosis to prevent complications

• Multislice CT scans with realistic 3-dimensional reconstruction and virtual

bronchoscopy focused as an alternative to rigid bronchoscopy
Materials and Methods
• Study place: Not mentioned

• Study period: mentioned (March 2011 to October 2013)

• Approval: mentioned (the institutional review board)

• Ethical consideration: not mentioned

• Funding: not mentioned (No disclosure of funding received for this work from any
Organization)

• Conflict of interest: not mentioned (none)

Materials and Methods
• Study population: mentioned
• Suspected to have foreign body aspiration according to their history, physical examination and
chest X-ray
• 21 (8 females, 13 males, age range from 18 month to 7 years)
• Inclusion and exclusion criteria not mentioned

• Multidetector CT technique : mentioned

• Technique, sedation, interpretation, post processing
• Brochoscopy procedure : mentioned

• No. of surgeon and experience: Not mentioned

• No. of radiologist and experience: Not mentioned

Results
• Method of statistical analysis: Not mentioned

• Summary of results : mentioned

• Author's major findings clearly presented with 5 tables:

• Table 1. Common clinical presentations and physical examination of 21 patients
• Table 2. Multislice CT findings
• Table 3. Location of detected FB according to bronchoscopy
• Table 4. Correlation between multislice CT & bronchoscopein detection of FB
• Table 5 Sensitivity, specificity and accuracy of CT in detecting FB
Results
Results
• Variety of foreign bodies retrieved have been mentioned: pie chart would have
been better
Discussion
• Explanation of research findings : present
• False positive:1 (Retained secretions and artifacts)
• No confident report the presence of FB according to CT findings:1 (small FB in the
distal subsegmental bronchus, obscured by the surrounding segmental lung
consolidation)
• Comparison with other studies : done
• The sensitivity of MDCT was 94.4%, specificity was 75% and accuracy was 90.4%,
slightly less than results of Soo-long Hong et al. ( sensitivity of 100% and specificity
of 66.7%)

• Practical significance of the research : stated

• Simulates an endoscopist’s view of the internal surface of the airway

• Limitation of study : mentioned

Conclusion
• Not mentioned separately
• MDCT virtual bronchoscopy should be considered in pediatric patients with
pulmonary infiltrates that fail to resolve in the usual time (10–14 days).
• MDCT may be also useful in ruling out a foreign body in patients with a low
level of suspicion and normal or nonspecific chest radiography findings and in
showing the exact location of the foreign body before bronchoscopy

• Direction for further research : Not mentioned

References
• Vancouver system

• 28 Journal articles
Strength
• Addresses visual bronchoscopy as a diagnostic tool which is not invasive, without
need of general anesthesia

• Data were collected after bronchoscopic procedure (recall bias)

• Only few such comparative study has been published in pediatric population (VB vs
RB)
Limitations
• Relatively small number of patients

• Could not show the sub-segmental parts of the tracheobronchial system

• Radiation hazard and need of sedation

• Costly

• Only available in higher centers

Literature Review
Advantage of Computed Tomography (CT) Virtual
Bronchoscopy in the Evaluation of Children with
Suspected Foreign Body Airway
Morishetty Yogi1, Kagithapu Surender1, Lingaiah Jadi2, Sulakshana Chavan1, Pilli Prathiba1
• 1Department of Pediatrics, Kakatiya Medical College, MGM Hospital, Warangal, India
• 2Department of ENT & HNS, Chalmeda Anand Rao Institute of Medical Sciences, Karimnagar, India

Received 25 January 2016

accepted 8 March 2016 International Journal of Otolaryngology
published 11 March 2016
and Head & Neck Surgery
 Introduction
• Foreign body aspiration into the tracheobronchial tree; frequent and serious cause
of respiratory distress under 3 years of age
• Sudden onset of cyanosis, cough and wheezing are the principal symptoms
• Approximately one third of the children admitted present with normal chest X-ray
result
• Virtual bronchoscopy
• relatively new, non-invasive procedure
• easily obtained by post processing of a routinely acquired high resolution CT
data set
• Early diagnosis and intervention are fundamental
 Introduction
• Objectives
• to study the diagnostic accuracy and advantage of virtual bronchoscopy over
rigid bronchoscopy in the evaluation of children with suspected FBA and to
plan for early management

• to study the clinical spectrum of children attending with suspected FBA

 Methodology
• Source of data:
• department of pediatrics and Otorhinolaryngology at MGM Hospital, Warangal
• 1.5 Yrs during 2012-2013
• Study:
• observational Study of 37 patients
• Inclusion criteria:
• all patients aged 12 yrs and below with a history suggestive of foreign body in
the tracheobroncial tree
( sudden onset of cough, difficulty in breathing, wheezing and decreased air entry
into the lungs)
 Methodology
• Exclusion criteria:
• 13 yrs and above
• patients presenting with features of cerebral hypoxia secondary to foreign
body aspiration

• Investigations done :CBP, HIV, HBSAG, Blood urea, sr.creatinine, CT, BT, Chest X-ray
PA & Lateral view and CT Virtual bronchoscopy

Data were recorded in the case sheet and used for study
 Results s

• common age of presentation was 1 - 3 yrs of age (70.28%)

• male preponderance
Results s
Results s
Results s
Results s
Results s
 Results s

Vegetative matter; the

majority (73%)

Fig. Pie chart showing percentage of various types of

foreign bodies
 Discussion s

Sensitivity and Specificity of virtual bronchoscopy were 96.5% and 75% respectively

Advantages:
identifies the foreign body and also localizes the foreign body in the Bronchial lumen

shorten the operative time for rigid Bronchoscopy

avoids unnecessary invasive procedure of rigid Bronchoscopy

Limitations of the study:

costly investigation and not available in all centers

In definite foreign body aspiration rigid Bronchoscopy is diagnostic as well as

therapeutic
 Conclusion
• Tracheobronchial foreign body aspiration; higher incidence in younger children aged 1
- 3 years
• Virtual bronchoscopy
• should be considered ;in suspected foreign body aspiration, when chest X-ray is
normal to avoid needless rigid bronchoscopy
• useful in screening cases of occult foreign body as it has sensitivity, specificity, and
validity
Avoiding unnecessary bronchoscopy in children with
suspected foreign body aspiration using computed
tomography
Alexander T. Gibbons a, Alejandra M. Casar Berazaluce b, Rachel E.Hanke b, Neil L. McNinch a,c,
Allison Persona ,Tracey Mehlman a, Michael Rubin a, Todd A. Ponsky a, b ,⁎
a Akron Children's Hospital, Akron, OH
b Cincinnati Children's Hospital Medical Center, Cincinnati, OH
c Rebecca D. Considine Research Institute, Akron, OH

Received 19 September 2019

Accepted 29 September 2019
 Introduction
• Foreign body aspiration (FBA) : relatively common
• pediatric population
• representing approximately 17,500 emergency room visits and 2000 inpatient
hospitalizations in the US each year
• < 4 years of age
• Consequences; hospitalized patients suffering an anoxic brain injury, mortality rate of 1.8%
• Rigid bronchoscopy ;gold standard for diagnosis and the definitive therapeutic intervention
for FBA
• Complications: severity from temporary desaturation to cardiac arrest (2.6%–14%)
• major complications occurring in 1% and mortality in 0.42%–0.8%
• A diagnostic tool that is both superior to plain films and less invasive than bronchoscopy
needed :
? computed tomography (CT)
 Introduction
• Purpose of the study
• to compare patients presenting with possible FBA who underwent bronchoscopy alone
to those who had a low-dose CT scan of the chest, with or without bronchoscopy
• Primary outcome
• Hypothesis
• rate of positive bronchoscopy would be greater in the group undergoing a
preprocedure CT

• Secondary outcomes
• to evaluate the impact of CT on
• complication rate
• procedure time
• and to examine the diagnostic properties of CT for the diagnosis of FBA
 Methods
• Study design: retrospective review, from June 1, 2012 to October 1, 2018

• Patient selection: All patients < 18 years of age who were evaluated for foreign body
aspiration

• Place of study: single tertiary children's hospital

• Exclusion : All patients who underwent bronchoscopy emergently were excluded from the
study

• Approval : granted by the Akron Children’s Hospital Institutional Review Board

 Methods
• Follow-up telephone survey
• To validate negative CT findings, all patients who had FBA ruled out by normal chest CT
and who did not undergo bronchoscopy were included in a follow-up telephone survey
• If did not speak English or did not have a working telephone number listed; excluded
• permission was obtained
• The survey addressed
• persistent respiratory symptoms?
• readmission to the hospital for respiratory symptoms?
• patient underwent bronchoscopy after discharge?
• if so, whether a foreign body was found?
 Methods
• Interobserver variability
• images reread by two of three staff radiologists, blinded to the initial read
• Based on the initial read and the rereads, interobserver reliability was calculated
 Methods
• Statistical analysis
• Calculation of full summary statistics  distribution-based statistical testing (Wilcoxon
rank-sum test),which was completed
• to assess for potential differences in continuous (chi-squared test of independence for
categorical) demographic and baseline characteristics, as well as clinical outcome
measures
• True negatives;
• no foreign body on bronchoscopy+ if responded to the survey + did not have a foreign
body found after discharge (or had a normal respiratory exam in the electronic medical
record after discharge)
• Patients without follow-up (either by survey or in the EMR) excluded from this analysis
• A receiver operating characteristic (ROC) curve analysis to assess the potential diagnostic
ability of both CT and CXR on FBA
• Statistical analyses were completed using SAS 9.4 / 14.2 © (SAS Institute, Cary, NC)
 Results

no evidence of baseline differences between the two groups (CT ± bronchoscopy vs. bronchoscopy only) for age,
duration of symptoms, or gender (p=0.78, 0.54, and 0.28, respectively)
Results

primary outcome

Patients with only a bronchoscopy;

significantly less likely to have a positive
bronchoscopy than those who had a
positive CT prior to bronchoscopy
(RR 0.71, 95% CI 0.59–0.91, p <0.01)
 Results

• 1 false-positive motion artifact at the level of concern at the time of the study.
• For the 17 patients who had their foreign body confirmed;
16 (94.1%)location of the foreign body correctly predicted on CT
1 discordant findinglocated the foreign body in the right lower lobe
bronchus instead of the predicted bronchus intermedius.
• 2 patients CT read equivocal, but which favored pneumonia over FBA
 both had negative bronchoscopies
Results
Results
Secondary outcomes:
• Bronchoscopy alone no more likely to
suffer a complication than CT with or
without bronchoscopy (p=0.13)
• No evidence of significant differences
between the groups in terms of;
steroid use,
time to procedure,
length of procedure,
or length of stay
• median time to bronchoscopy for
all patients: 6.5 h
• median time to a CT result: 3.0 h
• This difference was statistically
significant
(p < 0.01).
 Results
• Of the 49 patients who had a CT but did not undergo subsequent bronchoscopy, 44
were eligible for the follow-up telephone survey.
34 patients who responded to the survey;
9 patients; follow-up medical records were available

• The median time to follow-up was 1.23 years

• 3 patients (9%) ultimately underwent bronchoscopy for their symptoms; none of

these patients  foreign body on evaluation
 Results
• The follow-up;
validation for the negative bronchoscopy findings and allowed for calculation of
the diagnostic properties of CT and CXR

• ROC curve analysis;

high level of diagnostic ability for CT, with an area under the curve of 0.99 (95% CI
0.97–1.00).

• CT chest for suspected FBA

Sensitivity of 100%, specificity of 98%,positive-predictive value of 94%, and
negative-predictive value of 100%.
 Results
• For CXR, ROC curve analysis;
Diagnostic ability no better than chance, with an area under the curve of 0.55
(95% CI 0.50–0.60).
• CXR for suspected FBA ;
sensitivity of 13%, specificity of 97%, positive-predictive value of 78%, and
negative-predictive value of 58%

• Interobserver reliability
The overall agreement was almost perfect ( p <0.001), as was the agreement on
the presence (p <0.001) or absence ( p<0.001) of a foreign body.
Substantial agreement for equivocal reads (p<0.001).
• 1 false-positive was marked as negative on both of the blinded re-reads.
 Discussion
• Positive bronchoscopy rate of 60.9% for patients with bronchoscopy alone

CT
• Positive predictive value was 94.1%

• No false negatives

• Location was also able to be correctly predicted 94.1% of the time

• None of the 34 contacted patients were later found to have a foreign body; chart
review suggested the same for an additional nine patients

• CT far superior to CXR

 Discussion
• No differences in terms of overall complications between those who had only a
bronchoscopy and those who had a CT with or without bronchoscopy

• All PICU admissions after the procedure were in the bronchoscopy-only group

• Potential benefit of using CT to diagnose FBA : for triage in community hospitals

• Data showed reduction for negative bronchoscopy rate, from 39.1% to 6%, with
even less radiation CT and without the need for contrast

• Only five of the 69 patients required sedation, which was able to be achieved
with midazolam alone

• The time to diagnosis with CT is much faster than with bronchoscopy

 Discussion
Limitations:
• Subject to selection bias and coding errors (As a retrospective chart review)

• Only 75.6% of the patients presenting after January 2016

underwent a CT scan possible that there was a bias in which patients were
selected for imaging that was not detected

• Unable to reach all eligible patients for the telephone survey

• Potentially have missed a patient who may have gone to another hospital to
receive care (who underwent CT without a bronchoscopy & were not
diagnosed with FBA)
 Conclusion
• Low-dose chest CT is a remarkably effective and consistent tool for diagnosing FBA in
children, with a sensitivity of 100% and a specificity of 98%.

• It can be performed quickly with minimal radiation exposure and can prevent
unnecessary bronchoscopies
•Thank you