Table of Contents
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Abstract
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Case Presentations
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Introduction
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Critical Appraisal of the Literature
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Etiology And Pathophysiology
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Differential Diagnosis
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Prehospital Care
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Emergency Department Evaluation
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Initial Evaluation
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Diagnostic Studies
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Radiographic Studies To Assess For Signs Of An Aspirated Foreign Body
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Specialty Consultation
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Treatment
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Special Populations
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Controversies And Cutting Edge
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Disposition
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Summary
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Risk Management Pitfalls For Management Of Inhaled Foreign Bodies
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Time- And Cost-Effective Strategies
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Case Conclusions
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Clinical Pathway For Management Of Inhaled Foreign Bodies
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Tables and Figures
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Table 1. Physical Examination Findings Based On Anatomical Location
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Table 2. Differential Diagnosis Based On Signs And Symptoms
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Figure 1 Airway Foreign Body With Atelectasis Of The Left Lung
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Figure 2. Screw In The Left Mainstem Bronchus
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Figure 3. Sunflower Seed Lodged In The Subglottis
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Figure 4. Subcutaneous Emphysema And Pneumomediastinum
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Figure 5. Right-Sided Hyperexpansion And Mediastinal Shift
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Figure 6. Foreign Body In The Lower Trachea, Shown By Coronal Reconstruction
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References
Abstract
Foreign body inhalation affects thousands of children every year, and it remains a significant cause of morbidity and mortality in children. Inhaled organic or inorganic foreign bodies can become lodged in the posterior nasopharynx, larynx, trachea, or bronchi. Presentation of foreign body inhalation can range from nonspecific respiratory symptoms to respiratory failure associated with a choking episode. In this issue, an in-depth review of the etiology, pathophysiology, diagnosis, and treatment of inhaled foreign bodies is presented. Risk factors for foreign body inhalation and clinical clues to diagnosis, as well as emergent management of inhaled foreign bodies are reviewed. A systematic approach, as described in this issue, will aid in timely and accurate diagnosis and treatment of inhaled foreign bodies, thereby limiting future complications and morbidity.
Case Presentations
A mother runs past triage screaming, “My daughter is choking!” You run over to assess the child, who is coughing but has good air entry bilaterally, no retractions, and appears generally well in between coughs. The mother reports that her 3-year-old was eating trail mix and started coughing and gasping for air. You debate the need for imaging and wonder how long you should observe this child.
A resident approaches you to present a 6-year-old boy brought in by his father after the child swallowed a small magnetic toy. The father tells you his son coughed and gagged, and now reports that it feels like there is something in his throat. What imaging should you obtain, and what consultants should you call, if any?
You are evaluating a 2-year-old girl who has had 1 week of fever, coughing, and increasing respiratory distress with no known history of foreign body ingestion. You obtain an x-ray that shows significant air trapping in the right lung field, as well as right middle lobe pneumonia. What should you do to stabilize this patient? Is there a role for bronchodilators, racemic epinephrine, and/or steroids? Is any other imaging needed to rule out an inhaled foreign body?
Introduction
Inhaled foreign bodies remain a significant cause of morbidity in children, with reported mortality between 0 and 1.8%.1-3 Prior to the advent of advanced endoscopic techniques, mortality rates were reported to be as high as 24%.4
Exploring their surroundings with their mouths is a normal part of development that puts children at higher risk of accidental foreign body inhalation than adults. Children aged < 3 years are at greater risk for inhalation of foreign bodies than older children. These young children have immature oropharyngeal coordination, poorly developed or no molar chewing, higher respiratory rates, are more likely to be active and playing while eating, and more likely to experience reflex inhalation while laughing or crying.5-7
According to the United States Centers For Disease Control and Prevention (CDC), an estimated 17,000 children aged < 14 years presented to the emergency department (ED) for choking-related episodes in 2001 (29.9 persons/100,000 population). Approximately 10% of these patients were admitted to the hospital. Choking rates were highest for infants aged < 1 year and decreased with age, with a slight peak in the 5-year-old to 9-year-old age group. Overall, 59.5% of these children were treated for choking on a food substance, 31.4% on a nonfood substance, and 9% on an undetermined substance. The incidence of choking on food versus nonfood substances varied with age. Food substances accounted for 75.7% of choking-related episodes in children aged 5 to 14 years, 58.4% in children aged 1 to 4 years, and 52.1% among infants aged < 1 year. When considering inhaled or aspirated foreign bodies, organic food substances are the most common. Hard candy was the most commonly inhaled food substance (64%), and coins were the most frequently inhaled nonfood substance (18%). Coins accounted for 18.2% of choking-related episodes among children aged 1 to 4 years.8 However, these data do not distinguish between choking episodes resulting in coins lodged in the esophagus versus the airway.
Foreign body inhalation can present variably, ranging from nonspecific respiratory symptoms to respiratory failure associated with a choking episode. Delayed diagnosis of > 24 hours is common and is associated with increased complications and mortality.9 In a 2012 meta-analysis of 1063 papers published over a 30-year period, delayed diagnosis of > 24 hours occurred in an estimated 40% of patients, and complications occurred in approximately 15% of these patients.9 A 2005 retrospective study cited pneumonia, bronchiectasis, and bronchoesophageal fistula as complications of diagnosis delayed > 1 month. Misdiagnosis and parental delay in seeking care were cited as common reasons for delayed diagnosis, although all patients presented with a chief complaint of chronic cough.10
Critical Appraisal Of The Literature
A literature search was performed in PubMed using a combination of the search terms pediatrics, child, infant, toddler, inhaled, aspirated, tracheobronchial foreign body, and aspiration pneumonia. Over 150 articles published in the English language were reviewed, and 89 were included in this issue.
Many case series and a significant number of retrospective studies were available, but very few prospective studies were found. There is a lack of uniformity of definitions and management recom-mendations from center to center, and between specialties. Additionally, there is a paucity of emergency medicine literature, as most articles originate from otolaryngology and surgical literature.
Risk Management Pitfalls For Management Of Inhaled Foreign Bodies
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“The x-ray appears normal, so there can’t be a foreign body.”
Normal x-ray findings do not exclude radiolucent foreign body aspiration. Additionally, radiographic signs may be delayed > 24 hours. Most aspirated foreign bodies are organic, which includes food products, paper, and other mostly radiolucent objects. Radio-opaque objects include glass and metal; however, many plastic objects will not be radio-opaque.
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“No one saw him choke or cough, so a foreign body is not on my differential.”
While a witnessed choking episode is helpful in suspecting the diagnosis of foreign body inhalation, it is not present in the majority of cases, and, therefore, its absence does not exclude an inhaled foreign body.
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“Some kids are just prone to pneumonia; it doesn’t mean it’s a foreign body.”
Recurrent or nonresolving unilateral pneumonia should raise the emergency clinician’s suspicion for a retained inhaled foreign body, and workup should be done before the assumption is made that the child is simply prone to pneumonia. Infection usually occurs distal to the site of obstruction, as a late complication.
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“I thought patting the choking toddler, who was coughing and gasping, on the back would help to dislodge the foreign body he was chok-ing on, but instead, his status worsened and he stopped breathing.”
In infants aged < 12 months, chest compressions or back blows are the preferred method to dislodge a foreign body. In older children, abdominal thrusts are preferred. However, these methods are indicated in cases of complete obstruction and should not be attempted if a patient is coughing or able to speak (partially obstructed), as these methods can cause complete obstruction.
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“I saw a patient bite off a piece of a ‘glove balloon’ and start coughing right in front of me. What is the harm of trying to get it out with my finger while it still may be in his posterior pharynx?”
By the time a patient is coughing, the foreign body is probably at least at the level of the larynx. Blind finger sweeps can not only further dislodge any material that is left in the posterior pharynx, but can cause significant trauma to the delicate tissues. In this case, direct visualization with direct laryngoscopy and the use of Magill forceps for removal at the bedside may be indicated.
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“He has no symptoms, so let's just discharge him.”
Foreign body inhalation may be asymptomatic for hours to weeks after the event. History and index of suspicion, in addition to the presence of symptoms, should guide the decision to image and/or observe the patient.
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“He is wheezing and the x-ray shows atelectasis. He isn’t really improving in the ED, but it’s probably just asthma. Let’s admit him for steroids, bronchodilator therapy, and observation.”
While there may be a role for bronchodilator therapy in the event of an inhaled foreign body, any patient with abnormal x-ray findings who fails to improve with bronchodilator therapy should be assessed for a possible inhaled foreign body. Inspiratory/expiratory films, fluoroscopy or CT, as well as a thorough history and physical examination, may help elucidate the diagnosis.
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“This child will never cooperate with inspiratory and expiratory films; let’s just do a CT.”
An x-ray may show signs of air trapping or a radio-opaque foreign body without inspiratory/ expiratory films. Additionally, although the sensitivity of decubitus films is debatable, they may show air trapping that would be an indication for bronchoscopy, thus avoiding a CT. Disadvantages of CT are the cost and time of testing, the possible need for sedation with its inherent risks, and the risks of radiation.
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“There is no way my child could have inhaled a toy. It just wouldn’t fit!”
According to the 1994 Child Safety Protection Act, any toy with small parts (defined as < 4.44 cm) is considered a choking hazard to small children.
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“The child has stridor, but the chest x-ray is negative, so there is no foreign body, right?”
Stridor is indicative of a tracheal or laryngeal foreign body, both of which may not be seen on chest films. Anterior-posterior and lateral neck films should be obtained in the case of stridor. The index of suspicion should drive the decision to order a bronchoscopy for a foreign body rather than image alone.
Tables And Figures
References
Evidence-based medicine requires a critical appraisal of the literature based upon study methodology and number of subjects. Not all references are equally robust. The findings of a large, prospective, randomized, and blinded trial should carry more weight than a case report.
To help the reader judge the strength of each reference, pertinent information about the study, such as the type of study and the number of patients in the study will be included in bold type following the references, where available. The most informative references cited in this paper, as determined by the author, will be noted by an asterisk (*) next to the number of the reference.
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* Zhijun C, Fugao Z, Niankai Z, et al. Therapeutic experience from 1428 patients with pediatric tracheobronchial foreign body. J Pediatr Surg. 2008;43(4):718-721. (Retrospective case review; 1428 patients)
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Passali D, Lauriello M, Bellussi L, et al. Foreign body inhalation in children: an update. Acta Otorhinolaryngol Ital. 2010;30(1):27-32. (Review)
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Eren S, Balci AE, Dikici B, et al. Foreign body aspiration in children: experience of 1160 cases. Ann Trop Paediatr. 2003;23(1):31-37. (Retrospective review; 1160 patients aged < 15 years)
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Tamiru T, Gray PE, Pollock JD. An alternative method of management of pediatric airway foreign bodies in the absence of rigid bronchoscopy. Int J Pediatr Otorhinolaryngol. 2013;77(4):480-482. (Case review; 7 patients)
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* Rodriguez H, Passali GC, Gregori D, et al. Management of foreign bodies in the airway and oesophagus. Int J Pediatr Otorhinolaryngol. 2012;76 Suppl 1:S84-S91. (Review)
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Shubha AM, Das K. Tracheobronchial foreign bodies in infants. Int J Pediatr Otorhinolaryngol. 2009;73(10):1385-1389. (Retrospective review; 102 patients aged < 3 years)
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Crawford NW. Foreign body aspiration in a child detected through emergency department radiology reporting: a case report. Eur J Emerg Med. 2007;14(4):219-221. (Case report; 1 patient)
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United States Centers for Disease Control and Prevention. Ten leading causes of death and injury. Available at http://www.cdc.gov/injury/wisqars/leadingcauses.html. Accessed 5/1/15. (CDC web-based injury statistics query and reporting system)
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* Foltran F, Ballali S, Passali FM, et al. Foreign bodies in the airways: a meta-analysis of published papers. Int J Pediatr Otorhinolaryngol. 2012;76 Suppl 1:S12-S19. (Meta-analysis)
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Saquib Mallick M, Rauf Khan A, Al-Bassam A. Late presentation of tracheobronchial foreign body aspiration in children. J Trop Pediatr. 2005;51(3):145-148. (Retrospective review; 128 patients)
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* Chiu CY, Wong KS, Lai SH, et al. Factors predicting early diagnosis of foreign body aspiration in children. Pediatr Emerg Care. 2005;21(3):161-164. (Retrospective review; 53 patients)
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Higuchi O, Adachi Y, Ichimaru T, et al. Foreign body aspiration in children: a nationwide survey in Japan. Int J Pediatr Otorhinolaryngol. 2009;73(5):659-661. (Retrospective survey study; 163 cases)
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Singh H, Parakh A. Tracheobronchial foreign body aspiration in children. Clin Pediatr (Phila). 2014;53(5):415-419. (Review)
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Pan H, Lu Y, Shi L, et al. Similarities and differences in aspirated tracheobronchial foreign bodies in patients under the age of 3 years. Int J Pediatr Otorhinolaryngol. 2012;76(6):911- 914. (Retrospective chart review; 316 patients aged < 3 years)
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Oncel M, Sunam GS, Ceran S. Tracheobronchial aspiration of foreign bodies and rigid bronchoscopy in children. Pediatr Int. 2012;54(4):532-535. (Retrospective review; 184 patients aged < 16 years)
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Sih T, Bunnag C, Ballali S, et al. Nuts and seed: a natural yet dangerous foreign body. Int J Pediatr Otorhinolaryngol. 2012;76 Suppl 1:S49-S52. (Data analysis; 17,000 patients aged 0-14 years, 60 institutions)
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Hidaka H, Obara T, Kuriyama S, et al. Logistic regression analysis of risk factors for prolonged pulmonary recovery in children from aspirated foreign body. Int J Pediatr Otorhinolaryngol. 2013;77(10):1677-1682. (Case review; 77 cases)
-
Shah BR, Lucchesi M. Atlas of Pediatric Emergency Medicine. 1st ed. New York: McGraw-Hill Medical Publishing Division; 2006. (Textbook)
-
Hada MS, Chadha V, Mishra P, et al. “Slam dunk”: a case report of an unusual metallic foreign body. J Bronchology Interv Pulmonol. 2012;19(2):156-158. (Case report; 1 patient)
-
Berchialla P, Snidero S, Stancu A, et al. Predicting severity of foreign body injuries in children in upper airways: an approach based on regression trees. Risk Anal. 2007;27(5):1255- 1263. (Data analysis)
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Dias E. An unusual case of foreign body aspiration in an infant. Ann Med Health Sci Res. 2012;2(2):209-210. (Case report; 1 patient)
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Walz PC, Scholes MA, Merz MN, et al. The internet, adolescent males, and homemade blowgun darts: a recipe for foreign body aspiration. Pediatrics. 2013;132(2):e519-e521. (Case series; 3 cases)
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Chen M, Zhang J, Liu W, et al. Clinical features and management of aspiration of plastic pen caps. Int J Pediatr Otorhino-laryngol. 2012;76(7):980-983. (Retrospective chart review; 44 patients aged 35 months-12 years)
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Soysal O, Kuzucu A, Ulutas H. Tracheobronchial foreign body aspiration: a continuing challenge. Otolaryngol Head Neck Surg. 2006;135(2):223-226. (Retrospective chart review; 140 patients)
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* Widome MD. American Academy of Pediatrics. Committee on Injury and Poison Prevention. Injury Prevention and Control for Children and Youth. 3rd ed. Elk Grove Village, IL: The Academy; 1997. (Practice guidelines)
-
Swanson KL. Airway foreign bodies: what’s new? Semin Respir Crit Care Med. 2004;25(4):405-411. (Review)
-
Karakoc F, Cakir E, Ersu R, et al. Late diagnosis of foreign body aspiration in children with chronic respiratory symptoms. Int J Pediatr Otorhinolaryngol. 2007;71(2):241-246. (Retrospective chart review; 654 cases)
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Mu L, He P, Sun D. The causes and complications of late diagnosis of foreign body aspiration in children. Report of 210 cases. Arch Otolaryngol Head Neck Surg. 1991;117(8):876-879. (Retrospective review; 210 patients)
-
Friedman EM. Tracheobronchial foreign bodies. Otolaryngol Clin North Am. 2000;33(1):179-185. (Review)
-
Heyer CM, Bollmeier ME, Rossler L, et al. Evaluation of clinical, radiologic, and laboratory prebronchoscopy findings in children with suspected foreign body aspiration. J Pediatr Surg. 2006;41(11):1882-1888. (Retrospective chart review; 160 patients)
-
Cohen S, Avital A, Godfrey S, et al. Suspected foreign body inhalation in children: what are the indications for bronchoscopy? J Pediatr. 2009;155(2):276-280. (Prospective study; 142 patients aged 0-14 years)
-
Ibrahimov M, Yollu U, Akil F, et al. Laryngeal foreign body mimicking croup. J Craniofac Surg. 2013;24(1):e7-e8. (Case report)
-
Atmaca S, Unal R, Sesen T, et al. Laryngeal foreign body mistreated as recurrent laryngitis and croup for one year. Turk J Pediatr. 2009;51(1):65-66. (Case report)
-
AuBuchon J, Krucylak C, Murray DJ. Subglottic airway foreign body: a near miss. Anesthesiology. 2011;115(6):1300. (Case study)
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Cakir E, Torun E, Uyan ZS, et al. An unusual case of foreign body aspiration mimicking cavitary tuberculosis in adolescent patient: thread aspiration. Ital J Pediatr. 2012;38:17. (Case report)
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Aslan AT, Yalcin E, Ozcelik U, et al. Foreign-body aspiration mimicking congenital lobar emphysema in a forty-eight-day-old girl. Pediatr Pulmonol. 2005;39(2):189-191. (Case report)
-
Veras TN, Hornburg G, Schner AM, et al. Use of virtual bronchoscopy in children with suspected foreign body aspiration. J Bras Pneumol. 2009;35(9):937-941. (Case series; 2 patients)
-
Saliba J, Mijovic T, Daniel S, et al. Asthma: the great imitator in foreign body aspiration? J Otolaryngol Head Neck Surg. 2012;41(3):200-206. (Retrospective chart review; 55 patients)
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Kugelman A, Shaoul R, Goldsher M, et al. Persistent cough and failure to thrive: a presentation of foreign body aspiration in a child with asthma. Pediatrics. 2006;117(5):e1057- e1060. (Case report)
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Huankang Z, Kuanlin X, Xiaolin H, et al. Comparison between tracheal foreign body and bronchial foreign body: a review of 1,007 cases. Int J Pediatr Otorhinolaryngol. 2012;76(12):1719-1725. (Retrospective chart review; 1007 patients)
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Vunda A, Vandertuin L. Nasopharyngeal foreign body following a blind finger sweep. J Pediatr. 2012;160(2):353. (Case report)
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Abder-Rahman HA. Infants choking following blind finger sweep. J Pediatr (Rio J). 2009;85(3):273-275. (Case series; 3 infants)
-
Berg MD, Schexnayder SM, Chameides L, et al. Part 13: pediatric basic life support. 2010 American Heart Association guidelines for cardiopulmonary resuscitation and emergency cardiovascular care. Circulation. 2010;122(18 Suppl 3):S862- S875. (Practice guidelines)
-
Dorfman A, Pauze D, Tilney P. A near fatality in a 6-month-old boy from an aspirated toy. Air Med J. 2011;30(2):64-67. (Case report)
-
Even L, Heno N, Talmon Y, et al. Diagnostic evaluation of foreign body aspiration in children: a prospective study. J Pediatr Surg. 2005;40(7):1122-1127. (Prospective observational study; 98 patients)
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Paksu S, Paksu MS, Kilic M, et al. Foreign body aspiration in childhood: evaluation of diagnostic parameters. Pediatr Emerg Care. 2012;28(3):259-264. (Retrospective chart review; 147 patients)
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Ezer SS, Oguzkurt P, Ince E, et al. Foreign body aspiration in children: analysis of diagnostic criteria and accurate time for bronchoscopy. Pediatr Emerg Care. 2011;27(8):723-726. (Retrospective chart review; 191 patients aged 0-14 years)
-
Hammoudi K, Bakhos D, Bakhos-Merieau E, et al. Persistent dysphonia showing a laryngeal foreign body in a child. Arch Pediatr. 2011;18(7):764-766. (Case report)
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Orji FT, Akpeh JO. Tracheobronchial foreign body aspiration in children: how reliable are clinical and radiological signs in the diagnosis? Clin Otolaryngol. 2010;35(6):479-485. (Retrospective chart review; 103 patients aged < 14 years)
-
Kiyan G, Gocmen B, Tugtepe H, et al. Foreign body aspiration in children: the value of diagnostic criteria. Int J Pediatr Otorhinolaryngol. 2009;73(7):963-967. (Retrospective chart review; 207 patients)
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* Hitter A, Hullo E, Durand C, et al. Diagnostic value of vari-ous investigations in children with suspected foreign body aspiration: review. Eur Ann Otorhinolaryngol Head Neck Dis. 2011;128(5):248-252. (Review)
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Hu M, Green R, Gungor A. Pneumomediastinum and subcutaneous emphysema from bronchial foreign body aspiration. Am J Otolaryngol. 2013;34(1):85-88. (Case report)
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Gupta RK, Gupta A, Sanghvi B, et al. Subcutaneous emphysema: an unusual presentation of foreign body aspiration. J Bronchology Interv Pulmonol. 2009;16(2):124-126. (Case report; 2 patients)
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Kothari V, Sonkhya N, Sharma C, et al. Pneumothorax secondary to foreign body inhalation in an infant. Indian J Otolaryngol Head Neck Surg. 2006;58(2):211-212. (Case report; 1 patient)
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Jhamb U, Sethi GR, Puri R, et al. Surgical emphysema: a rare presentation of foreign body inhalation. Pediatr Emerg Care. 2004;20(5):311-313. (Case report; 1 patient)
-
Girardi G, Contador AM, Castro-Rodriguez JA. Two new radiological findings to improve the diagnosis of bronchial foreign-body aspiration in children. Pediatr Pulmonol. 2004;38(3):261-264. (Retrospective review; 133 patients aged < 3 years)
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* Sersar SI, Rizk WH, Bilal M, et al. Inhaled foreign bodies: presentation, management and value of history and plain chest radiography in delayed presentation. Otolaryngol Head Neck Surg. 2006;134(1):92-99. (Retrospective review; 3300 patients aged > 10 years)
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Mortellaro VE, Iqbal C, Fu R, et al. Predictors of radiolucent foreign body aspiration. J Pediatr Surg. 2013;48(9):1867-1870. (Retrospective review; 138 patients)
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* Boufersaoui A, Smati L, Benhalla KN, et al. Foreign body aspiration in children: experience from 2624 patients. Int J Pediatr Otorhinolaryngol. 2013;77(10):1683-1688. (Retrospective review; 2624 patients)
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Cataneo AJ, Cataneo DC, Ruiz RL Jr. Management of tracheobronchial foreign body in children. Pediatr Surg Int. 2008;24(2):151-156. (Retrospective chart review; 164 patients)
-
Assefa D, Amin N, Stringel G, et al. Use of decubitus radiographs in the diagnosis of foreign body aspiration in young children. Pediatr Emerg Care. 2007;23(3):154-157. (Retrospective review; 41 patients aged > 5 years)
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Bai W, Zhou X, Gao X, et al. Value of chest CT in the diagnosis and management of tracheobronchial foreign bodies. Pediatr Int. 2011;53(4):515-518. (Prospective cohort study; 45 patients)
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Manach Y, Pierrot S, Couloigner V, et al. Diagnostic performance of multidetector computed tomography for foreign body aspiration in children. Int J Pediatr Otorhinolaryngol. 2013;77(5):808-812. (Multicenter prospective study; 303 patients aged 6-16 years)
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Bhat KV, Hegde JS, Nagalotimath US, et al. Evaluation of computed tomography virtual bronchoscopy in paediatric tracheobronchial foreign body aspiration. J Laryngol Otol. 2010;124(8):875-879. (Prospective cohort study; 40 patients)
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Hong SJ, Goo HW, Roh JL. Utility of spiral and cine CT scans in pediatric patients suspected of aspirating radiolucent foreign bodies. Otolaryngol Head Neck Surg. 2008;138(5):576-580. (Prospective case series; 51 patients)
-
Adaletli I, Kurugoglu S, Ulus S, et al. Utilization of low-dose multidetector CT and virtual bronchoscopy in children with suspected foreign body aspiration. Pediatr Radiol. 2007;37(1):33-40. (Prospective case series; 37 patients)
-
Gang W, Zhengxia P, Hongbo L, et al. Diagnosis and treatment of tracheobronchial foreign bodies in 1024 children. J Pediatr Surg. 2012;47(11):2004-2010. (Retrospective chart review; 1024 patients aged > 13 years)
-
Ma G, Yang J, Liu S. Anesthetic management of bronchial rupture following extraction of a fishbone from the bronchus after 5 months. Paediatr Anaesth. 2014;24(5):544-546. (Case report; 1 patient)
-
Righini CA, Morel N, Karkas A, et al. What is the diagnostic value of flexible bronchoscopy in the initial investigation of children with suspected foreign body aspiration? Int J Pediatr Otorhinolaryngol. 2007;71(9):1383-1390. (Prospective study; 70 patients)
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Ozguner IF, Buyukyavuz BI, Savas C, et al. Clinical experience of removing aerodigestive tract foreign bodies with rigid endoscopy in children. Pediatr Emerg Care. 2004;20(10):671- 673. (Retrospective review; 53 patients)
-
Tariq SM, Succony L, Bhatia RS. Spontaneous expulsion of a sharp foreign body. J Bronchology Interv Pulmonol. 2012;19(4):319-322. (Case report; 1 patient)
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Hasdiraz L, Oguzkaya F, Bilgin M, et al. Complications of bronchoscopy for foreign body removal: experience in 1,035 cases. Ann Saudi Med. 2006;26(4):283-287. (Retrospective chart review; 1035 pediatric patients)
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Cavel O, Bergeron M, Garel L, et al. Questioning the legitimacy of rigid bronchoscopy as a tool for establishing the diagnosis of a bronchial foreign body. Int J Pediatr Otorhinolaryngol. 2012;76(2):194-201. (Retrospective chart review; 32 patients)
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Rodrigues AJ, Scussiatto EA, Jacomelli M, et al. Bronchoscopic techniques for removal of foreign bodies in children’s airways. Pediatr Pulmonol. 2012;47(1):59-62. (Retrospective review; 78 patients)
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* Tang LF, Xu YC, Wang YS, et al. Airway foreign body removal by flexible bronchoscopy: experience with 1027 children during 2000-2008. World J Pediatr. 2009;5(3):191-195. (Retrospective review; 1027 patients)
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Cai Y, Li W, Chen K. Efficacy and safety of spontaneous ventilation technique using dexmedetomidine for rigid bronchoscopic airway foreign body removal in children. Paediatr Anaesth. 2013;23(11):1048-1053. (Retrospective review; 80 patients)
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Mani N, Soma M, Massey S, et al. Removal of inhaled foreign bodies--middle of the night or the next morning? Int J Pediatr Otorhinolaryngol. 2009;73(8):1085-1089. (Retrospective case review; 165 patients)
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Li Y, Wu W, Yang X, et al. Treatment of 38 cases of foreign body aspiration in children causing life-threatening complications. Int J Pediatr Otorhinolaryngol. 2009;73(12):1624-1629. (Retrospective case review; 38 cases)
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Ulku R, Onen A, Onat S, et al. The value of open surgical approaches for aspirated pen caps. J Pediatr Surg. 2005;40(11):1780-1783. (Retrospective review; 19 cases)
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Thatte NM, Guglani L, Turner DR, et al. Retrieval of endobronchial foreign bodies in children: involving the cardiac catheterization lab. Pediatrics. 2014;134(3):e865-e869. (Case report; 2 patients)
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Varshney R, Zawawi F, Shapiro A, et al. Use of an endoscopic urology basket to remove bronchial foreign body in the pediatric population. Int J Pediatr Otorhinolaryngol. 2014;78(4):687- 689. (Case report; 2 cases)
-
Chung PH, Wong KK, Lan LC, et al. Peanut aspiration: an avoidable life-threatening condition. Hong Kong Med J. 2012;18(4):340-342. (Case report; 2 patients)
-
McAfee SJ, Vashisht R. Removal of an impacted distal airway foreign body using a guidewire and a balloon angioplasty catheter. Anaesth Intensive Care. 2011;39(2):303-304. (Case report; 1 patient)
-
Sabra O, El-Bitar M. The role of beta-2 agonists in foreign body aspiration. Eur Arch Otorhinolaryngol. 2009;266(4):571- 572. (Case report; 1 patient)
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Jacob SS, Jacob JJ, Paul TV. Foreign body aspiration in a boy with Prader-Willi Syndrome. Singapore Med J. 2008;49(1):e12- e14. (Case report; 1 patient)
-
Budhram G, Murman D, Lutfy L, et al. Sonographic confirmation of intubation: comparison of 3 methods in a pig model. J Ultrasound Med. 2014;33(11):1925-1929. (Animal study)
-
Weaver B, Lyon M, Blaivas M. Confirmation of endotracheal tube placement after intubation using the ultrasound sliding lung sign. Acad Emerg Med. 2006;13(3):239-244. (Cadaver study; 68 intubations)
-
Werner SL, Smith CE, Goldstein JR, et al. Pilot study to evaluate the accuracy of ultrasonography in confirming endotracheal tube placement. Ann Emerg Med. 2007;49(1):75- 80. (Prospective randomized controlled pilot study; 33 patients)
-
* Gregori D, Scarinzi C, Berchialla P, et al. The cost of foreign body injuries in the upper aero-digestive tract: need for a change from a clinical to a public health perspective? Int J Pediatr Otorhinolaryngol. 2007;71(9):1391-1398. (Multicenter cost analysis; 2103 consecutive cases)