From the Guidelines
Bronchoscopy is not routinely indicated for asymptomatic pediatric patients with a history of foreign body ingestion. The decision to perform bronchoscopy in such cases should be made on an individual basis, considering the patient's history, physical examination, and results of previous diagnostic tests 1. According to the European Respiratory Journal, flexible bronchoscopy can be performed for diagnostic and therapeutic purposes, but it is generally contraindicated for the removal of endobronchial foreign bodies, treatment of massive haemoptysis, and in the diagnosis of acute epiglottitis 1.
Key Considerations
- The initial approach for asymptomatic pediatric patients with a history of foreign body ingestion should focus on clinical assessment, radiographic evaluation, and observation.
- Bronchoscopy becomes necessary only when there is clinical suspicion of foreign body aspiration into the airway, which typically presents with symptoms such as coughing, wheezing, stridor, or respiratory distress.
- The decision to perform bronchoscopy should be based on the risk-benefit assessment, as the procedure requires general anesthesia in children and carries its own risks 1.
- If the history strongly suggests aspiration despite absence of symptoms, or if the child is very young with unreliable symptom reporting, bronchoscopy may be considered on a case-by-case basis after consultation with a pediatric pulmonologist or otolaryngologist.
Indications for Bronchoscopy
- Airway obstruction
- Stridor/noisy breathing
- Persistent/recurrent wheezing
- Radiographic abnormalities
- Atelectasis
- Recurrent/persistent consolidations
- Localised hyperinflation
- Chronic cough
- Suspected foreign body aspiration
- Haemoptysis
- Evaluation of the artificial airway
- Therapeutic bronchoscopy
- Restoration of airway patency
- Mucus plugs or blood clots
- Alveolar filling disorders
- Special procedures
- Bronchoalveolar lavage
- Brushing or biopsy of the bronchial mucosa
- Biopsy of endobronchial lesions
- Transbronchial biopsy
- Administration of drugs
- Endoscopic intubation
In truly asymptomatic children with normal radiographic findings and no history suggesting aspiration, watchful waiting is appropriate with instructions to return if respiratory symptoms develop 1.
From the Research
Role of Bronchoscopy in Asymptomatic Pediatric Patients with a History of Foreign Body Ingestion
- Bronchoscopy is a crucial procedure for the removal of foreign bodies from the airways, especially in pediatric patients 2, 3.
- In cases where a foreign body is suspected to have entered the lower respiratory tract, immediate and adequate actions are required to solve the problem, and bronchoscopy should be conducted in every suspected case of foreign body aspiration 2.
- The procedure is particularly important for asymptomatic patients, as it can help prevent potential complications such as respiratory distress, esophageal erosions, or even an aortoesophageal fistula 4, 5.
- Flexible bronchoscopy is increasingly being used as the initial diagnostic procedure in children with an uncertain history of choking, in the absence of physical and radiological lung changes, and in chronic complaints requiring the exclusion of a foreign body in the airways 2.
- The decision to perform bronchoscopy should be based on the patient's clinical presentation, the type and location of the foreign body, and the risk of potential complications 3, 5.
Indications for Bronchoscopy
- A history of witnessed ingestion or aspiration event should raise the clinical suspicion for an aspirated foreign body 3.
- Patients with upper-airway foreign bodies are more likely to present in respiratory distress, while those with lower-airway foreign bodies may present with more subtle signs such as coughing or wheezing 3.
- Immediate intervention is required in patients with hemodynamic instability or respiratory distress, and bronchoscopy may be necessary to remove the obstructing foreign body and secure the airway 3.
Timing of Bronchoscopy
- In cases where a foreign body is suspected to have entered the airways, bronchoscopy should be performed as soon as possible to prevent potential complications 2, 3.
- The timing of bronchoscopy may depend on the patient's clinical presentation, the type and location of the foreign body, and the risk of potential complications 3, 5.
- In asymptomatic patients, bronchoscopy may be performed on an urgent basis, rather than an emergency basis, to allow for proper preparation and planning 5.