Foreign body aspiration can be a difficult diagnosis to establish. However, in a patient, particularly a child, who presents with an episode of sudden choking or spasmodic coughing, an aspiration event should be considered as a primary diagnosis. Radiographic studies may be helpful, but no test is sufficiently sensitive and specific to exclude the diagnosis of foreign body aspiration. A good history and examination is of greater import than a confirmatory x-ray study. Most importantly, the diagnosis of an airway foreign body cannot be excluded without bronchoscopy.
In the patient who presents with an episode of choking or coughing, and who has physical findings on pulmonary examination to suggest the presence of a foreign body (ie, wheezing, rhonchi, decreased breath sounds), a bronchoscopy should be performed. There is no need for additional radiographic studies. In the patient who has a history consistent with possible aspiration but a normal examination, x-ray studies including inspiratory and expiratory films, bilateral decubitus films, or fluoroscopy of the chest may be helpful. If there is a good history for aspiration, the examination is normal, and the radiographic studies are normal, then careful follow-up with repeat x-rays within 1 week of the event would be appropriate.
It is important to remember that early identification of an aspirated foreign body will lead to fewer long-term problems. Therefore, the endoscopist should expect that a certain percentage of patients (generally accepted at 10 to 20%) will not have a foreign body found on bronchoscopy. Otherwise, some foreign bodies will be missed, and complications from foreign body aspiration are almost always secondary to a delayed diagnosis.
There is an increasing place for fiber-optic bronchoscopy in evaluation for possible foreign body aspiration. In patients who have a chronic respiratory process even without a history of aspiration, one must consider foreign body aspiration as a cause of the pulmonary symptoms. Flexible bronchoscopy is a good way to survey the tracheobronchial tree. If a foreign body is found, then it is reasonable in adults and generally recommended in children to remove the flexible bronchoscope and perform a rigid bronchoscopy for extraction of the foreign material. As experience accrues and instrumentation improves, flexible bronchoscopy and extraction may become the major treatment option for this problem.
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