Suspected foreign body inhalation in children: What are the indications for bronchoscopy?

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To the Editor:

Cohen et al¹ should be congratulated on presenting such a clear approach to inhaled foreign bodies in children. Their study systematizes what has been our clinical approach over many years, emphasizing the importance of the initial history of aspiration and the presence of ongoing cough (or sudden onset of cough in the absence of a witnessed aspiration event), particularly in the toddler. Physical examination of the chest and chest radiography are important too but are less likely to be positive. Their article, however, gives no detail about the chest radiograph requested. The traditional teaching was for an inspiratory and expiratory chest film to look for differential emptying of the lung on expiration created by a ball-valve effect on the affected side. Capturing the correct respiratory phase is nearly impossible from most toddlers, rendering the test unhelpful unless there is significant atelectasis (more often after prolonged aspiration) or a radiopaque foreign body (rare). Our practice is to request lateral decubitus films, which guarantees good emptying of the lungs on the dependent side to emphasize gas trapping.² Can the authors clarify the chest radiography technique used in their study?

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References 

1. Cohen S, Avital A, Godfrey S, Gross M, Kerem E, Springer C. Suspected foreign body inhalation in children: What are the indications for bronchoscopy?. J Pediatr. 2009;155:276–280
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2. Lucaya J, Strife JL. Foriegn body aspiration: Imaging techniques. In:  Lucaya J,  Strife JL editor. Pediatric chest imaging. 2nd ed. Philadelphia: Springer; 2008;p. 201–203
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