Does this child have a foreign body aspiration

Does this child have a foreign body aspiration ? Pauchard JY, Bulatovic AM, Gehri M

Does this child have a foreign body aspiration? Why is the question important?

Does this child have a foreign body aspiration ? Life threatening airway obstruction

Does this child have a foreign body aspiration ? Acute cough and cyanose Normal radiography pulmonary Normal physical examen

Does this child have a foreign body aspiration ? History of choking event or suspicion of Fb. A = Bronchoscopy

Does this child have a foreign body aspiration? What are your objectives?

Does this child have a foreign body aspiration ? • Objectives – To review in litterature the diagnostic accuracy of clinical presentation (CP) and pulmonary radiography (PR) of foreign body aspiration (Fb. A) – Diagnostic and management algorithm of Fb. A – No previous review in litterature

Does this child have a foreign body aspiration? What is your method?

Does this child have a foreign body aspiration ? • Method – Research in Medline and Embase databases – Articles containing data regarding CP and PR of Fb. A • Inclusion criteria – Prospective studies • Exclusion – Retrospective data – Articles containing incomplete data for calculation of Se, Sp, LR for signs and symptoms of Fb. A

Does this child have a foreign body aspiration ? • Method – Bivariate analysis was used to calculate pooled estimates of Sensibility (Se), Specificity (Sp) and Likelihood ratio (LR) with 95% confidence intervals (95%IC) for signs, symptoms of CP and signs of PR – Use of Bayes theorem to calculate Pre and Post test probability for diagnostic algorithm

Likelihood ratio Positive or negative LR -Characteristic of diagnostic value -Probability of a positive (negative) sign in patients with the disease divided by the probability of a positive (negative) sign in patients without disease Positive LR Negative LR Diagnostic value >10 <0. 1 Very high 5 -10 0. 1 -0. 2 High 2 -5 0. 2 -0. 5 Moderate 1 -2 0. 5 -1 Minor 1 1 No

Does this child have a foreign body aspiration? What are your results?

Results (1): Study characteristic Authors Setting No of patients Age range Inclusion criteria Diagnostic Prevalence (%) Cohen (1) ED 142 3 m-14 y Acute episode of choking or acute persistent cough Bronchoscopy rigid or flexible 43 Even (2) PD 98 8 m-7 y Suspected Fb. A Bronchoscopy rigid 57 Righini (3) ED 70 Age median 24 m History or suspicion of Fb. A Bronchoscopy flexible or rigid 61 Ayed (4) Chest hospital 235 7 m-15 y Suspected Fb. A Bronchoscopy rigid 87 Martinot (5) PD 83 Age median 24 m Suspected Fb. A Bronchoscopy flexible or rigid 48 Total 628 66

Results (2): Accuracy for symptoms of Fb. A Symptoms by reference Sensibility (95%IC) Specificity (95%IC) Positive LR (95%IC) Negative LR (95%IC) Witnessed choking event (1, 2, 3, 4, 5) 82 (79 -86) 36 (30 -43) 1. 3 (0. 9 -1. 9) 0. 49 (0. 3 -0. 7) Cyanose (1, 5) 10 (4 -16) 98 (95 -100) 4. 1 (1. 1 -15) 0. 9 (0. 3 -3. 4) Dyspnea/Tachypnea (1, 3) 21 (13 -29) 89 (83 -94) 1. 8 (0. 9 -3. 8) 0. 9 (0. 4 -1. 9) Cough (1, 3, 4, 5) 77 (73 -82) 42 (34 -49) 1. 3 (0. 9 -2) 0. 55 (0. 4 -0. 8) Stridor (4, 5) 17 (11 -22) 66 (48 -83) 0. 5 (0. 2 -1. 1) 1. 3 (0. 5 -3) Fever (1, 5) 24 (15 -32) 70 (62 -78) 0. 8 (0. 4 -1. 4) 1. 1 (0. 6 -2)

Results (3): Accuracy for signs of Fb. A Signs by reference Sensitivity (95%IC) Specificity (95%IC) Positive LR (95%IC) Negative LR (95%IC) Normal auscultation (1, 2) 14 (7 -21) 37 (28 -45) 2. 3 (1. 2 -0. 4) 0. 2 (0. 1 -0. 4) Localized decreased breath sounds (1, 3, 5) 66 (59 -74) 85 (79 -91) 4. 3 (2. 5 -7. 6) 0. 4 (0. 2 -0. 7) Asymetric auscultation (4) 80 (75 -86) 72 (56 -89) 2. 9 (1. 2 -7) 0. 27 (0. 1 -0. 7) Localized wheezing (1, 3) 34 (25 -43) 86 (79 -93) 2. 5 (1. 2 -5) 0. 8 (0. 4 -1. 5) Wheeze (4, 5) 30 (25 -36) 76 (67 -86) 1. 3 (0. 7 -2. 4) 0. 9 (0. 5 -1. 7) Crakles (1, 3) 18 (10 -25) 88 (82 -94) 1. 5 (0. 7 -2. 3) 0. 9 (0. 4 -2)

Results (4): Accuracy for pulmonary radiographic signs of Fb. A Signs by reference Sensitivity (95%IC) Specificity (95%IC) Positive LR (95%IC) Negative LR (95%IC) Normal (1, 2, 4, 5) 32 (27 -40) 33 (27 -40) 2. 1 (1. 4 -3) 0. 5 (0. 3 -0. 7) Unilateral or lobar hyperlucency (4) 53 (45 -61) 87 (81 -92) 4 (1. 2 -7. 2) 0. 5 (0. 3 -1) Abnormal inspi/expiratory (3, 5) 86 (80 -91) 77 (67 -86) 3. 7 (1. 6 -8. 2) 0. 2 (0. 1 -0. 4) Mediastinal shift (1) 13 (5 -22) 100 0. 87 Pneumomediastin (1, 3) 2 (0 -5) 100 0. 98 Radio opaque foreign body (1, 2, 3) 13 (7 -18) 100 0. 9 Localized infiltrate (1, 3, 5) 18 (12 -24) 83 (77 -82) 1. 1 (0. 6 -2) 1 (0. 5 -1. 8)

Symptoms Pro Fb. A 70 -85 % Results (5): Diagnostic and management algorithm of Fb. A Witnessed choking event or acute cough or suspected Fb. A Probability Fb. A 66 % No Symptoms Prob Fb. A 47 % Symptoms present Prob Fb. A 70 -85 % Normal Auscultation Pro Fb. A 15 % Abnormal Auscultation Pro Fb. A 60 -75 % Normal Auscultation Pro Fb. A 31 -55 % Abnormal Auscultation Pro Fb. A 85 -95 % Normal pulmonary radiography Pro Fb. A 8% Abnormal pulmonary radiography Pro Fb. A 76 -100 % Normal pulmonary radiography Pro Fb. A 20 -35 % Abnormal pulmonary radiography Pro Fb. A 95 -100 % Bronchoscopy No bronchoscopy Clinical follow-up ? Clinical and radiological follow-up?

Does this child have a foreign body Aspiration? What are your conclusions?

Does this child have a foreign body aspiration? • Conclusion – This review demonstrates the diagnostic value of symptoms, physical signs and chest radiography – A diagnostic algorithm can be proposed for the indication of bronchoscopy – If children have no symptoms, a normal pulmonary examination and a normal chest radiography, the probability of Fb. A is very low and bronchoscopy is not necessary – This approach should be validated with a prospective study

Does this child have a foreign body aspiration? • References – 1. Cohen S and al. Suspected foreign body inhalation in children: What are the indications for bronchoscopy ? J Pediatr 2009; 155: 276 -80 – 2. Even L and al. Diagnostic evaluation of foreign body aspiration in children: a prospective study Pediatr Surg 2005; 40: 1122 -27 – 3. Righini CA and al. What is the diagnostic value of flexible bronchoscopy in the initial investigation of children with suspected foreign body aspiration? Int J Pediatr Otorhinolaryngo 2007; 71: 1383 -90 – 4. Ayed AK and al. Foreign body aspiration in children diagnostis and treatment. Pediatr Surg Int 2003; 19: 485 -8 – 5. Martinot A and al. Indications for flexible versus rigid bronchoscopy in children with suspected foreign body aspiration. Am J Respir Crit Care Med 1995; 155: 1676 -9 – 6. Akobeng AK and al. Understanding diagnostic tests 2: likelihood ratios, pre- and post-test probabilities and their use in clinical practice. Acta Paediatrica 2006; 96: 487 -91 – 7. Meyer N and al. La statistique Bayésienne: une approche des statistiques adaptée à la clinique. La Revue de Medecine interne 2009; 30: 242 -9 – 8. Doust J. Diagnosis in general practice. Using probabilistic reasoning BMJ 2009; 339: 1080 -85 J

What did you understand ? That … medecine is a science of uncertainty and an art of probability * Thank you for your attention * The principles and practice of the medecine Sir William Osler 1849 -1919