To compare the overall safety, efficacy, and resource utilization of ultra-low dose computed tomography (ULDCT) with multi-view chest x-ray (CXR) in children presenting with suspected foreign body aspiration (FBA). A single-center, retrospective chart review was conducted for patients ≤17 years of age with concern for FBA and presenting between 01/01/2018 and 07/31/2024. Computed tomography (CT) studies were categorized as standard, low, and ultra-low dose, based on reported CT dose index volume. Measures of diagnostic performance, estimated effective doses, and total variable costs per patient encounter were compared between imaging modalities. 330 patients were evaluated for FBA with CXR only (n=171), CT only (n=47), or both modalities (n=112). 132 patients underwent bronchoscopy with 107 foreign bodies discovered. Negative bronchoscopy rates ranged from 11% (n=1) in patients evaluated with CT only to 21% (n=18) in patients evaluated with CXR only. Seven patients evaluated with CXR only were later found to have missed airway foreign bodies. The sensitivity and specificity of ULDCT for tracheobronchial foreign bodies was 100%, respectively. Sensitivity and specificity were 74% and 83% for two-view CXR, and 82% and 67% for four-view CXR. Mean effective dose of ULDCT was 0.18 mSv higher than four-view CXR (P<0.001). Median total variable costs were similar among patients initially evaluated with CXR and CT (P=0.21). Reduced-dose CT showed greater sensitivity and specificity than CXR to diagnose FBA and can be delivered without a clinically significant increase in radiation exposure or hospital expenditure.

When the usual is unusual - Foreign body aspiration pneumonia.

Abstract Introduction Bronchial webs are fibrous membranes in the airway lumen. These are rare and can be congenital or acquired. Congenital lesions are formed from abnormal bronchus development while acquired webs may result from trauma, infection, inflammation, or immune changes. Bronchial webs are frequently underdiagnosed as presentation can be nonspecific. Medical management with steroids is common, however only a few pediatric cases necessitating interventional bronchoscopy procedures are reported. We present a case of a 5-year-old female with bronchial webs who underwent balloon dilation. Case A 5-year-old female with Moebius syndrome, anoxic brain injury, asthma, tracheostomy and ventilator dependence, eosinophilic esophagitis, g-tube dependence and hypotonia, presented as a transfer to our institution for medical optimization prior to long-term care facility placement. This patient had a history of multiple prolonged hospitalizations for respiratory failure. A recent admission in the setting of Adenovirus infection and pneumonia required Extracorporeal Membrane Oxygenation(ECMO) cannulation at an outside facility along with high ventilator settings, prolonged steroid courses, and continuous albuterol for persistent wheezing. Following transfer, we performed a flexible bronchoscopy, which showed multiple thin, translucent, intraluminal bronchial membranes with central pin-point perforations from the 6th to 8th generation bronchi in the right upper lobe, right lower lobe, and left lower lobe, consistent with bronchial webs. Bronchoalveolar Lavage cultures grew multidrug resistant pseudomonas and achromobacter. Computed Tomography (CT) chest showed severe bilateral bronchiectasis in the lower lobes likely post obstructive in nature. These webs attributed to her obstructive pathology and refractory response to asthma management. Interventional pulmonology performed balloon dilation of bronchial webs in the right lower and right upper lobes using Fogarty 5 Fr balloon catheters, resulting in successful dilation. Multiple subsequent bronchoscopies were performed that confirmed patency. Clinical status improved after dilation and prolonged antibiotics. However, she continued to require significant respiratory support due to severe bronchiectasis and inflammation. She later developed multiple complications including pneumomediastinum. After a protracted multidisciplinary effort to improve her lung disease, shared decision was made with family to redirected goals towards palliative care. Discussion Bronchial webs should be considered in patients with nonspecific cough, refractory asthma, obstructive lung disease following infection, trauma, foreign body aspiration or inflammation. Diagnosis is made via direct visualization through flexible bronchoscopy. Management may vary with cause however interventional bronchoscopy techniques such as balloon dilation may be utilized in pediatrics to restore airway patency. If left untreated, may lead to post obstructive atelectasis, hyperinflation, bronchiectasis, and permanent lung damage. This abstract is funded by: None

Dental aspiration is usually reported in children with underlying disorders, such as neuromuscular disorders, and is rare in healthy children. Although foreign body aspiration typically causes a persistent cough in infants, herein we report a healthy adolescent whose persistent cough was due to dental aspiration.

Abstract Introduction Pill aspiration, a subcategory of foreign body aspiration, occurs with prescribed or over-the-counter medications. These cases can represent diagnostically complicated scenarios as patients often present with nonspecific respiratory symptoms. The extent of injury depends on the composition of substance aspirated as well as timing of recognition and intervention. This case highlights an unusual presentation of a female who aspirated an iron containing multivitamin in the right lower lobe. Case report A 60-year-old female without significant past medical history presented to the emergency department with a one-day history of right sided chest discomfort, dry cough, and dyspnea. The patient was found to be afebrile and tachycardic to 120 beats per minute. Pertinent lab work includes white blood cell count of 18.4x103/uL. Chest X-ray showed a hazy right lower lobe opacity initially interpreted as likely atelectasis. CT angiography of the chest demonstrated 1.3 cm endobronchial lesion with a differential including carcinoid tumor versus obstructing vascular lesion. Empiric antibiotics were initiated for community acquired pneumonia (CAP) and pulmonology was consulted. Bronchoscopy performed on hospital day two identified a granular mass consistent with an aspirated pill and significant amount of purulent material distal to the lesion. The foreign body was removed, and the patient was discharged with antibiotics to complete a 10-day total course. At follow-up two weeks after discharge, repeat bronchoscopy showed granulation tissue without endobronchial nodularity or masses consistent with resolving injury. Discussion Pill aspiration of iron containing medication carries the potential for significant injury to the bronchial tree. In this case, iron in the patient’s multivitamin likely contributed to the mucosal injury and post-obstructive infection. Iron causes inflammation of varying severity to the mucosa but has the potential for more serious complications such as fibrosis and bronchial stenosis. This case underscores the significance of remaining vigilant for pill aspiration when evaluating patients with nonspecific respiratory complaints. Bronchoscopy was successfully performed, and she was discharged with a course of antibiotics for CAP complicated by post-obstructive purulence. This case emphasizes the critical importance of early bronchoscopy to inspect the airway and remove foreign material. Carcinoid tumor was appropriately considered in this case given the location of the lesion on chest imaging at presentation, which was ruled out upon luminal inspection. Repeat surveillance bronchoscopy is frequently required to ensure resolution of mucosal injury and prevent long-term sequela of damage. This abstract is funded by: None

Artificial Intelligence in Pediatric Bronchoscopy: Current Evidence and Future Perspectives

Introduction: Foreign body aspiration (FBA) in children typically presents with persistent or recurrent cough. This issue is seen mostly among the toddlers and preschoolers due to active pincer grasp and mouthing reflex. Incidence is more in males probably due to the nature to explore the surroundings. Other common symptoms associated with FBA are breathing difficulty. The problem is making an early diagnosis wherein the sharp clinical acumen, high index of suspicion is needed by the treating pediatrician because history may not be elicited in many situations.1,2 Some of the clues can be absence of fever in an acute accidental event, and sudden onset of symptoms like cough and breathing difficulty.2,3 Other signs developed could be due to the site of impaction in the respiratory tract like stridor. An accurate examination picking up the decreased or absent air entry on the affected side can help to arrive at a quick diagnosis. Diagnosis is aided by typical features of obstructive emphysema, collapse or mediastinal shift seen on a chest radiograph.2,3 In some cases clinical features will not be peculiar as seen above. Or else in some instances the duration of symptoms may not be acute. Also in some cases of delayed presentations or small radiolucent foreign bodies chest x-ray may show subtle signs rather than those mentioned above.4,5 In such cases many patients are diagnosed late or undergo many higher investigations like chest Tomography (CT) ending up bearing radiation exposure and also the cost. A pediatrician can sometimes be misled by such delayed or complicated presentations of foreign body aspiration.6 Here we discuss some of these cases which can help in timely diagnosing FBA in children.

Foreign Body Aspiration Presenting as Recurrent Bronchiolitis: Case Report.

The Clinical Impact of Pediatric Pulmonologist Involvement in Intensive Care Units: Bridging Expertise and Outcomes.

ACR Appropriateness Criteria® Ingested or Aspirated Foreign Body-Child.

Failure to improve after initial management in infants with suspected foreign body aspiration and apparent tension pneumothorax should prompt reconsideration of the diagnosis, including underlying congenital lung anomalies such as CPAM.

Tracheobronchial foreign body (FB) aspiration is a life-threatening condition, particularly in older adults. Despite its clinical significance, research on the etiology of adult FB aspiration, as well as real-world outcomes and complications associated with FB removal in lower airways, remains limited. This was a two-center retrospective cohort study in Japan. We included adult patients aged 18 years or older who underwent bronchoscopic FB removal between April 2010 and March 2025. A total of 28 patients were included in this analysis (mean age, 75.4 years [median age: 75 years]; range, 55–102 years). Nineteen patients (67.9%) were male. The most frequently reported symptoms were coughing (46.4%), sputum production (39.3%), and dyspnea (17.9%). A total of 30 FBs were identified, with dental prostheses (60.0%) being the most common type, followed by natural teeth (10.0%). FBs were slightly more common on the right side (53.3%) than on the left side (43.3%), with the right lower lobe being the most frequent site of lodgement (30.0%), followed by the left lower lobe (20.7%). The most frequently bronchoscopic findings were mucosal edema (36.7%) and bleeding (26.7%). FB removal was performed using flexible bronchoscopy in 26 patients (92.9), with the exception of two cases (7.1%) in which rigid bronchoscopy was employed. Bronchoscopy was performed in the endoscopy room for 21 patients (75.0%). Among the 28 patients, standard forceps were used in 24 (85.7%), followed by basket forceps, which was employed in 10 patients (35.7%). FB removal was successful in 26 (92.9%) patients. Regarding adverse events, hypoxia was the only complication observed, occurring in 18 patients (64.3%); no other adverse events were reported. Most FB in the lower airways can be successfully and safely removed via flexible bronchoscopy.

ABSTRACT Foreign body aspiration (FBA) is a life‐threatening condition predominantly affecting children between 1 and 3 years old, with males being more susceptible. While food items, particularly dried nuts and seeds, are the most common aspirated objects, other items, such as vegetables, beads, and small parts of school equipment, have also been reported. Most foreign bodies lodge in the right main bronchus due to its anatomical structure. Larger objects can obstruct upper airways, causing immediate symptoms, whereas smaller objects may lodge deeper, leading to subtler symptoms. The clinical diagnosis of FBA is challenging because initial symptoms are nonspecific. Radiologic imaging has limitations; chest radiography is normal in the majority of cases. Although chest CT scans offer high sensitivity and specificity, their use is associated with radiation exposure and high costs, which limit their wide availability, especially in resource‐limited settings. Point‐of‐care lung ultrasound (LUS) has emerged as an accurate, inexpensive, and nonirradiating diagnostic tool for lung pathologies, but its role in foreign body aspiration (FBA) diagnosis is not well established. We report the case of a 1‐year‐old boy who presented with acute chest discomfort, cough, and shortness of breath. Point‐of‐care LUS revealed the absence of lung sliding, a shrugged pleural line, absence of A‐lines, and consolidation (gray hepatization) of the right lung and visualization of cardiac pulsations through the right lung, which indicated a mediastinal shift toward the right lung (affected side). Subsequent chest X‐ray and bronchoscopy confirmed that a coffee seed was lodged in the right main bronchus, which was successfully removed. This case highlights critical LUS features that are suggestive of FBA in the right main bronchus. These findings may guide clinicians using point‐of‐care LUS in the initial evaluation of patients with suspected FBA. They also form a basis for future large‐scale research exploring the role of LUS in the diagnosis of FBA.

Introduction: This case describes an unusual presentation of complicated pneumoniasecondary to aspiration and subsequent migration of a vegetable foreign body into thepulmonary space in an infant. This rare occurrence, scarcely documented in our country, involved the intraoperative discovery of a grass awn partially embedded within thepulmonary parenchyma and extending into the pleural cavity. This case expands thecurrent knowledge regarding late complications associated with aspirated vegetableforeign bodies and underscores the diagnostic and therapeutic value of video-assistedthoracoscopic surgery (VATS).Case Report: The infant presented with persistent cough, fever, and progressiverespiratory distress that had been ongoing for two months. Physical examinationrevealed signs of respiratory failure, chest radiography showed pleural effusion, andCT tomography revealed pulmonary consolidation and septated pleural effusion withareas of cavitation in the right hemithorax. Pneumonia complicated by pleural effusionwas suspected; therefore, surgery was performed, during which an organic vegetableforeign body was removed. Conclusion: Aspiration of vegetable foreign bodies may present atypically and progress to severe complications if not promptly diagnosed. A thorough clinical history andvideo-assisted thoracoscopy serve as essential diagnostic and therapeutic tools, anda multidisciplinary approach supports favorable clinical outcomes.

Foreign body aspiration (FBA) may be complicated by secondary respiratory tract infection. The spectrum of pathogens associated with FBA in China remains poorly described. This study aimed to obtain contemporary data on the distribution of organisms among children with FBA in southwest China. We conducted a large-scale retrospective cohort study on children diagnosed with FBA via flexible bronchoscopy between 2017 and 2024. Bronchoalveolar lavage fluid (BALF) specimens were collected for microbial cultures, followed by comprehensive analyses of the pathogen spectrum. Among 862 FBA children, 256 (29.7%) had positive BALF cultures and 277 pathogens were detected. Compared to negative BALF culture group, the positive group was more likely to inhale sharp FB (p < 0.001) and have preoperative fever (p = 0.020), longer retention time of FB (p = 0.020) and longer hospital stay (p < 0.001). There were 193 (69.7%) Gram-negative bacteria, 67 (24.2%) Gram-positive bacteria and 17 (6.1%) fungi. Haemophilus influenzae (39.7%), Staphylococcus aureus (18.7%) and Enterobacter cloacae (7.9%) were the most frequently identified pathogens. All 17 Cases detected with fungal pathogens were clinically cured without antifungal medications. Preoperative fever, prolonged FB retention time and inhalation of sharp FB were risk factors for secondary infections associated with FBA. Antibacterial treatment might be considered in these cases. Haemophilus influenzae, Staphylococcus aureus and Enterobacter cloacae were the most common pathogens. FBA may pose a risk of fungal colonization even in immunocompetent children.

BACKGROUND Foreign body aspiration (FBA) is a life-threatening pediatric emergency, most common in 1-3-year-olds due to immature swallowing reflexes and exploratory oral behaviors. Common aspirated items include nuts, food particles and small toys, presenting with variable symptoms such as cough, dyspnea, wheezing or acute respiratory failure. Delayed diagnosis or improper management causes severe complications like post-obstructive pneumonia, atelectasis, bronchiectasis and irreversible airway stenosis, increasing morbidity and treatment complexity. CASE REPORT A 16-month-old girl was admitted with persistent cough, progressive dyspnea, intermittent fever, hoarseness, and occasional cyanosis that developed 6 days after accidental pine nut ingestion. Initial flexible bronchoscopy at a local hospital failed due to the foreign body's rigid texture and deep impaction in the right lower lobe basilar bronchus. Chest CT confirmed a pine nut shell in the B9/B10 segmental bronchus with surrounding inflammation. She was transferred for combined rigid-flexible bronchoscopy to establish a secure airway and enable precise visualization before holmium laser fragmentation broke the shell into retrievable fragments for complete removal. Two-week follow-up showed symptomatic B9/B10 stenosis, which improved significantly after sequential 3.5 mm and 4.0 mm balloon dilation. Her respiratory symptoms resolved and imaging confirmed restored lobar ventilation. CONCLUSIONS Rigid-flexible bronchoscopy synergy benefits removal of large rigid foreign bodies in sub-main bronchi by combining rigid bronchoscopy's airway security with flexible bronchoscopy's maneuverability and visualization. Holmium laser safely fragments hard foreign bodies with minimal airway trauma, and sequential balloon dilation effectively treats post-FBA stenosis. Individualized application guided by clinical assessment and imaging optimizes pediatric FBA outcomes.

Rigid bronchoscopy is central to the management of foreign body aspiration and haemoptysis. Catastrophic endobronchial bleeding remains rare but life threatening. We report a 60 year old man referred with a presumed chronic right lower lobe foreign body. Rigid bronchoscopy identified a firm endobronchial lesion. Piecemeal removal precipitated torrential haemorrhage with rapid desaturation and pulseless electrical activity arrest. Immediate wedging of the rigid bronchoscope achieved partial tamponade but failed to control bleeding. Emergency tracheostomy enabled salvage thoracotomy and right lower lobectomy, with restoration of haemodynamic stability. Histology demonstrated follicular lymphoma and pulmonary hamartoma. The patient made an uneventful recovery. This case identifies the technical principles of airway tamponade and prompt progression to definitive surgery, and highlights the importance of communication, situational awareness, and emotional regulation in managing thoracic surgical emergencies.

Rationale:Foreign body aspiration is most common in toddlers but can occasionally occur in adolescents. Sharp metallic foreign bodies pose a particular challenge for bronchoscopic removal because of the high risk of airway injury and the limitations of standard retrieval instruments. Complex cases may require innovative extraction techniques.Patient concerns:A 12-year-old boy presented with acute respiratory symptoms, including dyspnea, chest tightness, chest pain, cyanosis, and 1 episode of vomiting. No foreign body aspiration was reported at the initial presentation. After repeated and detailed history-taking, it was revealed that the patient had accidentally aspirated a foreign body while attending class.Diagnoses:Low-dose chest computed tomography demonstrated a hyperdense foreign body in the right lower lobe bronchus. Bronchoscopy confirmed a vertically impacted drawing pin, with its plastic head completely occluding the bronchial lumen.Interventions:A modified foreign body retrieval basket technique was applied. The basket was advanced over the sharp tip of the drawing pin and tightened around the mid–upper portion of the shaft, maintaining the tip in the center of the airway. The foreign body was then extracted by simultaneous withdrawal of the flexible bronchoscope and the basket.Outcomes:A drawing pin ~3 cm in length was successfully removed without airway injury. The patient recovered uneventfully, was discharged the next day, and remained asymptomatic during follow-up.Lessons:Vertically impacted metallic airway foreign bodies may be difficult to remove using standard bronchoscopic tools. The modified retrieval basket technique provides a safe and effective option for extracting high-risk metallic foreign bodies while avoiding thoracotomy.

Foreign body aspiration (FBA) is a frequent pediatric emergency with potentially serious complications. This study examines the clinical features, diagnostic challenges, and outcomes of FBA in children in the West Bank, Palestine, over 10 years, to fill a regional data gap and support improved prevention and management strategies. A retrospective cross-sectional analysis was conducted on electronic health records of 292 pediatric patients (0–18 years) from multiple tertiary hospitals in the West Bank, Palestine (Jan 2014– Jan 2024), using descriptive and inferential statistics. Most cases (75%) occurred in children under 3 years of age, with males accounting for (55.8%). The most common presenting symptoms were sudden coughing (91.1%) and choking (63%). Organic foreign bodies, particularly seeds (41.1%) and nuts (10.3%), were predominant, with type significantly associated with both gender (p < 0.001) and age group (p < 0.001). The right main bronchus was the most frequent site of impaction (30.5%). Complications, including pneumonia (13.7%) and radiologic abnormalities, including atelectasis (17.1%), were linked to delayed presentation (p < 0.05). Rigid bronchoscopy successfully removed foreign bodies in 92.1% of cases. FBA remains a notable pediatric health problem among Palestinian children. This study provides a descriptive overview of patterns of presentation, diagnosis, and management of FBA over a 10-year period and highlights gaps in hospital data recording. These findings contribute local evidence that may inform future preventive and clinical strategies. The retrospective design relies on the accuracy of electronic health records, and exclusion of cases with substantial missing data may have introduced selection bias.

Introduction: Foreign body aspiration is a medical emergency, especially in elderly patients with underlying chronic respiratory diseases such as chronic obstructive pulmonary disease (COPD). In such individuals, abnormal airway anatomy and limited pulmonary reserve amplify the risks. We report a case of successful bronchoscopic removal of a metallic dental instrument from the bronchus of a 78-year-old woman with emphysematous lungs, highlighting the importance of rapid, minimally invasive intervention. Description: A 78-year-old woman undergoing elective dental veneer placement aspirated a dental drill bit during the procedure. She was transferred immediately to the emergency department. On arrival, she reported throat discomfort but denied dyspnea or chest pain. Vitals were stable: BP 130/67 mmHg, HR 59 bpm, RR 16/min, SpO2 95% on room air. Laboratory findings were unremarkable. Chest radiography revealed a 3 × 0.5 cm radiopaque foreign body in the bronchus intermedius. An emergent flexible bronchoscopy was performed. The foreign body, consistent with a dental drill bit, was visualized and successfully retrieved from the bronchus. Mild blood-streaked secretions were observed, but no signs of purulence or endobronchial damage were noted. The patient remained stable and asymptomatic post-procedure and was discharged with no complications. Discussion: Although foreign body aspiration is more commonly reported in pediatric populations, it poses significant risks to elderly patients with COPD. In this case, the rapid coordination between emergency and pulmonary services enabled timely intervention with flexible bronchoscopy—the preferred first-line technique due to its safety and efficacy. This case underscores the need for aspiration precautions during dental procedures in high-risk individuals. It also highlights the value of maintaining interprofessional readiness for airway emergencies, where minimally invasive bronchoscopic techniques can rapidly restore airway patency and minimize morbidity.