Derivation of a clinical-radiological scoring system to predict foreign body aspiration in children

Abstract

BACKGROUND

Foreign body aspiration (FBA) is a serious pediatric emergency in which delays in diagnosis and management may cause considerable morbidity. Although rigid bronchoscopy remains the procedure of choice, it is invasive and may be associated with complications.

AIM

To derive a clinical scoring system to predict FBA and aid in the selection of children for bronchoscopy.

METHODS

We performed a retrospective review of all children who underwent bronchoscopy for suspected FBA at our institute between 2013 and 2020. Clinical presentation, key historical features, examination findings, and radiological data were analyzed. Predictors of FBA were identified using regression analysis and weighted using adjusted odds ratios to develop a 17-point clinical-radiological score and an emergency decision-making algorithm.

RESULTS

A total of 274 bronchoscopies were performed, with a negative bronchoscopy rate of 34%. Regression modelling identified seven independent predictors that were incorporated into the 17-point score: Definite choking history (2 points), respiratory distress (1 point), absence of concurrent upper respiratory tract infection (4 points), no history of asthma/reactive airway disease (3 points), unilateral decreased air entry/wheeze (2 points), tachypnea (1 point), and unilateral hyperinflation on chest radiograph (4 points). A cut-off score of 7 yielded a sensitivity of 83% and a specificity of 63% for predicting FBA. Risk stratification showed an increasing probability of FBA with higher scores: ≤ 6 points (24%), 7-9 points (51%), and ≥ 10 points (85%).

CONCLUSION

While a low clinical threshold for bronchoscopy is often maintained in suspected FBA, the high negative bronchoscopy rate underscores the need for an objective tool to minimize unnecessary procedures without delaying intervention in high-risk children. The derived 17-point score demonstrated clinically useful discrimination ability and may support rational bronchoscopy selection.

Keywords: Foreign body aspiration; Bronchoscopy; Scoring system; Airway obstruction; Pediatric emergency; Risk stratification; Respiratory tract disease; Diagnostic prediction

Core Tip: Diagnosing pediatric foreign body aspiration remains challenging and is associated with high negative rigid bronchoscopy rates. We derived a novel 17-point clinical-radiological scoring system that achieved an area under the curve of 0.791 and a sensitivity of 83.4%. This score heavily emphasizes the absence of respiratory mimics (concurrent upper respiratory tract infections or asthma) alongside classic predictors. Accordingly, we propose a practical emergency algorithm in which children scoring ≥ 10 undergo immediate rigid bronchoscopy, while those scoring ≤ 6 may be initially evaluated with flexible bronchoscopy. This approach optimizes patient selection and reduces unnecessary invasive procedures and associated complications.