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Eur J Cardiothorac Surg 2005;28:369-374
© 2005 Elsevier Science NL

RETRACTED: Inhaled foreign bodies: management according to early or late presentation

Sameh Ibrahim Sersar a , * , Usama Ali Hamza a , Wael AbdelAziz AbdelHameed a , Reda Ahmed AbulMaaty a , NourEldean Noaman Gowaeli a , Sherif Abdou Moussa b , Shawki Mahmoud AlMorsi c , Muna Mohammed Hafez d

a Cardiothoracic Surgery, Mansoura University, 35516, Egypt
b Anaesthesia and ICU, Mansoura University, 35516, Egypt
c ENT, Mansoura University, 35516, Egypt
d Pediatrics, Mansoura University, 35516, Egypt

Received 24 February 2005; received in revised form 10 May 2005; accepted 11 May 2005.

* Tel.: +20 10 6166470; fax: +20 50 2265471. (Email: sameh001{at}yahoo.com).


   Abstract
Top
 Abstract
1. Introduction
 2. Materials and methods
 3. Results
 4. Discussion
 References
 
Objective: This retrospective study aims to compare the early and late clinical and management aspects of tracheobronchial aspirated foreign body (AFB), to evaluate the factors associated with delayed diagnosis of foreign body aspiration (FBA) in children and to compare clinical, radiological and bronchoscopic findings in the patients with suspected FBA. A retrospective review of a 10-year experience (from 1995 to 2005). A 1512-bed Mansoura University Hospital and 184-bed Mansoura University Emergency Hospital. Methods: The medical records of 3300 patients who underwent bronchoscopy for suspected FBA were reviewed. The data were analysed in three groups: the patients with negative bronchoscopy for FBA (group I), early (group II) and delayed diagnosis (group III). Foreign body was removed using the rigid bronchoscope with or without using the extracting forceps (Egyptian novel technique [Sersar IS, Abdulla AK, Abulela SA, Elsaeid AS, Abdulmageed NA. A novel technique to remove an inhaled foreign body without using a forceps. J Cardiovasc Dis 2004;2(4):157–158] described in the hand made illustration). Results: The majority of the patients with FBA were between 3 and 10 years of age. The penetration syndrome and decreased breath sounds were determined in a significantly higher number of the patients with FBA. The plain chest radiography revealed radio-opaque foreign bodies (FBs) in 23.56% of all patients with FBA. Pneumonia and atelectasis were significantly more common in the groups with negative bronchoscopy and with delayed diagnosis (P<0.01). The FBs were most frequently of vegetable origin, such as seeds and peanuts. A significant tissue reaction with inflammation and postbronchoscopic complications were more common in the delayed cases. The novel technique was used since then in 100 cases (4.62%) with a history of FBI (Pins and or small rounded materials). It was successful in 73 (73%) cases of non-impacted inhaled pins. Use of forceps was needed in 21 (21%) cases. Rebronchoscopy despite using both techniques was needed in six (6%) cases within 72h. Failed extraction of the inhaled FB occurred in three cases (3%) for whom bronchotomy was needed. Conclusions: Bronchoscopy is indicated on appropriate history and on suspicion. To prevent delayed diagnosis, characteristic symptoms, signs and radiological findings of FBA should be checked in all suspected cases. As clinical and radiological findings of FBA in delayed cases may mimic other disorders, the clinician must be aware of the likelihood of FBA.

Key Words: Foreign bodies • Radiography • Bronchoscopy


   1. Introduction
Top
 Abstract
 1. Introduction
2. Materials and methods
 3. Results
 4. Discussion
 References
 
Children tend to place and explore most objects in their mouths, so there is a significant risk of foreign body aspiration (FBA). Morbidity and mortality increase in the younger age group, presumably because children of a young age have narrow airways and immature protective mechanisms [2]. In one series, 78% of those who died after FBA were between 2 months and 4 years of age [3].

FBA is a life-threatening emergency and requires prompt removal, but sometimes it may remain undetected due to atypical history or misleading clinical and radiological findings [4,5]. Delayed diagnosis can occur when parents under-appreciated symptoms or when physicians overlook clinical and radiological findings. Inflammation and granulation tissue develop around the foreign body (FB) in delayed cases, and thus it is not uncommon for patients to be treated for other disorders such as persistent fever, asthma or recurrent pneumonia for a long period of time [6,7]. The diagnosis and removal of the object becomes much more difficult in such cases. Foreign body aspiration is one of the most common and serious problems among children accounting for 7% of lethal accidents in infants aged 1–3 years [2–4].

Coughing, choking, acute dyspnoea, and sudden onset of wheezing are the main symptoms of foreign body aspiration. Clinically, the problem is often apparent; however, symptoms can subside spontaneously and quickly even when a foreign body remains. Radiographic features depend on the size, location, duration, and nature of the foreign body. The chest radiograph may demonstrate a variety of findings including air trapping, atelectasis, consolidation, and bilateral overaeration [5].

Foreign body aspiration may result in either airway compromise and death or serious sequels such as recurrent pulmonary infections, atelectasis, and bronchiectasis. In order to prevent these complications, prompt diagnosis and removal of foreign body is mandatory [3,4,7,8].

Because of the risks of overlooked foreign body aspiration, even when there is a little suspicion or doubtful history, bronchoscopy is often performed for both definite diagnosis and treatment. Contrary to the general impression that bronchoscopy is simple and safe in paediatric patients, serious complications may occur even in experienced hands [8,10].

Therefore, definition of ideal diagnostic methods those minimise needless bronchoscopy for conditions that mimic airway foreign bodies and avoid delay when patients with foreign body require bronchoscopy is of utmost importance. Virtual bronchoscopy is a noninvasive technique that provides an internal view of trachea and major bronchi by three-dimensional (3D) reconstruction. The volumetric imaging data acquired by helical computed tomography (CT) can be manipulated and additional multiplanar and 3D reconstructions can be obtained. The use of virtual bronchoscopy technique in adults has been described [11–17].

It has been reported in the evaluation of suspected compression or narrowing of the trachea and main bronchi and in the treatment of esophageal atresia in infants and children [18,19].


   2. Materials and methods
Top
 Abstract
 1. Introduction
 2. Materials and methods
3. Results
 4. Discussion
 References
 
From January 1995 to February 2005, the medical records of 3300 children who underwent bronchoscopy for suspected FBA were reviewed. Age and sex of the patients, symptoms and signs, duration of symptoms before bronchoscopy, radiological and bronchoscopic findings including the type and the location of the FB were analysed in three groups. In group I (n=1135), patients had a negative bronchoscopy for FB; in group II (n=1900), patients received the diagnosis of FBA within 1 week of aspiration; in group III (n=265), the diagnosis of FBA was delayed beyond 1 week after aspiration. The diagnosis of FBA was confirmed by bronchoscopic examination. The inhaled FB was removed using a forceps or without using a forceps (Egyptian novel technique) which is a new technique to remove a foreign body (FB) from the airway using the rigid bronchoscope without using the extracting forceps. (Illustration).

It depends on:

1. Good cooperation between the thoracic surgeon and the anaesthesia team. You need good patient sedation and muscle paralysis. You must tell the anaesthesiologist that you may need very short time of anaesthesia and paralysis with the possibility of retrials. The patients are pre-oxygenated with 100% Oxygen mask and then the anaesthesia is then induced by fentanyl 1–2mg/kgm with propofol 2mg/kgm. Before the introduction of the bronchoscope, 5% lidocine is sprayed into the trachea under laryngoscopic control. It is maintained by propofol infusion in a dose of 5mgm/kgm per h with atracurium Besilate of 0.2mgm/kgm. The patients are ventilated either manually with a very high flow oxygen or through a traditional mechanical ventilation. Good anaesthesia should provide rapid induction, good ventilation and oxygenation, satisfactory degree of muscle relaxation with no or minimal postoperative complications. ECG monitoring and peripheral oxygen saturation are continuously monitored throughout the procedure.
2. Introduction of the rigid bronchoscope into the airway very slowly till you reach the foreign body, manipulate the bronchoscope till it completely surrounds the tip of the FB. Push the bronchoscope distally while the FB is in the centre of the tip of the bronchoscope, ask the technician to lower down the head of the operative table. Assisted by this postural drainage, the bronchoscope with the FB in the centre of its tip are withdrawn out under direct vision maintaining the postural drainage. It has the following advantages:
1. Minimal or no risk of airway tear.
2. Short time is needed.
3. Can be used for sharp objects with a small diameter as well as for friable organic FB that cannot be caught by the forceps.
4. Can be taught to the junior staff easily in the start of their career.

It has the following disadvantages:
1. It is not possible in all cases.
2. It needs a good cooperation and harmony between the anaesthesia and thoracic surgery team (1).

The statistical analysis was performed mainly for groups (2) and (3) with an analysis of variance (ANOVA) followed by Tukey's procedure and post hoc tests chi-square tests and Student's t test for independent samples or {chi} 2. The statistical significance level was fixed at a P-value <0.05.


   3. Results
Top
 Abstract
 1. Introduction
 2. Materials and methods
 3. Results
4. Discussion
 References
 
3.1 Clinical and radiological findings
Age and sex of the patients witnessed ingestions, signs and symptoms determined in the history, physical examinations, and duration of symptoms before bronchoscopy are listed in Table 1 . The difference was not significant for sex distribution (P>0.05). The mean age difference was significant between groups I and II (P<0.01). The number of the patients under the age of 1 year was significantly higher in group I than groups II and III (P<0.01), and the number of the patients above the age of 3 years in group (2) was significantly more than groups (1) and (3). The majority of the patients with FBA were between 3 and 10 years of age (929 patients) (48.89% in group II) and between 1 and 3 years (63 patients) (30.94% in group III).


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  		Table 1. The demographic data of the patients
 
There was no significant difference between the groups regarding wheezing, but choking episodes and coughing were determined in a significantly higher number of the patients in groups II and III compared with group I (P<0.01). The differences were significant between groups II and III for witnessed ingestion associated with a choking episode and coughing. Decreased breath sounds were determined in a significantly higher proportion of patients in group III than groups I and II (P<0.01). The relative number of the patients who had clinical findings of pneumonia was significantly higher in group III than groups I and II. The duration of symptoms was significantly longer for the patients in group III compared with the other groups (P<0.01).

A plain chest radiograph was routinely obtained in all suspected cases, but 100 patients underwent emergency bronchoscopic removal of the FB without undergoing pre-bronchoscopic radiography or coming with a CT chest and no plain chest X-ray is done (3.03%). Paired inspiratory and expiratory films are theoretically ideal, but were not routinely feasible due to lack of cooperation as most of our patients were younger than school age.

Radiological findings on plain chest radiography are listed in Table 1. The radiographs revealed radio-opaque FBs in 467 endobronchial tree and 12 in the oesophagus. The number of the radio-opaque FBs was significantly higher in group II than group III (P<0.05). Emphysema was more common in children with FBA. Obstructive emphysema (Air traping) was significantly higher in groups II (P<0.01) and III (P<0.05) than group I. Atelectasis and pneumonia were significantly more common in groups I and III compared with group II (P<0.01). The number of normal radiographs was significantly higher in group I than the other groups with FBA (P<0.05). Atelectasis was determined in 317 patients (9.6%), from whom 3.09% were negative. Fifty records of chest fluoroscopy were found, and 41 were positive for air trapping and mediastinal shift suggesting FBA, which was later confirmed by bronchoscopy. Nine hundred patients had some significant clues in their histories and/or physical examinations, but they had negative radiographs, or the patients were too young to cooperate to produce an appropriate film. Two hundred and fifty computed tomography (CT) records of the chest were found. CT was performed for the differential diagnosis of suspected cases having atypical histories, clinical and radiological findings. Virtual bronchoscopy was done in three cases only as the history was not highly suspicious and the general anaesthesia was a major concern.

The complications were recorded in 147 patients (4.45%). They were significantly higher in groups III (P<0.01) and II (P<0.05) than group I. They included irreversible arrest in four cases, major airway injury requiring repair in 10 cases, barotrauma needing an ICT in 15 cases, failure to extract the FB in 44 cases who required rebronchoscopy, from whom 24 patients required re-rebronchoscopy. Bronchotomy was done in 13 cases of impacted FB with distal airway obstruction. Pulmonary resections were done in seven cases and all were in group III. Laryngeal oedema was recorded in 67 cases of whom 25 cases required temporary tracheostomy (Table 2 ).


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  		Table 2. The clinical, radiological data and complications of the procedures
 
3.2 Bronchoscopic findings
The types of the aspirated FBs are very broad. The majority were radiolucent 1561 patients (76.44%) and they were most frequently of vegetable origin (Fig. 1 ). The most frequent radio-opaque FB determined by plain chest radiography and bronchoscopy were pins (Fig. 2 ). The locations of FBs are listed in Table 1. The majority of the FBs were located in the bronchus and there was no statistically significant difference for the left and the right sides for both groups. The organic foreign bodies included peanut, organic materials, Walnut, Carrot, Apple, Sunflower, Chickpea, peach tail, tangrene tail, coffee bean, organic pip, crystallised fruit, Coconut, Pistachio, Almond, Soya, Dried cereal, Popcorn. The inorganic foreign bodies included plastics, plastic peg, plastic pearl, toy and pins.


Figure 1
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  		Fig. 1. Right lower lobe collapse due to an organic FB.

 

Figure 2
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  		Fig. 2. Pin very distal in the right basal segmental bronchi.

 
Review of the bronchoscopy reports showed that significant tissue reaction was more common in group III. While inflammation and granulation tissue around the object with copious mucoid, purulent secretion was determined in most of the patients in the group with delayed presentation. In all but one of the 44 patients, the FB was removed successfully with one trial of rigid bronchoscopes under general anaesthesia. Only 20 patients needed bronchotomy or pulmonary resections. Our Egyptian novel technique (Sersar Technique) was introduced in 2004 April and was used since then in 100 cases (4.62%) with a history of FBI (Pins and or small rounded materials). It was successful in 73 (73%) cases of non-impacted inhaled pins and rounded organic materials (Illustration) (Fig. 5 ). It is simply rigid bronchoscopic removal of inhaled foreign bodies without using a forceps but using the postural drainage assisted with suction. All the patients with suspected FBI were admitted in our centre at least for 24h. The longest hospital stay was 24 days. In group III, it ranged from 2 to 24 days.


Figure 5
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  		Fig. 5. (1)–(6) It is hand-made description of the Egyptian novel technique (Sersar Technique) using the postural drainage.

 

   4. Discussion
Top
 Abstract
 1. Introduction
 2. Materials and methods
 3. Results
 4. Discussion
References
 
The diagnosis of FBA is elusive in delayed cases. Children may present with no history of aspiration or atypical history with non-specific symptoms [4,5,8,9].

Accurate history and a high index of suspicion are needed to prevent delayed diagnosis and the complications.

Age of the patient is one of the significant criteria in diagnosis of the suspected cases. As we observed in our study, whether it is an early or delayed presentation, approximately 52.29% of FBA (1726 patients) occur below the age of 3 years. We found that the incidence of FBA increases between 1 and 3 years of age. We also determined that the possibility of negative bronchoscopy in suspected cases is significantly high under the age of 1 year. This may be due to mucous plugs, which can mimic FBA, causing obstruction of the bronchioles because the airways of infants of this age are narrower. The high rate of negative bronchoscopy may be due to the fact that CT was unavailable or unreliable at a time in out centre; the patients could not be trusted to return for outpatient follow-up and we usually broaden the scope of indications for rigid bronchoscopy.

The most common signs and symptoms of FBA are choking, coughing, wheezing and decreased breath sounds [12,13]. Of all these signs and symptoms, the most predictive one is witnessed aspiration associated with a choking episode (penetration syndrome). Long-standing FBs can cause significant inflammation and tissue reactions; and with delayed presentation, additional symptoms and signs of unresolved or recurrent pneumonia and persistent cough may occur [8–10]. In our study, we also showed that the clinical signs and symptoms of pneumonia were found in a significantly higher number of the patients with delayed diagnosis.

Radio-opacity of FBs prevents misinterpretation of the symptoms and provides an early and accurate diagnosis. In the present study, only (479 patients) 15.72% of all FBs were radio-opaque and we also found that the number of the radio-opaque FBs was significantly less in the group with delayed diagnosis. The type of FB is an important factor that determines the progress of the pathology caused by the lodgement. As we determined in our study, most aspirated FBs are radiolucent and most frequently of food origin [12–15]. In children younger than 3 years, 80% of airway FBs are found to be food or other radiolucent items [13]. If the clinician only trusts the radiological findings and does not consider an early bronchoscopy in patients with strong history, the diagnosis can be delayed if there are no indirect signs indicating the presence of a radiolucent object on the plain chest radiograph. This is important, because the longer a FB is left in situ, the greater the inflammatory response and the likelihood of complications. The inflammatory response is much more significant with food particles. Because of their oil content, most frequently inhaled vegetable matters, such as peanuts, seeds and nuts set up intense inflammatory responses, thus narrowing the airway further, causing consolidation to develop distal to the obstruction. Obstructive emphysema is the typical indirect radiological sign of a radiolucent inhaled object. Hyperinflation due to a check valve obstruction by the object and reflex oligaemia due to hypoventilation cause unilateral hyperlucent lung [2]. In our study, the most significant indirect radiological signs of FBA we found were emphysema, atelectasis and pneumonia. While emphysema was observed in both early and delayed presentation of FBA, atelectasis and pneumonia were determined significantly in higher number of the patients with delayed diagnosis. In persistent bronchial obstruction, pneumonia develops in 9–26% of cases [17–19]. In the present study, 222 patients (6.72%) of which the patients with FBA had pneumonia, but the number increased significantly with delayed presentation (in 27.16%). In the delayed cases, the bronchoscopic evaluation showing intense inflammatory changes with increased granulation and mucoid secretion confirmed our pre-bronchoscopic clinical and radiological findings suggesting pneumonia. Plain chest radiography shows atelectasis in approximately 25% of the patients with FBA [17–19]. In this study, atelectasis was determined in (317 cases) 9.6% of the patients with FBA, and in the delayed cases it increased to 32.7%. With persistent lodgement, the object may progress distally resulting in complete endobronchial obstruction and mucosal inflammation with oedema, granulation and viscous secretion, which aggravates the pathology and may result in atelectasis (Figs. 3 and 4 ).


Figure 3
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  		Fig. 3. (A) Plain X-ray chest showing a nearly left total opacity with ipsilateral mediastinal shift due to an organic FB. (B–E) CT chest showing a nearly total lung collapse with ipsilateral mediastinal shift due to an organic foreign body.

 
A convincing history and suspicious plain chest radiography are the two main criteria for the need for bronchoscopic diagnosis of FBA. Most of our patients come to our emergency hospital. Their parents are not aware with our primary care system. They just come to the hospital whether the emergency or the paediatric hospital where they are referred to us. The indication for bronchotomy in our patients was failed three trials of bronchoscopic removal of an impacted organic FB with distal airway obstruction whether partial or complete or failed bronchoscopic removal of an impacted inorganic FB with or without symptoms for fear of the inflammatory response. The indications for pulmonary resections were not for FB but for destroyed segment, lobe or lung and the FB was accidentally found.

In the presence of normal radiographs and a strong history, the radiologist and clinician, depending on their experiences and facilities, should decide whether the child should undergo fluoroscopy or bronchoscopy. If an expiratory film cannot be obtained due to lack of cooperation, or negative radiological findings are present, then fluoroscopy may help to detect the presence of a FB. If present, air trapping and shift of mediastinal structures to the opposite side can be easily identified at fluoroscopy. We do rigid bronchoscopy for suspected history with any chest trouble with persistent radiologic abnormalities. Although CT occasionally demonstrates an opacity not visualised on the plain film, it should not be considered as one of the initial diagnostic methods for FBA. CT may help with the differential diagnosis of suspected cases having atypical histories, clinical and radiological findings with delayed presentation and complications. The differential diagnosis in such cases include tracheobronchial obstructions caused by external compression of airways (e.g. enlarged lymph node, tumours, cardiac enlargement) or intra-luminal obstructions (e.g. tumours, granulomatous tissue, as in tuberculosis, secretions and mucous plugs as in bacterial pneumonia, cystic fibrosis, asthma, pulmonary abscess and acute laryngotracheobronchitis). Virual bronchoscopy was done for three cases. It was helpful to diagnose an endobronchial obstruction. Rigid bronchoscopy showed the FBI as the cause of this obstruction.

Children with FBA may present with atypical or misleading history, clinical and radiological findings. Misdiagnosis such as asthma, pneumonia, croup and reactive airway diseases may lead to a delayed diagnosis. To prevent complications caused by delayed diagnosis, the clinician must maintain a high index of suspicion. In suspected cases, a more extensive history and physical examination should be obtained. Regardless of radiological findings, when FBA is the suspected diagnosis in a patient with a history of a witnessed episode of choking, a transient cyanosis and coughing, an early bronchoscopic examination should be considered. Negative radiography and fluoroscopy should not preclude bronchoscopy in patients with a strong history.


Figure 4
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  		Fig. 4. (A) CT chest Mediastinal window showing FBI in the right upper lobe bronchus. (B) CT chest Pulmonary window showing FBI in the right upper lobe bronchus.

 

   Acknowledgments
 
The authors present their thanks to Professor Mohammed Mounir Elsaeid, MD, Professor Shabban A. Abulela, MD and Professor Abed Abdel Samea Mowafy, MD for their assistance, advice and support.


   References
Top
 Abstract
 1. Introduction
 2. Materials and methods
 3. Results
 4. Discussion
 References
 

  1. Sersar IS, Abdulla AK, Abulela SA, Elsaeid As, Abdulmageed NA. A novel technique to remove an inhaled foreign body without using a forceps. J Cardiovasc Dis 2004;2(4):157-158.
  2. Johnson DG, Condon VR. Foreign bodies in pediatric patients. Curr Probl Surg 1998;35:273-279.
  3. Black RE, Johnson DG, Matlak ME. Bronchoscopic removal of aspirated foreign bodies in children. J Pediatr Surg 1994;29:682-684.[CrossRef][Medline]
  4. Metrangelo S, Monetti C, Meneghini L, Zadra N, Giusti F. Eight years' experience with foreign-body aspiration in children: what is really important for a timely diagnosis?. J Pediatr Surg 1999;34:1229-1231.[CrossRef][Medline]
  5. Svedstrom E, Puhakka H, Kero P. How accurate is chest radiography in the diagnosis of tracheobronchial foreign bodies in children?. Pediatr Radiol 1989;19:520-522.[CrossRef][Medline]
  6. Swischuk LE. The chest. In: Swischuk LE, editor. Emergency imaging of the acutely ill or injured child. 3rd ed. Baltimore, MD: Williams & Wilkins; 1994. pp. 1-150.
  7. Vane DW, Pritchard J, Colville CW, West KW, Eigen H, Grosfeld JL. Bronchoscopy for aspirated foreign bodies in children. Arch Surg 1988;123:885-888.[Abstract/Free Full Text]
  8. Zerella JT, Dimler M, McGill LC, Pippus KJ. Foreign body aspiration in children: value of radiography and complications of bronchoscopy. J Pediatr Surg 1998;33:1651-1654.[CrossRef][Medline]
  9. Pasaoglu I, Dogan R, Demircin M, Hatipoglu A, Bozer AY. Bronchoscopic removal of foreign bodies in children: retrospective analysis of 822 cases. Thorac Cardiovasc Surg 1991;39:95-98.[Medline]
  10. Zaytoun GM, Rouadi PW, Baki DH. Endoscopic management of foreign bodies in the tracheobronchial tree: predictive factors for complications. Otolaryngol Head Neck Surg 2000;123:311-316.[CrossRef][Medline]
  11. Vining DJ, Liu K, Choplin RH, Haponik EF. Virtual bronchoscopy: relationships of virtual reality endobronchial simulations to actual bronchoscopic findings. Chest 1996;109:549-553.[Abstract/Free Full Text]
  12. Ferretti GR, Vining DJ, Knoplioch J, Coulomb M. Tracheobronchial tree: three-dimensional spiral CT with bronchoscopic perspective. J Comput Assist Tomogr 1996;20:777-781.[CrossRef][Medline]
  13. Fleiter T, Merkle EM, Aschoff AJ, Lang G, Stein M, Gorich J, Liewald F, Rilinger N, Sokiranski R. Comparison of real-time virtual and fiberoptic bronchoscopy in patients with bronchial carcinoma. Am J Roentgenol 1997;169:1591-1595.[Abstract/Free Full Text]
  14. Higgins WE, Ramaswamy K, Swift RD, McLennan G, Hoffman EA. Virtual bronchoscopy for three-dimensional pulmonary image assessment: state of the art and future needs. Radio-Graphics 1998;18:761-778.[Abstract]
  15. McAdams HP, Goodman PC, Kussin P. Virtual bronchoscopy for directing transbronchial needle aspiration of hilar and mediastinal lymph nodes: a pilot study. Am J Roentgenol 1998;170:1361-1364.[Abstract/Free Full Text]
  16. Haponik EF, Aquino SL, Vining DJ. Virtual bronchoscopy. Clin Chest Med 1999;20:201-217.[CrossRef][Medline]
  17. Burke AJ, Vining DJ, McGuirt Jr WF, Postma G, Browne JD. Evaluation of airway obstruction using virtual endoscopy. Laryngoscope 2000;110:23-29.[CrossRef][Medline]
  18. Konen E, Katz M, Rozenman J, Ben-Shlush A, Itzchak Y, Szeinberg A. Virtual bronchoscopy in children: early clinical experience. Am J Roentgenol 1998;171:1699-1702.[Abstract/Free Full Text]
  19. Lam WW, Tam PK, Chan FL, Chan KL, Cheng W. Esophageal atresia and tracheal stenosis: use of three-dimensional CT and virtual bronchoscopy in neonates, infants, and children. Am J Roentgenol 2000;174:1009-1012.[Abstract/Free Full Text]



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