title: Delayed diagnosis and treatment of foreign body aspiration in China: the roles played by physician inexperience and lack of bronchoscopy facilities at local treatment centers.
abstract: OBJECTIVE
  We examined if lack of on-site bronchoscopy facilities and the inexperience of initial treating physicians contributed to missed or delayed diagnosis of tracheobronchial foreign body aspiration (FBA) in pediatric patients presenting with respiratory distress.
  
  
  METHODS
  The medical records of 340 patients examined by bronchoscopy in our otolaryngology department from January 2009 to August 2012 were reviewed. Age, gender, clinical history, findings on physical examination, facilities at the initial treatment site (bronchoscopy or not), bronchoscopic findings (type and location of the FB), and initial diagnosis, were examined in terms of the delay between initial treatment and bronchoscopy-based diagnosis of FBA.
  
  
  RESULTS
  The vast majority of patients (324/340, 95.29%) were 3 years of age or younger and a foreign body was located in 309 (90.88%). Of these 340 cases, 261 had been referred from other facilities (76.76%) whereas 79 had come directly to our hospital (23.24%). The median delay between initial treatment and bronchoscopic diagnosis was significantly shorter in those treated initially in our institution compared to referrals (24 h [1 h to 60 days] vs. 168 h [1 h to 366 days]; P < 0.01). The initial diagnosis was FBA in 135/261 referral cases (51.72%), significantly lower than in cases first treated in our institution (69/79, 87.34%; P < 0.01). Foreign body aspiration was confirmed in 127/135 referral cases (94.07%) and 62/69 directly treated cases (89.86%) (χ(2) = 1.193, P > 0.05). Of the 126 referral cases diagnosed with other conditions before coming to our hospital, FBA was confirmed in 114. Complications were significantly less frequent in cases treated directly than in referrals (24/79, 30.38% vs. 155/261, 59.39%; P < 0.01).
  
  
  CONCLUSIONS
  Local treatment facilities, most lacking bronchoscopy facilities and physicians who were trained to recognize FBA, misdiagnosed at least 44% of patients with respiratory distress and this led to significant delays in treatment. Greater regional access to bronchoscopy and improved training of primary care physicians will enhance diagnostic accuracy and reduce treatment delays.
authors.affiliation: Department of Otolaryngology, Guangzhou Women and Children's Medical Center, The Affiliated Hospital of Guangzhou Medical University, Guangzhou, Guangdong Province 510120, China.
authors.forename: Zhenyun
authors.initials: Z
authors.lastname: Huang
authors.forename: Dabo
authors.initials: D
authors.lastname: Liu
authors.forename: Jianwen
authors.initials: J
authors.lastname: Zhong
authors.forename: Jing
authors.initials: J
authors.lastname: Zhou
mesh_terms: D000402:Airway Obstruction / Q000175:diagnosis / Q000628:therapy; D001999:Bronchoscopy / Q000379:methods / Q000706:statistics & numerical data; D002648:Child; D002675:Child, Preschool; D002681:China; D002983:Clinical Competence; D015331:Cohort Studies; D057210:Delayed Diagnosis; D005260:Female; D005547:Foreign Bodies / Q000175:diagnosis* / Q000628:therapy*; D019538:Health Care Surveys; D006297:Health Services Accessibility / Q000191:economics / Q000706:statistics & numerical data*; D006801:Humans; D008297:Male; D020380:Needs Assessment; D012017:Referral and Consultation / Q000706:statistics & numerical data; D012189:Retrospective Studies; D018570:Risk Assessment; D018709:Statistics, Nonparametric; D014132:Trachea
keywords: Bronchoscopy; Choking; Emergency medicine; Foreign body aspiration (FBA); Pediatrics