Does the time between aspiration and retrieval of an airway foreign body affected the pediatric patient’s outcome? During the American Broncho-Esophagological Association annual meeting, held as part of the 2007 Combined Otolaryngology Spring Meeting in San Diego, Matthew Lutch, MD, from the Department of Head and Neck Surgery/ Otolaryngology at Kaiser Permanente Medical Center in Oakland, CA, presented his study that specifically addressed this question.
Our research sought to determine if there was a temporal trend toward more frequent complications and poorer outcomes in pediatric patients with suspected and diagnosed foreign body aspirations [FBA], said Dr. Lutch. We wanted to validate our practice patterns to determine if deferring airway endoscopy to the following morning resulted in worse outcomes.
At our institution, we approach each pediatric patient with a suspected or known FBA on an individual basis, continued Dr. Lutch. A comprehensive assessment including, but not limited to, detailed history, physical exam, plain film radiography, and oximetry, is completed. For those patients who are entirely stable and present after hours, we routinely admit them and schedule a laryngotracheobronchoscopy for the next operative day.
To the best of my knowledge, there are no universally accepted protocols or guidelines for the management of pediatric patients with suspected foreign bodies, Dr. Lutch said. There is extensive evidence in the literature demonstrating that a history of witnessed aspiration is the single best positive predictor for FBA. Plain film chest X-rays are commonly obtained and useful in identifying radiopaque foreign bodies; however, a negative chest X-ray never rules out FBA.
Difficulties in Diagnosing
According to Dr. Lutch, the difficulty with diagnosing FBA lies in the clinical exam. Pediatric patients present with nonspecific respiratory signs and symptoms that may include cough, wheeze, tachypnea, decreased breath sounds, and pneumonia. Some patients may be entirely asymptomatic during the early aspiration period. Operative laryngotracheobronchoscopy is mandatory in patients with suspected FBA. However, negative endoscopies are quite common, with 25 percent incidence reported in the literature. In our series, that number approached 50 percent.
Few studies specifically address optimal timing for endoscopy, Dr. Lutch continued. However, many pediatricians, emergency room physicians and otolaryngologists equate FBA and even ‘suspected’ FBA to airway emergency. This is evidenced by archaic adages such as ‘the sun never sets on an airway foreign body.’ In our small, retrospective cohort, we found no difference in outcomes between pediatric patients with FBA who were managed with emergent versus delayed urgent bronchoscopy.
Study Data
Using data from an 11-year period, Dr. Lutch recorded the time between the witnessed aspiration event (or the symptomatic period compatible with a possible aspiration) to the time of bronchoscopic retrieval, as well as intraoperative findings, postoperative complications, and days in the hospital for 40 pediatric cases of FBA.
Twenty-seven patients presented with a history of a witnessed FBA and 17 of these patients (63%) had a foreign body on bronchoscopy; patients without this history had a foreign body only 31% of the time. History of witnessed aspiration remains the single best predictor of positive foreign body aspiration. Other presenting symptoms included a choking episode, stridor, wheezing, shortness of breath, recurrent/paroxysmal cough, persistent/recurrent pneumonia, and cyanosis in the absence of known cardiac or pulmonary disease.
The median time from suspected FBA to surgical intervention was 48 hours, with a range of 45 minutes to 240 days. In patients who had a foreign body, such as a nut, piece of metal, barrette, pen cap, and candy wrapper found on bronchoscopy, the time from event to intervention was less (median 26 hours) than patients with no foreign body discovered (median 54 hours). Time intervals were measured in quartiles; patients were divided into two groups based on whether they received intervention in less than 12 hours (emergent retrieval) or between 12 and 48 hours (delayed urgent retrieval).
The time from FBA to bronchoscopy was not a significant predictor of complication rates in patients who were not in acute distress. Although no complications were found in the two cohorts, complications, such as prolonged intubation and repeat bronchoscopy, did occur in patients who underwent bronchoscopy more than 48 hours after FBA.
All patients were discharged from the hospital within four days, except for four patients who required an additional length of stay up to three days. None of these patients had evidence of FBA on bronchoscopy and were treated as inpatients for pneumonia.
Diagnosis and Treatment Recommendations
According to Dr. Lutch, all unstable children with suspected FBA require expeditious bronchoscopy, as there are some situations when an undue delay could prove disastrous, such as the aspiration of disk batteries, desiccated vegetable matter, large conforming foreign bodies, unstable foreign bodies, and those causing complete laryngotracheal obstructions. Even when the nature of the foreign body is unknown, a patient with progressive respiratory embarrassment, including worsening tachypnea, hypoxia, hypercarbia, and loss of voice should undergo emergent intervention.
However, Dr. Lutch feels that pediatric patients who are not in acute distress may benefit from waiting a few hours to optimize surgical conditions by ensuring that the operating room staff is intimately familiar with the bronchoscopic apparatus, the anesthesia staff is experienced in pediatric airway cases, critical care specialists are available, and there is ready access to a pediatric intensive care unit. A short delay also allows for clearance of GI contents.
It is unusual for more than eight hours’ notice to be required to mobilize these resources, said Dr. Lutch. Our clinical experience shows that such delays have no adverse effect on outcomes. It is necessary to counsel the families of patients, as well our pediatric colleagues, that performing rigid bronchoscopy in a delayed urgent fashion can potentially avert disaster by optimizing every circumstance surrounding foreign body removal.
©2007 The Triological Society