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.
Explore this issue:November 2007
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.