airway foreign bodies: bronchoscopy - · pdf file · 2017-02-14airway foreign...

Airway Foreign Bodies: Airway Foreign Bodies: BronchoscopyBronchoscopy

Difficult peripheral and upper lobe FBs:Difficult peripheral and upper lobe FBs:Difficult peripheral and upper lobe FBs:Difficult peripheral and upper lobe FBs: Fluoroscopic guidance maybe helpful.Fluoroscopic guidance maybe helpful. Flexible bronchoscopy can also be helpful.Flexible bronchoscopy can also be helpful.py ppy p

Repeat bronchscopy once FB removed.Repeat bronchscopy once FB removed. Must perform complete endoscopic evaluationMust perform complete endoscopic evaluation Must perform complete endoscopic evaluation Must perform complete endoscopic evaluation

to rule out multiple FBs (incidence 5to rule out multiple FBs (incidence 5--19%).19%). Consider esophagoscopy to evaluate forConsider esophagoscopy to evaluate for Consider esophagoscopy to evaluate for Consider esophagoscopy to evaluate for

accompanying esophageal FBs if symptoms of accompanying esophageal FBs if symptoms of dysphagia or vomiting.dysphagia or vomiting.y p g gy p g g

McGuirt WF, et al. Laryngoscope 1988. Inglis AF, Wagner DV. Ann Otol Rhinol Laryngol 1992.

Airway Foreign Bodies: Airway Foreign Bodies: BronchoscopyBronchoscopy

If i i i l l f lIf i i i l l f l If initial attempt at removal unsuccessful:If initial attempt at removal unsuccessful: Consider delay for few days to permit improvement Consider delay for few days to permit improvement

i i fl ii i fl iin inflammationin inflammation Antibiotics and steroidsAntibiotics and steroids

Bronchoscopy not successful <1%Bronchoscopy not successful <1% Thoracotomy or thoracoscopy may be necessary.Thoracotomy or thoracoscopy may be necessary.

Foreign Body Aspiration Requiring Foreign Body Aspiration Requiring TTThoracotomyThoracotomy

Airway Foreign Bodies: AnesthesiaAirway Foreign Bodies: AnesthesiaAirway Foreign Bodies: AnesthesiaAirway Foreign Bodies: Anesthesia

Most airway FBs are removed under generalMost airway FBs are removed under generalMost airway FBs are removed under general Most airway FBs are removed under general anesthesiaanesthesia Careful monitoring.Careful monitoring.gg Spontaneous ventilation preferred to apneic technique.Spontaneous ventilation preferred to apneic technique. Avoid preoperative sedation.Avoid preoperative sedation.p pp p 100% oxygen after induction with inhalational agents.100% oxygen after induction with inhalational agents. Avoid too much positive pressure through Avoid too much positive pressure through

bronchoscope.bronchoscope. Laryngoscopy should be performed by endoscopist.Laryngoscopy should be performed by endoscopist.

Fidkowski CW, et al. Anesth Analg 2010.

Airway Foreign Bodies: Airway Foreign Bodies: y gy gComplicationsComplications

Laryngeal edema traumatic laryngitis pneumonia postobstructiveLaryngeal edema traumatic laryngitis pneumonia postobstructive Laryngeal edema, traumatic laryngitis, pneumonia, postobstructive Laryngeal edema, traumatic laryngitis, pneumonia, postobstructive pulmonary edema, laryngotracheal stenosis, pneumothorax, pulmonary edema, laryngotracheal stenosis, pneumothorax, pneumomediastinum, bronchopneumomediastinum, broncho--pleural fistula, lung abscess.pleural fistula, lung abscess.D l i di i i i k f li iD l i di i i i k f li i Delay in diagnosis increases risk of complications.Delay in diagnosis increases risk of complications.

Complications have decreased over the past several decades.Complications have decreased over the past several decades. Improved equipment.Improved equipment.p q pp q p Development of Hopkins rodDevelopment of Hopkins roddecreased missed or incompletely removed decreased missed or incompletely removed

FBsFBs Overall complication rateOverall complication rate15% (44% 20 years earlier)15% (44% 20 years earlier) Minor complicationsMinor complications12%12%

Postop atelectasis, wheezing, stridorPostop atelectasis, wheezing, stridor Major complicationsMajor complications3%3%

>1 week hospitalization or open surgery required>1 week hospitalization or open surgery required

Inglis AF, Wagner DV. Inglis AF, Wagner DV. Ann Otol Rhinol LaryngolAnn Otol Rhinol Laryngol 1992.1992.

Esophageal Foreign BodiesEsophageal Foreign BodiesEsophageal Foreign BodiesEsophageal Foreign Bodies FB ingestion very common in children.FB ingestion very common in children. FB ingestion more common than FB aspiration.FB ingestion more common than FB aspiration. 1500 deaths per year from complications of FB 1500 deaths per year from complications of FB

ingestion.ingestion. 75%75%--80% in children (usually < age 5)80% in children (usually < age 5) Most common FBMost common FBcoin (75%)coin (75%)

92,166 cases reported to poison centers in 2003.92,166 cases reported to poison centers in 2003.

Most common FB causing fatalityMost common FB causing fatalitypiece of hotdog piece of hotdog leading to airway compressionleading to airway compression

Crysdale WS, et al. Ann Otol Rhinol Laryngol 1991. Lemberg PS, et al. Ann Otol Rhinol Laryngol 1996. Stack LB, Munter DW. Emerg Med Clin North Am 1996. Watson WA, et al. Am J Emerg Med 2004.

Esophageal Foreign BodiesEsophageal Foreign BodiesEsophageal Foreign BodiesEsophageal Foreign Bodies

P i i k f h l f i b diP i i k f h l f i b di Patients at risk for esophageal foreign bodies:Patients at risk for esophageal foreign bodies: Children < age 5Children < age 5 Psychiatric patientsPsychiatric patients Patients with underlying esophageal diseasePatients with underlying esophageal disease Edentulous adultsEdentulous adults

Digoy GP. Otolaryngol Clin N Am 2008.

Esophageal Foreign BodiesEsophageal Foreign BodiesEsophageal Foreign BodiesEsophageal Foreign Bodies

Common locations for FB to lodge:Common locations for FB to lodge:Common locations for FB to lodge:Common locations for FB to lodge: Upper esophageal sphincter/cricopharyngeus (63Upper esophageal sphincter/cricopharyngeus (63--84%)84%) Gastroesophageal junction (5Gastroesophageal junction (5--20%)20%)p g j (p g j ( )) Crossing of aorta (10Crossing of aorta (10--17%)17%) Crossing of left mainstem bronchusCrossing of left mainstem bronchus

When foreign bodies lodge in other areas, must When foreign bodies lodge in other areas, must consider congenital esophageal stricture or stenosis.consider congenital esophageal stricture or stenosis.

33--5% have initially unsuspected 25% have initially unsuspected 2ndnd FB.FB.

Smith SA, Conners GP. Pediatr Emerg Care 1998. Stack LB, Munter DW. Emerg Med Clin North Am 1996. Hawkins DB. Ann Otol Rhinol Laryngol 1990.

Esophageal Foreign Bodies: Esophageal Foreign Bodies: PresentationPresentation

Can present after brief symptoms or with chronic Can present after brief symptoms or with chronic p y pp y pdysphagia.dysphagia.

Can present with mildCan present with mild--toto--moderate respiratory moderate respiratory distressdistresscompliance of wall between trachea andcompliance of wall between trachea anddistressdistresscompliance of wall between trachea and compliance of wall between trachea and esophagus (10%).esophagus (10%).

Acute symptomsAcute symptomscoughing, choking, gagging, coughing, choking, gagging, d h i d li k/ h i id h i d li k/ h i idysphagia, drooling, neck/chest pain, airway symptomsdysphagia, drooling, neck/chest pain, airway symptoms

Chronic symptomsChronic symptomschange in eating habits, weight change in eating habits, weight loss, dysphagia, wheezing, SOBloss, dysphagia, wheezing, SOB, y p g , w g,, y p g , w g,

Suspect that any choking event with cyanosis/LOC is Suspect that any choking event with cyanosis/LOC is due to airway FB until proven otherwise!due to airway FB until proven otherwise!

Esophageal Foreign Bodies: Esophageal Foreign Bodies: TTEvaluation and TreatmentEvaluation and Treatment

History and physical examHistory and physical exam Often not witnessed.Often not witnessed. Radiologic imagingRadiologic imaging Radiologic imagingRadiologic imaging

Radiographs Radiographs Frequently radioopaqueFrequently radioopaque PA/Lat CXRPA/Lat CXR PA/Lat neck filmsPA/Lat neck films

Contrast studiesContrast studies EsophagoscopyEsophagoscopy

Esophageal Foreign Bodies: Esophageal Foreign Bodies: EsophagoscopyEsophagoscopy

Safest method of esophageal FB removal is under generalSafest method of esophageal FB removal is under general Safest method of esophageal FB removal is under general Safest method of esophageal FB removal is under general anesthesia with a protected airway and esophagoscopy.anesthesia with a protected airway and esophagoscopy.

Removal of esophageal FBs in radiology suite with Removal of esophageal FBs in radiology suite with fl d b ll h b d !fl d b ll h b d !fluoroscopy and balloon catheter can be very dangerous!fluoroscopy and balloon catheter can be very dangerous!

Should have variety of instruments available for Should have variety of instruments available for endoscopic removal of FB:endoscopic removal of FB:endoscopic removal of FB:endoscopic removal of FB: ForcepsForceps Balloon cathetersBalloon catheters BasketsBaskets BasketsBaskets

Proper preparation.Proper preparation. Practice on duplicate FB.Practice on duplicate FB.pp


Repeat esophagoscopy once FB is removed to Repeat esophagoscopy once FB is removed to assess for injury and look for 2assess for injury and look for 2ndnd FBs.FBs.

A small percentage of FBs cannot be removed A small percentage of FBs cannot be removed endoscopically and require cervical endoscopically and require cervical esophagotomy and/or thoracotomy.esophagotomy and/or thoracotomy.


CoinsCoins 30% rate of spontaneous passage 30% rate of spontaneous passage

into stomach within first 24 hours.into stomach within first 24 hours. Option for expectant managementOption for expectant management Option for expectant management Option for expectant management

for 12for 12--24 hours in asymptomatic 24 hours in asymptomatic patients.patients.

Repeat CXR shortly before removalRepeat CXR shortly before removal Repeat CXR shortly before removal Repeat CXR shortly before removal procedure.procedure.

Chance of passing into stomach Chance of passing into stomach related to location in esophagus:related to location in esophagus:related to location in esophagus:related to location in esophagus: Upper third: 14%Upper third: 14% Middle third: 43%Middle third: 43% Lower third: 67%Lower third: 67% Lower third: 67%Lower third: 67%

Soprano JV, et al. Arch Pediatr Adolesc Med 1999. Calkins CM, et al. J Pediatr Surg 1999. Waltzman M, et al. Pediatrics 2005.

Esophageal Foreign Bodies: Esophageal Foreign Bodies: Evaluation and TreatmentEvaluation and Treatment

CoinsCoins Rigid esophagoscopy techniques.Rigid esophagoscopy techniques.g p g py qg p g py q Flexible endoscopy techniques.Flexible endoscopy techniques. Blind balloon catheter Blind balloon catheter

techniquetechniquedangerous!dangerous! Esophageal bougienage.Esophageal bougienage.

Soprano JV, et al. Arch Pediatr Adolesc Med 1999. Calkins CM, et al. J Pediatr Surg 1999. Waltzman M, et al. Pediatrics 2005.

Esophageal FB: 2 CoinsEsophageal FB: 2 CoinsEsophageal FB: 2 CoinsEsophageal FB: 2 Coins


Food ImpactionFood Impaction Food ImpactionFood Impaction Up to 70% of patients have Up to 70% of patients have

underlying esophageal underlying esophageal b lib liabnormality.abnormality.

Repeated esophageal food Repeated esophageal food impactionimpactionmust consider must consider possibility of eosinophilic possibility of eosinophilic esophagitis.esophagitis.

Can consider pushing bolus Can consider pushing bolus p gp ginto stomach.into stomach.

Glucagon injections to help Glucagon injections to help bolus pass into stomachbolus pass into stomachbolus pass into stomach.bolus pass into stomach.

Lemberg PS, et al. Ann Otol Rhinol Laryngol 1996.


Sharp/Pointed ObjectsSharp/Pointed ObjectsSharp/Pointed ObjectsSharp/Pointed Objects “Advancing points perforate; trailing points do not.”“Advancing points perforate; trailing points do not.” “Search not for the foreign body, but for the point “Search not for the foreign body, but for the point g y, pg y, p

of the foreign body.” of the foreign body.” C. Jackson 1914C. Jackson 1914

Techniques for removing safety pinTechniques for removing safety pinq g y pq g y p StraighteningStraightening Point sheathingPoint sheathing Endogastric versionEndogastric version Closing (ClerfClosing (Clerf--Arrowsmith safety pin closer)Arrowsmith safety pin closer)

Holinger LD. Ann Otol Rhinol Laryngol 1990.

Esophageal FB: Piece of GlassEsophageal FB: Piece of GlassEsophageal FB: Piece of GlassEsophageal FB: Piece of Glass

Esophageal FB: Upholstery StapleEsophageal FB: Upholstery Staplep g p y pp g p y p

Esophageal FB: Light BulbEsophageal FB: Light BulbEsophageal FB: Light BulbEsophageal FB: Light Bulb

Esophageal FB: Hair ClipEsophageal FB: Hair Clipsop agea : a C psop agea : a C p

Esophageal FB: Guitar PickEsophageal FB: Guitar Pickp gp g

Esophageal FB: JackEsophageal FB: JackEsophageal FB: JackEsophageal FB: Jack

Esophageal FB: CrucifixEsophageal FB: Crucifixp gp g

Esophageal Foreign Bodies: FollowEsophageal Foreign Bodies: Follow--UpUpp g gp g g pp

Esophagram when concern for perforation.Esophagram when concern for perforation.P i i h i ifi h l i j h ldP i i h i ifi h l i j h ld Patients with significant esophageal injury should Patients with significant esophageal injury should undergo repeat esophagram to evaluate for stricture.undergo repeat esophagram to evaluate for stricture.

Recurrent FBs:Recurrent FBs: Recurrent FBs:Recurrent FBs: Eosinophilic esophagitisEosinophilic esophagitis Stricture/stenosisStricture/stenosis Degenerative or neuromuscular disease of esophagusDegenerative or neuromuscular disease of esophagus Negligence/abuseNegligence/abuse

P i d h i f FB l d i lP i d h i f FB l d i l Persistant dysphagia after FB removal despite normal Persistant dysphagia after FB removal despite normal anatomic studies:anatomic studies: Degenerative or neuromuscular disease of esophagusDegenerative or neuromuscular disease of esophagus Degenerative or neuromuscular disease of esophagusDegenerative or neuromuscular disease of esophagus

Disk Battery IngestionDisk Battery Ingestiony gy g <2% FB ingestions.<2% FB ingestions. Can cause mucosal injuryCan cause mucosal injury Can cause mucosal injury Can cause mucosal injury

<1 hour after ingestion.<1 hour after ingestion. Very high pH liquid leaks Very high pH liquid leaks

out of battery (45% NaOHout of battery (45% NaOHout of battery (45% NaOH out of battery (45% NaOH or KOH).or KOH).

Caustic injury, absorption Caustic injury, absorption of toxins pressureof toxins pressureof toxins, pressure of toxins, pressure necrosis, electrical tissue necrosis, electrical tissue damage (cell death).damage (cell death).C lC l Can result on severe Can result on severe esophageal injury, esophageal injury, perforation, stricture perforation, stricture f ti d d thf ti d d thformation, and death.formation, and death.

Disk Battery IngestionDisk Battery IngestionDisk Battery IngestionDisk Battery Ingestion

Larger diameter batteriesLarger diameter batteriesmore severe injuries; less more severe injuries; less gg jjlikely to passlikely to pass

Rapid FB removal is crucial.Rapid FB removal is crucial. If battery passes into stomach, it will likely pass safely If battery passes into stomach, it will likely pass safely

into stool. into stool. If battery remains in stomach more than 48 hours, If battery remains in stomach more than 48 hours,

should consider endoscopic removal.should consider endoscopic removal.

Disk Battery IngestionDisk Battery Ingestiony gy g

Disk Battery IngestionDisk Battery Ingestions atte y gest os atte y gest o

Prevention of Foreign Bodies and Prevention of Foreign Bodies and Caustic IngestionsCaustic Ingestions

Best approachBest approach Legal commercial/policy modificationLegal commercial/policy modification Legal commercial/policy modificationLegal commercial/policy modification Public educationPublic education


Chevalier JacksonChevalier JacksonJJ “The work of physicians “The work of physicians

in prevention equals their in prevention equals their ddwork in curing disease.”work in curing disease.”

1927 1927 Federal Caustic Federal Caustic Poison LawPoison LawPoison LawPoison Law Signed by President Signed by President

Coolidge.Coolidge. Required special labeling Required special labeling

of caustic agents with of caustic agents with “Poison. Dangerous”“Poison. Dangerous”gg


“Each specimen is evidence that a child’s life is in danger when he “Each specimen is evidence that a child’s life is in danger when he l i h ll h hi fi T hi i f f il i h ll h hi fi T hi i f f iplays with toys smaller than his fist. Teaching prevention of foreignplays with toys smaller than his fist. Teaching prevention of foreign--

body accidents has been a lifetime’s work.”body accidents has been a lifetime’s work.”

“Nuts shells seeds and pits; each one put a child’s life in jeopardy“Nuts shells seeds and pits; each one put a child’s life in jeopardy Nuts, shells, seeds, and pits; each one put a child s life in jeopardy. Nuts, shells, seeds, and pits; each one put a child s life in jeopardy. Peanut candy has killed many babies.”Peanut candy has killed many babies.”

“Evidence of the filthy and careless habit of putting coins in the “Evidence of the filthy and careless habit of putting coins in the y p gy p gmouth. A child’s life was avoidably endangered by each coin. Such mouth. A child’s life was avoidably endangered by each coin. Such accidents are preventable by the simple expedient of keeping such accidents are preventable by the simple expedient of keeping such things out of the mouth.”things out of the mouth.”gg

“Each pin needlessly endangered the life of a child. Safety pins are “Each pin needlessly endangered the life of a child. Safety pins are really danger pins; they should be kept closed and out of reach of really danger pins; they should be kept closed and out of reach of hild ”hild ”children.”children.”

C. Jackson. 1938.


Consumer Product Safety CommissionConsumer Product Safety Commission Consumer Product Safety CommissionConsumer Product Safety Commission 1960 Federal Hazardous Substance Act (FHSA) 1960 Federal Hazardous Substance Act (FHSA) 1994 Child Safety Protection Act (CSPA)1994 Child Safety Protection Act (CSPA) 1994 Child Safety Protection Act (CSPA)1994 Child Safety Protection Act (CSPA)

Requires chokingRequires choking--hazard warning labels on packaging for hazard warning labels on packaging for small balls, marbles, and toys/games with small parts.small balls, marbles, and toys/games with small parts., , y /g p, , y /g p

Bans any toys with small parts for children < age 3.Bans any toys with small parts for children < age 3.

2008 Consumer Product Safety Improvement Act2008 Consumer Product Safety Improvement Acty py p Choking hazard safety warnings must be displayed on Choking hazard safety warnings must be displayed on

advertisements, catalogs, websites, etc. advertisements, catalogs, websites, etc.


Consumer ProductConsumer ProductConsumer Product Consumer Product Safety Commission Safety Commission 19791979--minimum size minimum size

criteria for toys used by criteria for toys used by children <3 y.o.children <3 y.o.

31 7 mm diameter; 25 431 7 mm diameter; 25 4 31.7 mm diameter; 25.431.7 mm diameter; 25.4--57.1 mm length57.1 mm length

Small Parts Test Small Parts Test FixtureFixturecylinder into cylinder into which products or parts which products or parts must not fitmust not fitmust not fitmust not fit

Reilly JS. Ann Otol Rhinol Laryngol 1990. Reilly JS, et al. Pediatr Clin North Am 1996. Reilly JS, et al. Am J Otolaryngol 1995.


FoodFood--Related ChokingRelated Choking Food Choking Prevention Acts (2002, 2003, 2005) Food Choking Prevention Acts (2002, 2003, 2005) FDA Office of Choking Hazard EvaluationFDA Office of Choking Hazard Evaluation

Prevention of Foreign Bodies and Prevention of Foreign Bodies and C stic In estionsC stic In estionsCaustic IngestionsCaustic Ingestions

AAP Policy StatementAAP Policy Statement——Prevention of Choking Among Prevention of Choking Among Children. Children. PediatricsPediatrics 2010; 125: 6012010; 125: 601--607.607. FDA should establish a systematic process for evaluating and FDA should establish a systematic process for evaluating and

addressing foodaddressing food--related choking.related choking.gg gg Health care professionals should intensify chokingHealth care professionals should intensify choking--prevention prevention

counseling and provide guidance to caregivers on appropriate counseling and provide guidance to caregivers on appropriate food and toy selection.food and toy selection.food and toy selection.food and toy selection.

Food manufacturers should design new foods and redesign Food manufacturers should design new foods and redesign existing foods to minimize choking hazards.existing foods to minimize choking hazards.

CPSC sho ld eval ate c rrent gaps in choking hazard standardsCPSC sho ld eval ate c rrent gaps in choking hazard standards CPSC should evaluate current gaps in choking hazard standards.CPSC should evaluate current gaps in choking hazard standards. CPR and choking first aid should be taught to all parents, CPR and choking first aid should be taught to all parents,

teachers, and child care providers.teachers, and child care providers.


Instruct parents to avoid feeding seeds and nuts Instruct parents to avoid feeding seeds and nuts to small children.to small children.

Instruct parents to keep small objects out of Instruct parents to keep small objects out of reach of children.reach of children.

Emphasize careful child supervision.Emphasize careful child supervision. Emphasize danger of latex balloonsEmphasize danger of latex balloons Emphasize danger of latex balloons.Emphasize danger of latex balloons.

SummarySummarySu a ySu a y

Upper aerodigestive tract foreign bodies are not Upper aerodigestive tract foreign bodies are not uncommon.uncommon.

Careful history and physical examination.Careful history and physical examination.y p yy p y Appropriate selection of radiographic studies.Appropriate selection of radiographic studies. Low threshold for endoscopyLow threshold for endoscopy Low threshold for endoscopy.Low threshold for endoscopy. Important to have proper preparation, Important to have proper preparation,

i d i di d i dequipment, and an experienced team.equipment, and an experienced team. Emphasize prevention!Emphasize prevention!

airway foreign bodies: bronchoscopy - · pdf file · 2017-02-14airway foreign...

Documents