Hey there, listeners. This is Rod from Cincinnati Children's. If you haven't already, download the Stay Current in Pediatric Surgery app. We've got brand new content, a brand new layout. I really think you're gonna love it, but the reason I bring it up here is because if you're listening to a podcast, and our guest is talking about A new research article or an image, we can give it to you right there in the app, so you can look, learn, listen, all in real time with our podcasts. But until then, enjoy the episode. If you're anything like me, just the thought of an airway foreign body gives you a lump in your throat. But don't worry. In today's episode, we're just gonna talk about the basics. I mean, diagnosis and initial management for patients with suspected airway foreign bodies. And to do that, We're gonna jump this conversation off with some anatomy. So the classic location for airway foreign bodies is in the right main stem bronchus. That's Dr. Katherine Hart. She's an otolaryngologist at Cincinnati Children's Hospital, and that is just because the takeoff to the right lung, that right main stem, is a little bit more in line. And so when something falls down into the airway, it has a tendency to take the most direct path, which is into that right main stem. OK, so that right main stem is a straight shot for an aspirated foreign body. But what age group should we expect to see these in, and what are they even aspirating? So the most common age groups are younger than 4 years. Now keep in mind it can happen at any, any time. I've taken airway foreign bodies out of adults before. Um, they're oftentimes very interesting stories when that happens, but they most commonly occur in kids younger than 4 years, and that's because those are the kids that are most likely to put things into their mouth as they're sort of exploring their environment. Um, the peak incidence is really between 1 to 2 years, and oftentimes in kids under 1 year, we don't, uh, immediately suspect a foreign body, uh, but if they have siblings, you, and the history fits, you always have to consider a foreign body because it is not uncommon for an older sibling to share something with, with a baby and they then aspirate it. So while I appreciate siblings sharing with each other. You've got to watch out in those patients who are under 4 years old. Now, when it comes to food, are there certain types of food that might be worse than others? So it tends to be things that are not easy to chew, so things like nuts. Popcorn or popcorn kernels, uh, seeds of things, edamame are not uncommon, um, because it's something that a lot of people think of as healthy and will feed to children, um, but because it's shaped much like a nut and they're actually a little bit hard to chew, they can end up down in the airway as well. OK, so a house with some really good edamame is going to raise my suspicion, but What about some presenting symptoms that should raise our suspicion? So the most common presenting symptoms are cough, right? So they'll come with a history that is concerning for a possible foreign, foreign body aspiration. Um, but, but they'll have either a continued cough after a choking, choking event, or they'll, they'll present with, with some wheezing or noisy breathing, um, usually again following a choking event or them having something in their mouth that would make you suspect a possible foreign body. Now sometimes, depending on the size of the foreign body and the location. And they'll present with more severe respiratory compromise, right? So those kids who have a foreign body that's higher up in their airway may actually present with stridor or with the actual impaired difficulty breathing in some cases where they're actually, you know, cyanotic or apnneic because the foreign body is causing obstruction. OK, so let's say we have a high suspicion like that. How are we going to assess this patient initially? So this is one of those things where with any airway concern, the first thing that we train our residents to do is the minute you walk in the door, you're assessing the respiratory status of the child, right? Are they working hard to breathe? Do they have retractions? Are they tachypnic? Are they sitting really, really still and really focused on breathing, which you'll sometimes see in kids who are actually dealing with a very severe airway compromise. So that's really the first thing you have to do. Um, and then you want to get them on on monitors to make sure that their, their oxygen saturation is OK and that their cardiac status is, is OK and that hemodynamically they're stable in cases if there's more severe compromise. So Dr. Hart, you had talked about a few of the signs and symptoms you would have your residents and fellows look for when you walk in to see a patient. That's Ray Hanke. She is a general surgery resident out at Penn State University. What other findings are you most likely to find in physical exam? So the things that that you're looking for, again, it's some of the more, the more subtle signs of impaired respiratory status. So you'll look for tachypnea, um, especially in younger kids. You, you look at how their whole body is breathing, right? So especially um infants and toddlers, they don't breathe with, if they're really working hard to breathe, they're not breathing with just their lungs, but you can look for things like nasal flaring or retractions, um, either, you know, subcostal or uh suprasternal. Um, to really try and get a gauge of how hard are these kids working to breathe, then you're listening for persistent cough. Um, and then you also, this is, there aren't too many times where ENTs get out their stethoscopes, but this is a time where, where you actually want to listen to the lungs, um, and make sure that breath sounds are, are equal on both sides and that they're not diminished or that you don't hear very focal wheezing, uh, because that's oftentimes. A telltale sign that there's something down there, the lungs will be completely clear except for, say, the right upper lobe or the right middle lobe. Sometimes you can't get that specific when you're listening, but um if there, if there's a difference from one side to the other, then it makes it less likely to be, say, either a viral process or um reactive airway disease and more likely to be an airway foreign body. All right, so now I've done my physical exam. I think that there's an aspirated foreign body. Should I get some imaging? So the first thing to do is just get a chest x-ray, right? Unfortunately, a lot of um things that kids aspirate, um, are, are going to be um radiolucent, so you're not gonna be able to see them on an X-ray. Um, sometimes you get lucky and you can actually see the foreign body, um, and that makes it makes it really easy. Management decision. Um, if, if it's something though that doesn't show up in an X-ray, in addition to just your standard two-view chest X-ray, you can do lateral decubitus X-rays, right? So that's where, where the child is positioned initially with one side down and then with the other side down, um, and you're looking for air trapping on the affected side. Um, and that that is because you will see if you have enough airway obstruction from the foreign body, it can cause a ball valve effect, and the air can get in, but it can't get out. So when you put that affected side down, it, it normally should sort of make that lung volume decrease, but if there's an airway foreign body, um, That's, that's creating that ball valve effect. The down lung will still stay just as inflated. It can sometimes be a pretty subtle finding, but if you see it, it's considered essentially patopneumonic for an airway foreign body. If you don't see it, it doesn't necessarily rule it out, but does make it a little bit less likely. Wait, Rod, hold up, hold up. Yeah, what's up, Todd? What about chest CT? Wait, chest CT? Yeah, chest CT. Uh, what do you mean? I mean, a lot of these bronchoscopies are negative, and so you're putting airway instrumentation into someone with reactive airway disease. Yeah, that's a good point. A lot of recent studies are now suggesting the use of CAT scan to help diagnose these patients. We started doing this in Akron. Huh, interesting. In fact, Alex Gibbons did a retrospective study out of Akron Children's Hospital to look at the efficacy of using chest CT. So we had to go straight to the source. In this study, we sought to evaluate the accuracy of utilizing a low-dose CT scan of the chest, in order to diagnose foreign body aspiration in children. That's Alex Gibbons, he's the first author on this article that we're talking about, and it's actually linked under the media player, check it out. We accomplished this with a combination of retrospective chart review and follow-up telephone survey. What we found was that this modality had a specificity of 98% and a sensitivity of 100% while being much less invasive than the traditional rigid bronchoscopy used for diagnosis. Talk about a breath of fresh air. Thank you, Alex. So let's talk about a different clinical scenario. If you have a patient that's having a difficulty phoning their cyanotic, their stridor, and you're really suspicious of a large airway obstruction, what should be your next steps? So if you're, if you have a child who is in acute distress and has a significant respiratory compromise, that is something that has to be dealt with emergent. Right, so that's not something where you're gonna wait until anesthesia gives you the OK to go up to the operating room. Um, you're gonna move them to your trauma bay in your emergency department if that's not where they are already, um, and you're gonna look, um, you're gonna, you know, do immediate direct laryngoscopy and make sure sure there's nothing obstructing either the supraglottis, which can sometimes happen in small kids if they, depending on what the foreign body is. It can, it can cause obstruction higher, higher up, so it's not even actually in the airway itself, but it's obstructing airflow enough that that the child's in distress, or you can have something that's lodged right at the level of the glottis, in which case you can oftentimes reach in with a McGill's, which is pretty readily available with just standard intubating equipment or your, your crash cart and remove it straight away. What about those frustrating moments where it's like you see it and you can grab it, but you just can't pull it out. If for some reason it's something that is big enough that it's causing severe obstruction and you either can't get a hold of it or you can get a hold of it, but you can't get it out, which thankfully doesn't happen very often, but can happen. Um, then you have to, then the next step is the surgical airway, um, and so in a child, um, older than the age of 8, you would do just a cricothyrotomy, um, if, you know, the general recommendation in kids under the age of 8 is you're not supposed to crike them, um, but do an actual, you know, emergency trachea. om y which is actually easier to perform in many kids than you would think, um, or you do a needle cricothyrotomy rather than an actual crike, and that's just because of the relative size is much smaller and so doing a cricothyrotomy in a in a small child is technically an incredibly challenging thing to do. What about the gray area? Like you're pretty sure that there's an aspirated foreign body, but they're not like an emergency, we gotta do a crike right here in the trauma bay, then what do we do? So in those cases, and I would say that's, to be quite honest, the vast majority of the foreign bodies fall into that category. Um, you would take them, um, up to the operating suite and you would, um, under general anesthesia, uh, do bronchoscopy. Now, generally speaking, if you think there's a foreign body there. You should be going straight to rigid bronchoscopy. Wait, Rod, hold up, hold up. Yeah, what's up, Todd? I want to make one quick point. Yeah, go for it. When you go in to do an airway form body, these can often be very rushed emergent cases, and I really would suggest. That the listeners make sure that they know exactly how to set up their own bronchoscope because the staff at night may not be that comfortable. So really make sure you know how to set up the scope. So what do you guys do to make sure everyone knows how to set it up correctly? We actually have instruction pictures on the bronchoscopy cart that show step by step how to set it up. You know, that's not a bad idea. All right, let's get back to Doctor Hart. Depending on what equipment your institution has available, you should hopefully have a variety of endoscopic, um, graspers. Um, they come in all sorts of uh different, different forms, um, that allow you to grasp different objects, right? So for, um, if you, if it's a coin, right, so we, we'd We have a special coin grasper and we have one that's called a peanut grasper where the shape of the instrument is different for depending on the foreign body that you are anticipating having to remove. Hey Rod, hold up. Yeah, what's up? Got one more comment. All right, let's hear it. The bronchoscope grasper is sometimes a bit difficult to use in a small patient, since it doesn't often have enough room. For the jaws to open wide enough to be able to grab the foreign body, and it really obstructs the view. Good point. So what do you do? Scott Bollinger, a partner of mine, showed me a cool trick of using a wire urology endoscopic grasper that you can put down the aspiration side channel of the bronchoscope, just a cool little trick. For these patients, say you went and you removed a foreign body, is there any particular follow-up that you should have? So if it's an acute foreign body, um, and it, once you take it out, there's really nothing else going on, then, then to be quite honest, no, you don't really need to follow up. Um, we basically tell them if, you know, if there's cough that persists, fever, um, then either give us a call or see your pediatrician. The kids that do need follow-up are those who've had a chronic foreign body, and when you take it out, um, there is either granulation tissue or inflammation at the level that you remove the foreign body from, right? So if you have something that is lodged in that right main stem and it's been there long enough, even when you take it out, there can be, you know, the, the mucosa is going to have reacted to it, and you can A lot of granulation tissue at the site, so you worry in those kids that they may actually then develop some some subsequent stenosis of the bronchus. And so those are kids that that generally require follow-up to make sure that that's not occurring. And if it is starting to occur, you can proactively manage it before it develops into, into a bad stenosis, depending on what you're removing and Big it is, you can certainly create issues at the level of the glottis, right? So you're having to pass your bronchoscope between the vocal cords and then you're going to be removing whatever the foreign body is out of the vocal cords. And so if it's big enough or sharp enough, you can create injuries at at those levels, and I specifically mentioned the glottis just because it's, it's one of the narrower points. Um, and the vocal cords are more vulnerable to injury. Um, now, removing sharp objects from the airway is a, is, it can create, I mean you can actually, you know, create a rent in the airway if you're trying to remove something like a, a pin or a needle, something that has a sharp edge, um, and so that would be something in those kids, you're probably going to be watching them postoperatively to make sure that, that, that, that hasn't occurred. All right, so let's summarize the key points here, because this could be a really challenging and scary situation, especially in the middle of the night. So, maintain a high index of suspicion, especially in those patients where the story doesn't quite add up, or there's something really strange on physical exam. Because honestly, the obvious aspiration events are gonna be right there in your face, and all the other ones might not be so clear. Then you gotta make a decision, do we go to the OR? Do we go to the scanner? And then keep in mind that where you practice might not be the same as where you trained, so make sure you understand what equipment's available, or who you have to help you with this. Is the rest of the team educated on how to set up a bronchoscope? Lastly, it might be worthwhile to make friends with your local ENT because some of these cases might need some multi-disciplinary support. Last thing, I wanna thank Ray Hankey and Alex Gibbons. They're the ones who did the real work here. They actually did this interview back in 2020, and I just shook the dust off and added some music here and there. So thank you guys both, and I'm Rod Gerardo from Cincinnati Children's. Until next time, remember, knowledge should be free.
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