Airway and esophageal foreign bodies: Update Course 2015

David, you're going to talk to us about foreign bodies. OK, so foreign bodies in 20 minutes, just like Belinda said, I probably won't cover everything we need to cover. Aero digestive foreign bodies are a are a challenging topic because there's an uneven skill set, probably because we haven't standardized treatment training. There's an intersection between multiple groups. Every hospital has a different arrangement, but pediatric surgery, gastroenterology, ENT oftentimes will intersect. And, um, and there's a variable understanding or. A comfort level with the equipment that's used. So the team that comes in at 2 in the morning to help you take out a foreign body may not be the team that's used to all the equipment. So it's really a place for knowing your equipment and knowing your facilities, um. Is, is key. Uh, not a lot of data to drive management of our digestive foreign bodies. There's a lot of data on, uh, statistics on, uh, from poison control centers and. Magnet and battery ingestions, but not a lot to say what the best treatments are. There's a few studies. And um we can say that there, there are tens of thousands of hospital admissions or at least ED visits with foreign body ingestions that maggot injuries are on the rise, maybe peaking. That we know that sort of the age peak age is about 2 to 3 years of age, combination of kids being distracted. Trying to eat on the run literally and figuratively, having incomplete dentition and poor swallowing coordination. Uh, and then later on as you go from young kids to older kids, you move from, uh, typically food ingestion or respiration to a non-organic, uh, you name it, toys. Here on the left you just see uh some aluminum foil in the esophagus on the right, a pin in the trachea. I think everybody has seen some versions of these, so I may not get to all of this, but I wanted to talk in brief about uh some issues of, uh, to start with imaging. I'll start with a question, uh, a pretty typical story of a 2 year old, uh. Who actually just conveniently came into our emergency room with a mom said choked on something, uh, was coughing and drooling, had a relatively normal looking chest X-ray, certainly no no radio opaque foreign body, and on the cubitus films on the left side, you'll see that the mediastinum has shifted downward appropriately on the right side to the screen right. The immediate stinum has not shifted and this in some people's view suggests hyperinflation of the right lung. So can I ask either the audience or our panelists, what would you do with this child now? I think this child needs bronchoscopy considering the history, the coughing, and the hyperinflation of the right lung. OK, absolutely. So it seems to be, uh, would, would, would there be any alternatives? Actually, I think I was, here's, here's my, here's my, what would you do slide. So would anybody consider any of these, uh, other alternatives? I wouldn't. Would anyone here? OK, so, uh, just as a, as a statement that, that X-ray imaging is, sorry, I was gonna say, yeah, I was the only question I would ask, which you're probably gonna get to is the last point you made, is there anyone here that would do flexible? Or was that something you were getting to? You would, I might. What are you crazy? I might. So there's not a great lot of literature on X-ray, but certainly they're neither sensitive nor specific, meaning that hyper lucency, the hyperinflation on the ipillateral side might or might not be a foreign body. It can certainly be a bunch of other things like a mucus plug or Uh congenital stenosis or something else. There is some evolving literature on virtual bronchoscopy by CT scan. It's high res. It's quick. There's certainly radiation exposure, but I think most of us, certainly in my training, if you're suspicious, you go look and make sure it's not. David, what if there wasn't hyperinflation? Good history, no hyperinflation. I might pat him on the back and see if it gets better. a.m. So this is, yeah, Mark, I was gonna say, so, I think it matters if, if you have, if they have a good history and anything else. So if there's just a little rattle or something on your auscultating because a lot of times these things are subtle, you don't necessarily get the uh. Get, get the hyperinflation, but usually there's something on the X-ray. Usually, you know, the radiologist will sit there and say, well, it's just not exactly right. But I do think you should have a low index of suspicion for scoping. But I would actually argue that if it's a patient that has a very low index of suspicion, because some of these, you go to the OR and there's nothing there, right? I mean, we've all done that, um. Except I know Todd, you may be better than the rest of us, but you have the anesthesiologist slip an LMA in, and it's not a real big deal to slip a flexible scope down and just see if you have something. And then if you have something that needs to be treated, then go to it, then you have your rigid stuff there. But I think the rigid scope is, is a little bit more invasive than just doing an LMA and a flexible scope. Flexible endoscopy for this patient. I, well this one sounds like there's something there. I'd probably go straight to rigid. I'm saying if you if you're leaning towards if it's one of these, it's just it's the history and maybe some really soft findings. That X-ray was very convincing. There's something causing that. Teach me then. Explain to me what is the size. What is the size of the ET tube, the minimal size that you can use a flexible. Scope through the ET tube. You're thinking about going through an LMA even better. Oh, through it, yeah, you do it through an LMA. So a a one year old, no problem, no problem, no problem, even through an ET tube, but I'm convinced, but wait a minute. Once you've put the child to sleep and you've intubated them or put a mask, a laryngeal mask, why don't you just put a scope down? Are you concerned of the trauma of the bronchoscopy? If, if it's a low index of suspicion, I think it's OK to put a little, a little scope, a flexible scope down and see if there's something there. Because because of, because of trauma, because you want to do less, less damage, less inflammation, it's, it's the whole minimally invasive thing, Mac. There are places where pulmonologists get referred to these patients, and they start with a flexible scope and they can take certain things out with a flexible scope, so that's not an unreasonable option. I have a question for everybody. What percent of the time with this story and this X-ray, do you do a bronchoscopy and find nothing to take out? And also, what if this was at 1 a.m.? what's the right timing, uh, for the procedure 1:30. OK, and how about the first question? How often do you think you find nothing? Well, well, I think if it's a symptomatic child, you'll find something. You may not find a foreign body, but you may find epiglottitis, bronchitis, so you will find something, but if it's a really symptomatic child. you'll find something. I, I, I think it'd be very rare that you would find something with that hyperinflation. That one that the cubitus film was, yeah, this one, pardon me, took the OR because of some, probably my impatience. We didn't have the flexible stuff to the bridge of bronc and had just a big mucus plug in the right upper mains, right upper lobe, so I had something that's exactly what you're pointing to, but if I'd done a little more aggressive chest PT, maybe it would have just gone away. I think the takeaway from this group is that everybody would look unless there's completely normal, maybe, but everybody would look, I think we can debate about what's the least invasive way and I'm certainly in favor of flexible if you have a low intake suspicion. Um, but that's the sensitivity, even though the X-rays that are sort of pathonemonic is not 100%, but it's appropriate to look because the real risk of the risk is that you're going to miss something, not that you're going to find nothing. So I, so I think, and in our, our place the ENT guys do most of this, but they're very aggressive about doing, they use rigid bronchoscopy, do ML. If there's a risk or a suggestion that there could be a foreign body there, they get scope. But then it comes back to not just treating an X-ray. You've got to treat the patient who's clinically symptomatic, right? And I think that's very important. And Mark didn't include a physical exam which I went right over, but he's correct, he said. Everything, if there's anything off. You need to scope High index of suspicion. That's your go when in doubt. It's you'll only be sorry if you didn't do it, right? This is just a picture of a virtual bronchoscopy. This would be, this was seen as a mucus plug in the left main stem. You can pick up other things in virtual bronchoscopy with congenital stenosis, malaysia, the rare intra airway infections or tumors, but I'd say this is not, not the first line. That's from. MR, I'm sorry, this is a CT scan reconstruction. So what's what's the radiation dose? What's the radiation dose of that? Lots. You're gonna need general anesthesia. Well, no, but at the current, at least this, this is a group I forget from where, uh, they say with high speed CT scan now you can actually even a two year old just kind of swaddle and get right through. So, so we're looking at a Swiss bronchus? Yeah, this, this is just a, yeah. So the question is, is the risk of the radiation versus the risk of anesthesia. And looking, And we talked a little bit about timing of retrieval, uh, I don't know that I share Todd's. And The idea that it was a lacking a radio opaque object that you need to go in in half an hour, I'd say soon. Uh, my point is, if I get called at 1 in the morning, I'm not going to do it at 6 and then the next day I would do it at 1 in the morning. Would everybody do it at 1 in the morning? Absolutely. If the child's symptomatic, so, well, symptomatic, sure, but what if it's not. I, I, I. Would you do it at 1? So Todd's point is that probably the peanut can move. It can move. OK. Well, if it's a peanut, I'm going immediately because it's a peanut, and then within it you don't know this. It'll tear up the airway, but if it's a piece of carrot that's as benign as you could get, I still would go in because it could flip. OK, uh, anesthetic considerations, I'll just say that I think it's a, like anything, it's really important to have a communication with this team to be in the room with the kids going to sleep before they go to sleep. Some people make a big deal about, uh, total IV anesthesia to avoid the airway, uh, leak of gasses that you, when, when you have an open airway. Um, most, I think it's really key to have a a discussion with anesthesiology. This is something that the NASA G, the GI sort of group came out with just recently, very thorough review of foreign bodies in terms of, um, it's just a useful reference. batteries have, have gotten a lot of press, and this is the key offender, the 3 volt 20 millimeter battery is just big enough to get lodged, and the higher voltage causes higher rates of electrochemical damage. Damage starts within. An hour you can have significant necrosis of the esophageal tissue if it's in the esophagus. So I think most of us have appreciated that battery ingestions are very morbid and can be mortal. And mandate immediate retrieval. So let me ask the, the group here, uh, I hope people can see, can't see so well on the screen. Uh, what would people do here? Very similar to the previous question. Would anybody do anything but endoscopy? Well, I'd like a lateral X-ray to see if it is a battery or not. OK, you know what, I, I have to apologize, you can't see perhaps on the screen, but here you can see a double disc sign, and it's. Go ahead. No, no, no, no, no, no, no, show, I want you to. Most batteries these days, if you get a good picture, you can see on, on it's so cool, two concentric circles, and that's pat mnemonic. Some people try to identify a number, but it sort of doesn't matter. I'm embarrassed to say I learned that this year from the whatever my fellow Nick Bruns went to the battery ingestion conference, and I think someone, you or Kathia, whoever presented showed that halo ring thing this entire time. I always thought you needed a lateral to see a battery. But you don't. And is it no matter how the battery's facing, you can always see that ring sign, right? It, uh, I think that's been one of the advocacy pieces that the National Battery ingestion hotline and network has really worked on ensuring that that toys that are aimed at kids less than 3 years of age have a secure a screw and locking some sort of device to keep the batteries from just falling out, to have awareness campaigns and pediatricians and national organizations. To really stress the importance of timely immediate removal, and you can see here this is a pretty Well, maybe not such a threatening looking esophagus, but after removal you can see the massive erosion, and a few weeks later there's still erosion. I think all of us have heard or seen or dealt with horror stories of having a battery removed and then realizing there's a hole between the trachea and the esophagus. OK, so what do you do? So what I do, what I would do is do a bronc first, OK, to make sure that there's not erosion, OK, on the other side, in which case then you really have a completely different, OK, you go in, there's no erosion on the bronc. Now what? Now you take the battery out and then what? And then you see. OK, it looks like that Do you they're even in G tube? Do you do an esophagram? Do you keep them in the hospital for 6 years? What? I never, I think you get a little more information if you kind of probe that, uh, to see, not, not literally probating, but a little bit of air and sufflation to see if you're concerned. Of course, a swallow is a good idea. There are some data on using steroids peri and postoperatively. That's probably more for airway swelling than for treatment of erosion, and I think a high index of suspicion for. Uh, repeat upper endoscopy and then perhaps passing it a feeding tube later. I just, I always, I always wonder that. I, uh, we know, OK, we got the battery out and then I had a kid a couple of weeks ago, it was terrible and I said, you know, what do I do now? I didn't know if I left an NG tube, um, didn't know how to just, like I just because it was circumferential, I left an NG tube. Then I said, how long, you know, I got an esophogram, do I keep re-scoping him every few weeks to make sure it's not stricturing? I, I, I felt like I was going overkill because I didn't see any really good data. Well, here's the scary part, uh, there's a small literature on days to weeks after removal of batteries, the aorta interficially with a sort of a sentimental bleed and sudden death. And this MRI sort of it shows a little bit where the arrow is. That's the aortic arch. That's, you know, the second point of constriction at the cricopharyngeal muscle, and this is already showing a little erosion on the track pad on the track pad. I can use the mouse. Wait, there's a white arrow there anyway. Uh, uh, uh, I forgot about that. So, uh, so that is, it's a little bit unanswered as to, um, which battery removal needs to have advanced imaging to look at, look for potential erosion. Uh, I would ask the audience, you know, what do you do with a child who comes in with a little bit of hemoptysis after, uh, or hematemesis after history of battery ingestion with this finding. What, what are the approaches to uh aortic enteric fistula, you know, say a 2 year old. Uh, you put a stent in it. I mean you call, you call vascular surgery and have them do an endovascular repair, but at least do an aortogram, angiogram. Yeah, they'll do that first, but I think that this is what we've had, we've had not a battery that went through to the aorta, but we had a It was actually a G tube. Uh, the gastroenterologist had cut one of the mushroom peg tubes in an older kid, and the kid apparently wretched afterwards. And so about a few weeks later was getting an MRI of the spine looking at their scoliosis, and they're like, Oh, what's that? There's a peg through the esophagus into the aorta, and then the kid had a sentinel bleed and started. To bleed out. What saved that kid's life was, uh, the vascular surgery fellow had the wherewithal when we consulted them to, to bring a balloon an occlusion balloon with him, and he literally, the kid started to bleed out in the PICU and he ballooned, he like threw it in his groin and ballooned it right there and basically saved the kid's life and then we fixed everything else. Who ever thought of a peg? Crazy stuff, crazy stuff. Well, let's move on to, uh, magnets, another hot topic. I'm gonna fly through this real quick. Uh, comments were, um. There's people that like rigid, uh, there was a Naomi Galona says she does the airway CT to look for a foreign body like you showed, that's interesting. I've never, uh, done that. I. Not sure it's utility, but I, I think that's a great tool that I never knew about. Nathan Navotny says, um, he, he, he's just want to comment that he waits till the morning if the kid's stable, um, and. Uh, also, he said that Indiana treats this like a level one trauma activation. We'll get to that. OK, sorry, go ahead. So, just one comment for fun. Uh, Phil Gazero always speaks of the three ends the nickel battery. It's the negative side that causes the necrosis that ensues from that. Yeah, and the negative side is that is a smaller, that's the smaller of the two discs. The outer side obviously has a plus sign on it. That's the. The positive term, but the smaller disc is the negative. So there's another good question here, Todd, and that is, what do you do if it gets to the stomach? So I know I have an answer to that, but I is that something you're going to discuss, or should we discuss it? We can discuss it right now. OK. Question is, as a battery makes it to the stomach, do you go after it or not? And this was changed. My management changed. Thank you to your course in Washington DC that where I was told that I do it completely wrong. So, uh, well, we would never say that. We must. So what, let's just say, what do you do if the battery, do you go after it or not? Batteries in the stomach. Go after it, go after it. But why? Wait, we'll get to that. Oh, you want to do Y for each? No, but I, I, well, I, why do you go after it? I'm worried it's going to pass, continue to pass and get stuff lodged somewhere else, so I think that's, I don't think that's the right. I don't think that's the, that's the why. I think the why is because you don't know what happened between the mouth and the stomach. I think the batteries that have seen that. I mean, no, no, no, but they may have lodged somewhere in the esophagus, then, right? I mean, you still have to go after it, but you'll look at it going all the way down, right. So I think what's got in the stomach, take it out. What's that? You don't have to take it out. No, no, it gets to the stomach, but you're not diagnostic upper endoscopy. Or what you can do an esophagram, but would that actually show you erosion? But if it's, if it's not significant, well you can do nothing if it's not clinically significant in terms of saying that you would need to know what happened between the mouth and the stomach, uh, when you do remove the battery and you see erosion, you don't really do anything different either. So you're saying do an esophagram, yeah, or do nothing, but there's, but there's a, but I think there's an education piece to the parents that. If you see erosion, even if you're not going to change the immediate treatment, you know that erosion can evolve. If it's been lodged there for an hour, you have no idea what happened or how long it's been there. Probably just went right through. So then the, the risk is converting a partial thickness to a full thickness by doing your endoscopy. Yes, careful. I don't know, but it's. The risk of putting them on you don't, you don't need to put the kids to sleep and scope them, but you also don't need the battery. By the time it gets to the stomach, it's, it's, it's done. It's, it's shorted out. It's a course. So what I learned from their, their annual course was this, this algorithm that I'll find right now, the AAP algorithm, that says if it's greater than 2.5. Uh, centimeters. That's when you go after it. I got it down here. You got it. It's too small to see but because, because, because it's a bigger, because it's a bigger battery and it's gonna have more charge in it, or it will get, it won't pass. It's gonna get stuck. It'll get stuck at the ocecal valve or at or at the entrance. So I, that's that that that was that paper put together by the gastroenterologist, right? Was there was napkins at 2.5 centimeter or 6 centimeters in length either will not leave the pylorus or not make the sweep. That's the suggestion, yeah, that, that's the GI. That's the GI group. I'm not convinced of that because I mean there's very little that can get to the stomach and can't get all the way out. There's a few things that again if they're long that'll get held up by by the pylorus, it won't even get through there. But who, who has seen. A foreign body other than magnets caught up past that gets stuck somewhere past the pylorus. Does anyone, I've never actually I've seen a cortic get eroded into the duodenum, a coin, erode quarter, yeah, in the duodenum eroded in the duodenum. Wow, and I've seen ileocecal valve, some things you get stuck. So we don't have agreement. I've been lucky. I've been lucky. What I'm hearing though is plus or minus, do we need to evaluate the esophagus even though it's made into the stomach? I think we're split here. You say you wouldn't if there, so what I'm saying is that the catastrophe of an erosion of the esophagus with aorto fistula is not going to happen once it's in the stomach. It's the dealer's choice at that point. If it's too big. I would go after it with endoscopy. If it's not too big, I would leave it, and I wouldn't scope the child because you have to put the child under anesthetic, but I would explain to the parents that it could have been lodged in the esophagus. They have to be aware that there could be complications. So there was a case report, it's just a case report of a battery found in the stomach, let to go, and then a kid died of an aortic enteric fissure and and and necroppathy they found an erosion somewhere higher up at, you know, at the LES. You can argue that you wouldn't be doing anything. I saw that, yeah, yeah. But I would argue that you need to do something to evaluate the esophagus, and I would do an esophagram. I don't think you, if you can avoid putting them to sleep, then that's what I would do. And since we think that, since we believe that the smaller of the batteries are going to eventually pass, but I think because of the potential complications and the parents need to know that there is the potential complication of stricture or other types of things, that at a minimum they should have an esophagram. And if you let it go, how do you then follow it if you're just going to leave it there? Do you then follow it to see what great question. It goes all the way down. And how do you follow screening? That's it. So no X-rays. No, do you even do stool screening? No, I don't. I just do X-rays. I do nothing. Our gastroenterologist will like bring someone back for like weekly X-rays and until we hear about it and tell them to stop. Well, you'll occasionally have a parent who wants to test that, who wants to know what's gone, so. So maybe in that case I would do one X-ray at 6 weeks or something like that, but otherwise I would. It's interesting. I mean, I have had a patient who showed up who had serial X-rays, and this thing was there for months in the small bowel and never moved and ultimately had to go take it out. Wow. So they don't necessarily all pass. does happen, yeah. All right, we'll take a few words about magnets and. It's been a 9-fold increase in magnet ingestions or ER visits in the last 10 years, and I think everybody knows these. They're actually kind of cool until you have kids and then you think they're not so cool. Uh, I think most people are aware that it's, it's the joint magnets that can cause problems. Here looks like a joint magnet, but an endoscopy was found to have one magnet on either side of the. What am I doing here? Either side of the the epiglottis here and here we've seen, I think all of us have had experiences of magnets passing farther in. Uh So I'm sorry to do this, uh, the question from the audience is. We just discussed all this. Can we try to come up with a consensus, at least among this group? Are we, is there someone here that would endoscopically go after a battery in the stomach? Is there anyone here? Well, we said 2.5 centimeters. OK, so you would follow this algorithm that we will find and post in the chat. I follow that algorithm exactly. So the only difference between that algorithm is it doesn't talk about evaluating the esophagus. It says if it's small and it goes in the stomach, you're done. I think the addition to that algorithm is evaluate it. In some way is a reasonable thing. You don't have to do it, but it's some of us say evaluate the esophagus, but you don't have to go after it unless it's greater than 2.5 centimeters. Is that a fair enough? If you look at this also, they say if they're symptomatic, having abdominal pain, you can go that I think the algorithm says that too. I'll find it, but I think the answer to the audience is that I will post this algorithm that David's gonna show. Not just diameter length if it's greater than 6 centimeters. It's not going to pass, but Mark says it will. Sorry, the length also matters, and if it's greater than 6 centimeters, it's not likely to pass and you're going to have to retrieve that a 6 centimeter battery. No, no, I'm just saying of a foreign body. Oh, it's a car battery. No names mentioned. Uh, so I'll just ask the panel in terms of magnet retrievals, would anybody go after a single magnet? No, no, no, OK, stay out of the MRI though, yes. And then or, or, or now more than one magnet that's already passed into the stomach. Do people feel comfortable that those are joint magnets or do people want to retrieve them? So I wouldn't just go after them if they're, they're most likely joined if they're both in the stomach, uh, but they will become symptomatic if they're not, so I'd, I'd follow that kid. Go after it and there's no reason it can't cause problems further down. There's, it's once they join, they usually don't. They're true, they don't, but if it's sitting in the stomach, uh, I would rather know that they're out than worry about whether they're going to come apart. There's also a discussion of whether the depending on what kind of patient it is, if it's a patient who likes to eat a lot of sort of a follow up. Snack of metal, then it would be prudent to and how convinced can you be on a plane film that they're joined but that there's not a loop between them and that's how that's the issue they they move on but I think you need, I think you need a follow up X-ray to see if it's moved and if it's moved, if they're moving and they're moving and they're moving as a pair, a pair, I'm comfortable watching them exactly. The, the real, what if you have two in the small bowel that are in different places, you know, you have one in the right upper quadrant and one in the left lower quadrant in the small bowel. Take them out no matter what, what happens. So you'll do a laparoscopy and take them out. Yeah, I, I would, I would, I would not because if you operate on everybody, then everyone gets an operation. Some people, some of those kids will get away without an operation and you just need to watch them to be symptomatic. They just get peritonitis. Well, I'm only kidding. I agree with you I agree with you. I would do this. You're a magnemosis, right? Yeah, yeah, you think it would be magnemosis, but I have, we did have one that did get peritonitis from, from a battery erosion, not that we were watching, so it can happen. You think, you think it's a slow process and it is a magnemosis, but not always. Some of those magnets are, I mean, they, they're pretty strong magnets. So in Chicago we had, we had both a gastro, uh, splenic flexure colonic anastomosis and then a duodenome mesenteric anastomosis that it eroded through the colonic wall, one magnet kind of sealed itself over and probably didn't need an operation unfortunately, but had it almost had it auto patched himself. But anyway, all right, David. I use, the question is, if you have two magnets in two different areas, um, were you going to give them laxatives or something to promote motility to see if you can get these things to pass? I think the GI literature suggests that the peg or 360 or 33,600, whatever it is, because that's, that would be my approach. OK, I wanted to talk about coins, uh, because I learned something here, uh, that I thought was quite useful. Here's your lateral just in case, uh, so what would, what would the audience do here? So you think this is a quarter, you have a good story, whatever. Mark, can you show the, uh, the image. Great. Uh, so patient comes in, maybe has some drooling or dysphagia, but. Uh, let's say, you know, this is a coin and what would, what would be the options here? What time is it? In what's, in what time zone? So if the if it's a. Uh, at 11 p.m. and the kid's well, I would get another X-ray in the morning before going in after it. If it's middle of the day and I'm ready to go, I'll take it without getting a repeat X-ray. OK, now, why, why do you, why would you, why would you treat it differently based on the time of day? That's how I roll. So, so I think a lot of us do that, but it's, that's how you roll in bed, you mean 30, 30% of coins in the upper esophagus will pass spontaneously within 6 to 19 hours. Now that's obviously going to be a bit of a selection bias, and 60% of those lodged in the lower esophagus will pass spontaneously. Now I don't know that those are really takeaway numbers because the denominator is probably pretty unclear, but there's definitely a spontaneous passage rate. Does anybody do boujonaj? Sorry, but. So first of all, that doesn't look like a coin. Is that really a coin? It is a coin because it looks more egg shaped. It's But second of all, we, I think it's a, yeah, at our institution, we, uh, use boujoage really as the first line of treatment, assuming the child's not older and assuming that the duration is less than 12 hours, excuse me, less than 24 hours. If if there's an unknown duration, then we don't use bouchenards, but we've reported that experience of over 500. A few years ago and and it's been highly successful and then if it's not successful, then we take them to the operating room and do an endoscopy and retrieval and who does that and and where well, generally speaking, our fellows do that and they do it in X-ray under fluoroscopy. So and the bona is to push it forward. No, we, we, we pass a Foley catheter past the coin. Blow up the balloon using generally putting some contrast in it so you see the balloon and then you flip it out. So wasn't there some danger in that? Well worry about Asperger's. Yeah, we've not had that. We've not had those problems that other people write about or worry about. So Tom Sato just presented in Peru last week, two weeks ago, the Milwaukee Children's Hospital data. Can we have that slide, please? Thanks, Tom. No, no, go ahead. No, no, here we go, please. Go ahead, this, this. This is the Milwaukee Children's uh uh paper in in surgery that just came out about 5 or 6 months ago and, and they sort of combine a lot of things we just talked about so they, they actually do push boinage in the ED uh with either the ED senior residents or a surgery senior resident or fellow. Uh, they had a very high success rate with no problems other than not being able to get the coin down and then retrieved it at endoscopy and, uh, I, I, I may not get it right, but I don't think they followed any of their kids, they just said go home, just like we were talking about, once the coin gets in the stomach, they don't worry about it. And so this, I think was super eye opening to me, and I'd love to not only that, David, this, this blew me away when I saw their numbers. They weren't like 20. They had like 700 cases or maybe more. I think there were 1200 cases over the last 20 years. They looked at this, and they did it comparing it. You'd be proud to wit. They actually did a prospective or maybe it was retrospective, retrospective trial control comparing to the ENTs because the ENTs always went to the OR. And the pediatric surgeons always did boujonage, so they had two groups and they switched call every other night. So they actually had two groups with the same numbers over 20 years. It's a very powerful study and like 10fold cost savings, 500 bucks to do this 10fold and $5000 to go to the OR and usually admit overnight or at least. There was essentially almost no complications, but the only few that there were were in the ENT group were the ones that went to the OR. There was laryngospasm. There were issues related to anesthesia. They had none, right? I think for them. Do they sedate the kids? No, no. They say this is a hot dog. It's a blue hot dog. We're going to let you swallow it. Bam. Do they have a time frame of when they, I think it was less than 12. sort of 18 like 24 hours, maybe that's what it was, yeah, because there's the scary cases and I received a call within the last month from another institution where they use a Foley catheter in the emergency room, tried to dislodge the coin, and Then minutes later massive hemoptysis and then respiratory distress, intubation, kid had needed to go on ECMO and go to the operating room later that evening for a total tear, longitudinal tear of the trachea. And so, yes, that's one case, but that case cost a lot more money than the other cases that um you saved money. So there is a scary component to this. I know they addressed that time frame, and I just don't remember the answer, and I don't know the time frame of that case if they knew how long that coin was lodged there. I, I do think in the older child, if they come in at night and you decide not to do something at night, but planning on doing it the next morning, you do need to get an X-ray because some of those will pass. Uh, so I, I agree with you on that. But if it comes in in the middle of the day, are you going to wait to see if it passes, or you're going to go after it? No, we would generally do it that day. Does anyone use flexible? Yes. You do, yes. It's sort of a mandate in our hospital anyway, but yes. OK, great, uh, just a couple quick, quick, yeah, cause, yeah, no, you're actually, you're good, um. I won't get into this, this is just a kind of a frightening graph from the national. Battery ingestion hotline or foundation just showing this is major fatal outcomes from battery ingestion. You can see even though the red bars represent decreased incidence of the black line or the spike lines are these are increasing rate of fatalities, so it's certainly not a problem. Fixed. This is the one that that Todd mentioned. Um, it's the Alabama group and coordination with the Indiana group that, uh, basically made battery ingestion a level 1 activation just like a trauma, and they turn, they cut their 3, they, uh. Door to OR time down from 3 hours to I think 30 minutes. Uh, and I As much as I hate level one traumas, I love this idea because I really think that this is a, a battery injection can't be, um, made an add-on case or a let's wait for the case to be finished. It's going, I think it's a 2nd team call in. It's all hands on deck. I will say, oh, go ahead. I was sorry, I was just going to say the problem though is, uh, the identification that it's a battery and so, you know, the, the downtime is really getting to the ER to the identification. Once the identification is made, it's, it's very good to activate a, a trauma, but, but that's not the long period. Usually once surgery is called, um, you know, because they've identified a battery, then we go very fast. Now, I will, I will admit that somewhat recently we had a battery that came into the ER, but there were like 2 cases in the middle of the night, but there were like 2 cases going on in the OR and there was going to be a delay. And so I had our fellow take that battery out with the Foley balloon catheter because there was going to be a several hour delay in getting to the operating room. I'm not saying that's what you ought to do, but in select cases I think you ought to try to do whatever you can do to get the battery out as soon as you can. That's impressive to me because I would have thought the balloon would slide right past it because it's so embedded, but, but. You know, it's an end of one, so it worked. The downside is if it doesn't work, then you haven't really lost anything. Well how important it is to go fast, right? And it was a, it was a short term duration. It was a known battery and that type of thing. Or the danger is if there's erosion, you blow the balloon up, you could cause more agreed, but it was a relatively short term. So weighing all the factors involved, it seemed like. The most prudent thing to do at the time was to try to get it out using boujoage as fast as you could because you couldn't get to the OR. Yeah, did you then evaluate that child in any other way you then subsequently scope? No, we, we did an esophagram. We admitted him and then did an esophagram the next day. So I, I have a question, so the most urgent thing we do probably is a bad airway foreign body, like it's, it's scary. You got to go fast. Everyone's heart rates are high, and of all cases we do, it's the most difficult to set up for. Uh, I don't know why, and this is a plea to the endos to the endoscope companies, why is it so hard to put these 30 pieces together? Why can't, I don't know if there was a way to make it, and this size, oh that's too long, but this goes with this thing and that's too short, it's just, uh, that's one advantage of the fiber optic, but you can't grab as well, even the little grabby things are really wimpy, so um I wish there was a safer way, maybe to have them all preassembled. Maybe they're all sitting there designed differently. It's very true because, you know, often the nurses at night aren't the ones who work in the airway team. They're not sure how to put it together. You're fiddling with the thing because you only do one once a month. So I agree with you. but there are actually several in in places where all the pieces are there because half the time the problem is you don't even have all the pieces in the middle of the night. Dan, are they pre-assembled? Ah, it's not preassembled, but it essentially comes with a respiratory tech who knows how to put it together. So it's not just the pieces in the cart, but the person who can actually assemble the equipment. So I just listed a few things we talked about a few of them and we certainly don't have time to, to dissect them, but, uh, people will use rigid versus flexible call schedules and sharing of responsibilities varies by institution. There are a few papers on stimulation. Layer doll has a nice little, I've not seen it myself, but read, you know, a doll that simulates both, uh, airway evaluation and tracheotomy and all these kind of things, um. I think that the ENTs are more likely to do suspensory laryngoscopy because you a little better look at the hypopharynx and the glottis. Most of us, I think, just go in and Put our scopes in, uh, what do people do with sharp objects in the esophagus? People go after them, wait for them to pass. Like a, um, say a safety pin or a. They will pass and they usually flip in the esophagus or the stomach. If if it's stuck in the esophagus, you'd have it's stuck, but you say get an X-ray and it's there. Do you let it see if it passes and then just let it pass, pass, or? Usually you let it pass, pass, uh, because what happens is it flips in the stomach and then the, the head of the of the knee of the thing is pulled first, so the, the, the, the sharp part lags behind, trails behind trailing sharp edge because of the peristaltic motion. Is that right? There's, there's no right answer. Uh, some people advocate steroids after, uh, after airway and competence sequential. I think that I don't know if anybody's published on the variability of fellow experiences. Some programs have a super strong airway program and maybe the pediatric general surgery residents, fellows don't get exposure. Uh, I think it'd be interesting to address it, not here maybe, but at a program director's meeting. Um There's a question. Do you bill for the Foley retrieval? No, in our country, I'm realizing there are a lot of folks internationally who might not appreciate this, but in our country, if the staff is not present and participating, then you can't bill for a service. So there's no bill for the fellows to, to do it. I just finished with a with a. Kind of a fun or funny case from a few years ago where a girl swallowed her grandmother's ring. ENT went in to get it, and, uh, during the case, uh, I'm not sure exactly why they, they couldn't find it. So they got an X-ray, found a pneumothorax, so they called us thinking there may have been an esophageal tear. We put a chest tube in, they put a dopp huff in to feed her, and then got an esophogram a week later that showed no esophageal injury, uh, but not wanting to drag this, um, ring back out through the. esophagus with a potential exacerbating a tear, we decided to go through the stomach, so we placed a laparoscope and a transgastric port or intragastric port. Somehow they'd managed to put the Dobhuff through the ring. That wasn't intentional, I think, but it may have prevented it from leaving, and then we just took out the ring through that little gastronomy and. And everybody was happy. So, were you sure that you had an upper GI that showed no tear? I mean, did you think about just putting a scope down and pulling it back out instead of Yeah. We did, it didn't. OK, OK, so I have a question for everybody here, um, kind of like, uh, it's actually a real case that's happening right now where I'm from, but, um, a peanut was retrieved from a right main stem bronchus. It was to your point, sometime in the middle of the night and inadequate staffing and difficult assembling the, the, um, instruments together. Immediately post-op the child got a bilateral pneumothorax. Got chest tubes, has continuous air leaks, eventually they went away. Tubes were removed. Reoccurred after a coughing episode and on bronchoscopy has a linear tear above the carina. Doesn't look like a huge tear but has a linear tear above the carina. How, how would everybody approach this? A full thickness tear, yes. Well, I think, uh, There's two ways from, from my perspective, sorry to speak out here. The one is if it, if there is a um pneumo or or uh some kind of media style infection, I would put a chest tube in and treat it conservatively with antibiotics. If there's no evidence of leakage, I would treat it conservatively with antibiotics. Would you put a tube past, I don't know if you mentioned if this kid was intubated or not, but if you have persistent air leak, would you place a. Endotracheal tube pass the tear so that you could let it heal over that and I'm prevent trauma endotracheal or esophageal, I'm sorry, endotracheal. That's a good question. I don't know. So I think these heal on their own, the ones that I've dealt with, and if you could place a tube past the tear and just let it heal for a week, they typically heal on their own. You don't need to go and physically repair it. So it's right at the carina, just above the carina, and you could just main stem them. Or. intubated for any other reason besides this tear, and is there an air leak into the chest? The child is extubbatable at this point. Is there an air leak or no? Yeah, there is an air leak. So the chest. And last year I ended up using stents. Um, yeah, uh, Dan and I talked about a different case, uh, from a TEF was secondary to a battery ingestion, but I'm just wondering what the crowd's opinion was about using a Y stent in this, if it does not heal in about a week or so. I, I would consider fiber and glue. And putting that just right on the area and if you can get something past it, but I would try to occlude it from the inside with something, um, and see if you can get an air leak to stop. I think getting, putting a stent in to cover the tear and getting the child off positive pressure ventilation would be the things that would be most likely to result in a in it healing. And in that child you've already demonstrated that it stopped once, so I think it would be very likely to heal. Great, thanks. All right, that was great. That was, uh, no shortage of, uh, opinions on that one.