Ten years of paediatric airway foreign bodies in Western Australia
Introduction
A potential paediatric airway foreign body (PAFB) can present a diagnostic dilemma for the clinician. A PAFB can result in life-threatening sequelae, yet history and examination are often inconclusive [[1], [2], [3], [4]]. Chest x-ray and CT may assist in decision making but have associated risks [5,6]. Determining which patients warrant a general anaesthetic (GA) and microlaryngoscopy and bronchoscopy (MLB) versus watchful waiting is the most important decision for the clinician. Complications of intervention, including death, have occurred in patients for whom infection rather than foreign body was the source of symptoms [7]. MLB is the gold standard for diagnosing and removing PAFB, however there is a lack of consensus regarding when to proceed over watchful waiting for suspected PAFB.
We present a retrospective cohort study of paediatric patients who underwent MLB for suspected PAFB at the Princess Margaret Hospital (PMH) for Children in Perth, Western Australia (now known as Perth Children's Hospital) over 10 years in order to review clinical presentation and management.
This study presents a cohort of 127 children with a suspected airway foreign body who underwent MLB at PMH between 2007 and 2016. PMH is the only centre in Western Australia properly equipped to perform paediatric MLB and therefore this cohort should capture all such procedures undertaken for a suspected foreign body airway. Approval for the review was obtained from the Western Australian Health Department, Child and Adolescent Health Service (Geko: 064630). Cases were identified through review of a prospectively maintained operating theatre database through the search terms ‘laryngotracheobronchoscopy’, ‘laryngoscopy’, ‘bronchoscopy’, ‘oesophagoscopy’ and ‘foreign body’, as these were standard terms in the booking process.
The clinical charts of cases were reviewed and coded for demographic details, presenting history, clinical examination, radiological findings, length of stay, time from inhalation to procedure, type and location of foreign body, and any complications. Patients were referred to the PMH ENT team via a primary physician, respiratory physician or an emergency department from within Western Australia and MLB was performed under GA by an ENT Consultant using a rigid bronchoscope, Hopkins rod lens telescope with or without an additional flexible scope.
Patients were then observed on the ward or admitted to intensive care. Patients were routinely followed up by the paediatric respiratory team.
This study includes children who underwent MLB and does not include a review of children who were evaluated for foreign body and deemed to have low probability for aspiration and therefore did not undergo MLB. By selecting a cohort using these criteria the authors acknowledge the likelihood that children with a higher background risk of foreign body have been selected. An alternate approach would be to review all cases of paediatric foreign body, however a more refined analysis is enabled through focusing the study to cases undergoing MLB.
Section snippets
Patient demographics
One hundred and twenty seven children underwent MLB and 104 of these had a FB found (82% true positive rate). A male preponderance of 70% (89:38) was found. The age range included children from 7 months to 15.7 years with a mean age of 2.9 years (SD 3.3 years) and median of 1.7 years (IQR 1.1–2.6 years). The majority (62%) of PAFB occurred in the 0 to less than 2 years age ranges (Fig. 1).
History and examination
Ninety-seven children (76.4%) had a witnessed inhalation. One hundred and three children (81.1%) had a
Discussion
PAFB represents a diagnostic and management challenge for clinicians. History, examination and chest x-ray are non-specific and the condition can rapidly result in significant respiratory compromise. Performing a MLB for a suspected PAFB is not without risk, with cited complication rates ranging between 4 and 19%. Complications include desaturation, bronchospasm, bradycardia, airway trauma, pneumothorax, failure to remove FB(s), respiratory arrest, necessity of mechanical ventilation and death [
Conclusions
We have presented a large study with data points which are comparable to a number of other studies on this topic. The PPV of history, examination and radiological findings are high in this cohort and the number of negative MLBs performed is low.
The popularity of CT scanning for PAFB is increasing and this is a particularly valid diagnostic tool for use in patients with a low suspicion of FB as it has been shown to have a high NPV and therefore would avoid MLB in many children.
Our study
Declaration of competing interest
The authors whose names are listed above certify that they have NO affiliations with or involvement in any organization or entity with any financial interest (such as honoraria; educational grants; participation in speakers’ bureaus; membership, employment, consultancies, stock ownership, or other equity interest; and expert testimony or patent-licensing arrangements), or non-financial interest (such as personal or professional relationships, affiliations, knowledge or beliefs) in the subject
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