Paediatric foreign body aspiration matrix

Transcription

1 Paediatric foreign body aspiration matrix Award: Agfa Healthcare Diagnostic Prize Poster No.: R-0084 Congress: 2014 CSM Type: Scientific Exhibit Authors: A. Buxton, Z. Chen, M. Clift, Y. Dinh, J. Fernandes, N. Southwell; CALLAGHAN/AU Keywords: Conventional radiography, Respiratory system, Pediatric, Diagnostic procedure, Education, Foreign bodies, Atelectasis DOI: /ranzcr2014/R-0084 Any information contained in this pdf file is automatically generated from digital material submitted to EPOS by third parties in the form of scientific presentations. References to any names, marks, products, or services of third parties or hypertext links to thirdparty sites or information are provided solely as a convenience to you and do not in any way constitute or imply RANZCR/AIR/ACPSEM's endorsement, sponsorship or recommendation of the third party, information, product or service. RANZCR/AIR/ ACPSEM is not responsible for the content of these pages and does not make any representations regarding the content or accuracy of material in this file. As per copyright regulations, any unauthorised use of the material or parts thereof as well as commercial reproduction or multiple distribution by any traditional or electronically based reproduction/publication method ist strictly prohibited. You agree to defend, indemnify, and hold RANZCR/AIR/ACPSEM harmless from and against any and all claims, damages, costs, and expenses, including attorneys' fees, arising from or related to your use of these pages. Please note: Links to movies,.ppt slideshows,.doc documents and any other multimedia files are not available in the pdf version of presentations. Page 1 of 27

2 Aim Foreign body aspiration accounts for 82% of hospital admissions in paediatrics aged from 0 to 14, so a large number of these patients are at risk of unfavourable outcomes [1]. A method is sought to assess the medial imaging, medical and/or surgical needs of the paediatric patients who have aspirated a foreign body, which could be used to determine the severity of patient by a range of medical professionals. This could potentially provide the paediatric patients who have aspirated a foreign body more appropriate management and take the strain of resource away from Emergency Room Medical Doctors. Images for this section: Fig. 1: Paediatric foreign body aspiration matrix Page 2 of 27

3 Methods and materials Relevant journal articles and case studies are identified and analysed with common themes becoming apparent. These themes are able to be categorised into a chart or matrix, which assigns severity scores to four different aspects and then produces a summed total score indicating the level of patient management required. Scores are given to: patient presentation, patient's difficulty, mechanism of the aspiration of the foreign body and its location within the respiratory tract. Total scores from the matrix are classified into 3 categories: Minor, Major and Extreme. A suitable management pathway for each category is identified. Images for this section: Page 3 of 27

4 Fig. 1: Paediatric foreign body aspiration matrix Page 4 of 27

5 Results A. Presentation (Fig. 2) In paediatric foreign body airway obstruction diagnosis, clinical signs and symptoms have the highest sensitivity (97.8%) comparing to clinical history, physical examination findings and radiological findings [1]. Those symptoms can vary greatly depending on the time after a foreign body is aspirated. To classify these symptoms, they were divided to three different phases [2]. Initial phase: occur immediately after a foreign body has entered the airway. The most common initial symptom is a choking episode, followed by other airway distresses and symptoms such as gagging, wheezing, and/or stridor [3]. Perioral and temporary cyanotic episodes can also occur during this phase. For paediatric, this phase has the highest rate of death, therefore we gave this phase the highest score out of all phases in our Matrix [3]. Asymptomatic phase: is the second phase. During this phase the foreign body have potential to change its location combine with relaxation of reflexes can reduce all the initial symptoms. The diagnosis is potentially missed during this phase if there's no witness during initial phase. Asymptomatic can last from minutes to months [3]. This phase has the lowest potential to cause death and complication out of all phases; therefore we gave this phase the score of 1. Characteristic/ Symptomatic phase: is the third stage after the incident. During this phase symptoms of complication such as seizure, stridor, pneumonia, prolong cough, asthma an chest pain can occur due to the airway inflammation or infection from foreign body [3]. This is also the renewed symptomatic period [3]. With the high rate of complications we gave this phase a score of 2. Clinical symptoms has the highest sensitivity however its specificity is only 7.4% therefore we need other clinical findings before determine foreign body airway obstruction [1]. B: Patient difficulty (Fig. 3, 4) In the matrix, one of the most important aspects of examination finding: the patient difficulty is used to evaluate the severity of the patients. It includes the consciousness, ill appearance, state of comfort, degree of cooperation, level of irritation, nature of cry, reactions and expression of the patients [2]. Scores of from 1 to 3 are allocated to the Page 5 of 27

6 different levels of difficulty. However, the scores given for the same child at the same situation can be inconsistent depending on the interpretations of different assessors. C: Mechanism (Fig. 5) The physical properties and positioning of a foreign body in the airways can cause different levels of obstruction to the lungs. These are categorised and labelled as mechanisms, of which there are 4 main types: In the nasal cavity, laryngeal/subglottic and tracheal, the mechanism could be "two-way valve", "one- way valve", "no way valve". In the bronchial, they are "by pass valve", "check valve", "stop valve" and the "ball valve". Mechanically, the two-way valve and by-pass valve are the same, as is the one-way valve and check valve, then no-way valve and stop valve [4, 5]. a. Two-way valve/bypass valve (Fig. 6): It occurs when the size of foreign body is relatively small compared to the diameter of the airway (such as small, soft or flat organic items). The air flow is still maintained and patients are able to breathe without much difficulty [4, 5]. Normally it is not a life-threatening situation; therefore it is allocated a score of 1. b. One-way valve/check valve (Fig. 6): Occurs when a foreign body allows air entry during inspiration but prevents the exit of air during expiration (due to higher intra-thoracic negative pressure on inspiration and smaller diameter on expiration). It means the patient is able to breathe in, but has difficulty to breathe out [4, 5]. This is a concerning situation, so is worth a score of 2. c. No-way valve/stop valve (Fig. 6): It is the complete obstruction of the airway. The air can neither get in or out. In bronchial it could cause a partial consolidation or collapse in the lung. In other regions it can be associated with a life-threatening choke [4, 5]. Due to the severity of this mechanism, it is scored 3. d. Ball valve (Fig. 6): This type is specific for the bronchial obstruction. The affected bronchi are partially obstructed by a periodically prolapsing foreign body. In this case, the mediastinum will shift to the affected side and reduce air entry, inducing the early atelectasis or collapse in the lung [4, 5]. It may not be an emergent situation; however the complications induced later are more critical as the foreign bodies are inside the bronchi. Comparing to other regions, it is much more difficult to take them out; therefore it is allocated a score of 4. Page 6 of 27

7 D: Location (Fig. 7, 8) The specific location of the foreign body affects the presentation of the patient, modalities used for diagnosis, treatment, and complications which may occur. Therefore, identifying the location of the foreign body is important in cases of paediatric foreign body aspiration. The most common residence for a foreign body in the respiratory system is the nasal cavity, followed by the bronchial, tracheal and laryngeal/subglottic regions. With the severity of the complications induced by foreign body in different regions, these regions are respectively allocated a score in this matrix, from 1 to 4. In the nasal cavity, foreign bodies can be situated in any places. Nasal foreign body is the most common ENT clinical paediatric problem. Most of the patients are aged between 1 and 5, mainly due to their boredom and curiosity [8, 9]. However, 90% of the incidents happened are because of the absence of the supervision from the adult [9]. Patients may cough when aspirating; there could also be local pain or inflammation in the nose. Because it it relatively the least severe situation, it is given a score of 1. Laryngeal and subglottic foreign bodies make up about 5% of foreign bodies in paediatrics airways [5]. It can cause dyspnoea when the foreign bodies are large enough in the major airway; and when they are located adjacent to the vocal cords, they may induce hoarseness, loss of voice and inspiratory stridor. When serious enough, an obstructing laryngeal foreign body can cause asphyxiation, which carries a mortality rate of 45%. This region is given a score of 2. Tracheal foreign bodies consist of 4 % - 13% of foreign body aspiration cases [5]. If the foreign bodies are lodged in the trachea, it is more likely to be symptomatic than lodged in bronchi. However asymptomatic cases of tracheal foreign bodies do occur sometimes. Related symptoms include choking, severe coughing, vomiting, wheezing and laryngospasms. In episodes of acute choking, a bronchoscopy should be performed immediately [4]. Therefore, it is scored 3. Bronchial foreign bodies occupy the majority of the cases of paediatric foreign body aspiration, about 67-80%. In over 2/3 of these cases, foreign bodies are generally stuck in bronchi, the rest in the bronchioles [4]. Sudden choking is the most obvious symptom for diagnosis, as is coughing and wheezing. Breathing volume in the lung could also be reduced. Failure to diagnose and treat may lead to pneumonia or atelectasis [10]. Because foreign body is in the lung, a socre of 4 is assigned to this region. Images for this section: Page 7 of 27

8 Fig. 1: Paediatric foreign body aspiration matrix Fig. 2: Section A: Patient's Presentation Page 8 of 27

9 Fig. 3: Section B: Patient Difficulty Fig. 4: Classification of patient's difficulty Page 9 of 27

10 Fig. 5: Section C: Mechanism of Obstruction Type Page 10 of 27

11 Fig. 6: Mechanism of the Obstruction Type Page 11 of 27

12 Page 12 of 27

13 Fig. 7: Section D: Location of the foreign body Fig. 8: Respiratory tract anatomy Page 13 of 27

14 Conclusion Outcome (Fig. 9, 10) Most management decisions are determined by symptoms, physical examination and radiological findings [4]. Plain Imaging radiological findings, with a specificity of 74.1%, primarily diagnose foreign body aspiration [2]. CT is not recommended for paediatric patients, however its high contrast resolution allows it to locate non-radioopaque foreign bodies [5]. Our matrix offers an easy scoring system that leads to the most suitable management pathway. Minor: Minor airway obstruction may not require active management [4]. The child is encouraged to expel the object by coughing and further observation will indicate the outcome. Objects can be removed via blowing in the nose using a straw or encouraging the child to blow the object out. According to the matrix, foreign bodies in the bronchi or bronchioles cannot be classified as minor. Potential high risk complications generally always occur in these cases. Major: Second priority. Management is required within 24 hours. Most cases classified as major by the matrix involve the use of rhinoscopy, tracheoscopy and bronchoscopy as treatment. Different forceps, such as optical, toothed forceps, will be attached to the tip of the endoscope to retrieve the object during the examination [4]. Extreme: Immediate medical intervention required. When the child has severe signs of collapsed lungs or is unconscious, it is classified as extreme by the matrix. If clinical findings indicate pneumothorax and atelectasis, the child will be managed with a formal diagnostic and therapeutic endoscopy. Subdiaphragmatic abdominal thrust (Heimlich manoeuvre) is given to an asphyxiated child until the object is expelled (not recommended for infants) [4]. If asphyxiation persists, cricothyrotomy can be performed while the child is transferred to an operation theatre. Endoscopy and/or thoracotomy is required immediately to prevent further damage [5]. The child can be kept intubated or a long term intervention such as a tracheostomy is given. Scoring Framework Instructions: (Fig. 11) This system has been designed as a concept categorization scheme to assist medical staff to class the severity of foreign body aspiration in paediatric patients. The primary survey for a paediatric patient is as follows: Page 14 of 27

15 1. LISTEN (listen for breathing) 2. LOOK (look for air entry) 3. FEEL (feel for patients breath on carer's cheek) After the primary survey, a four part scoring table is used to determine the level of the patient's situation. In effect it gauges the possible course of action that is required. A + B + C + D = Outcome A. Presentation Each patient presenting with a foreign body obstruction can present in one of three phases. Asymptomatic shows no signs; characteristic Symptomatic shows signs associated with aspiration; initial is primary signs of aspiration B. Patient Difficulty Paediatrics can present in any state of difficulty, ranging from; 1. Relativelyt relaxed and little stressed 2. Restless and stressed 3. Frantic and panic stricken NOTE: whilst a paediatric patient may present to a medical facility in any of the aforementioned states, it is important to monitor paediatrics patient closely as often the pathology is not reflected in their engagement with staff. C. Mechanism The mechanisms for foreign body aspiration in Paediatrics are classed into two categories; 1. PRE BRONCHIAL : Nasal, Laryngeal and Subglottal and Tracheal a. Two-Way valve - Possible Obstruction Might not cause an obstruction (most common in trachea) b. No-Way Valve- Complete Obstruction; (most common: bronchus) Page 15 of 27

16 c. One-way valve; Inspiration and NO expiration; airway enlarge during inspiration) 2. BRONCHIAL : a. Bypass vale: partially obstruct b. Check Vale: Can Inhale, can't exhale c. Ball Vale Obstruction: partial obstruction object move and complete obstruct a bronchus d. Stop vale: Complete obstruction D Location: Each position poses its own difficulties and when insertion a score it's important to realise that each region of interest could have any of the mechanisms associated with it. a. Nasal cavity b. Laryngeal / Subglottic region c. Trachea d. Bronchus At all times the patient must be monitored for changes in the individual case. Case Study: (Fig. 12, 13, 14, 15) Anil Barela, a 12-year-old boy from the central India, swallowed a 3.5 inch (9cm) long living fish. He was playing a game with other children, which involved catching a live fish and swallowing it. Then Anil swallowed a still kicking fish. Instead of going down his oesophagus, the fish kicked its way into the larynx and down into the bronchus of the left lung. Anil soon started feeling short of breath and his breathing rate was reported 34 per minute, with 17 per minute considered normal. His blood oxygen level was lower than the normal as well. Anil was then sent for an X-ray, which showed resorptive (obstructive) atelectasis of the left lung cased by the fish's Ball valve obstruction of the airway. Page 16 of 27

17 The ENT specialists performed a 45-minute bronchoscopy to get the still alive fish out of the boy's lung. Anil survived the operation, but the fish was dead after being removed from the lung [17]. Based on the report of this real case, the boy was not choking at the very beginning, but suffering from some discomfort; therefore, section A and B of the matrix are both given a score of 2. The foreign body travelled to the patient's lung, allocate a score of 4 for the location. Due to the movement of the fish in the patient's lung, the mechanism should be the ball valve, which gets the score 4. The total score is 12, which belongs to the extreme category. According to the matrix, the patient should receive immediate medical intervention, such as endoscopy or surgery. This outcome matches the actual management of the case. Therefore, this matrix is supported by this case. Although this case study validated the matrix to be effective as the outcome of the matrix matched the identification and management of the real medical reports; however, the matrix still needs to be further validated prospectively. The scoring numbers need to be adjusted based on a large number of case studies and a clinical trial. The matrix, relates entirely to the airways and does not include esophageal foreign bodies, which could also paly a role in foreign body aspiration. Images for this section: Page 17 of 27

18 Fig. 1: Paediatric foreign body aspiration matrix Page 18 of 27

19 Page 19 of 27

20 Fig. 9: Score Fig. 10: Outcome Page 20 of 27

21 Page 21 of 27

22 Fig. 11: Instruction Fig. 12: X-ray showing resorptive (obstructive) atelectasis of the left lung that is indicative of the case history presentation. NB: Original image is NOT available. Page 22 of 27

23 Fig. 13: Anil Barela and the fish inhaled Page 23 of 27

24 Fig. 14: Anil Barela's score Page 24 of 27

25 Fig. 15: Fish pulled alive from boy's Lung after inhaling, India Page 25 of 27

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27 11. Kendall Regional Medical Center. Advantages of a Pediatric ER Kendall Regional Medical Center. (accessed 5 September 2013). 12. Pedersen, T. Doctors Push to Ease Children's Anxiety, Pain in ER Psych Central News. (accessed 5 September ). 13. Friedman SG. AAP urges better management of kids' pain and stress in ER National Children's Health Examiner.com. (accessed 5 September 2013). 14. Smith M. Isolation Ball Valves includes what is and how it works Ball a fix. (accessed 5 September 2013). 15. Times of India - Indore. Fish taken out from lungs of 12-year-old boy in Indore - The Times of India. (accessed 5 September 2013). 16. Gayle D. We've heard of a lungfish... but this is ridiculous: Emergency surgery saves youngster who inhaled fish in weird game Mail Online. (accessed 5 September 2013). 17. R7 Noticas. noticias.r7.com/saude/noticias/menino-de-12-anos-passa-por-cirurgia-para-retirarpeixe-de-9-cm-do-pulmao html?question=0 (accessed 5 September 2013). 18. Anil Barela. AlAGAS WEB. Retrieved from noticia/18714-menino-de-12-anos-passa-por-cirurgia-para-retirar-peixe-de-9-cm-dopulmao. Page 27 of 27