A Retrospective Study of Rigid Bronchoscopy in 58 Paediatric Cases with Acute Respiratory Distress

8/10/2019 A Retrospective Study of Rigid Bronchoscopy in 58 Paediatric Cases with Acute Respiratory Distress

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International Journal of Scientific and Research Publications, Volume 4, Issue 12, December 2014 1

ISSN 2250!15!

A Retrospective Study of Rigid Bronchoscopy in 58

Paediatric Cases with Acute Respiratory Distress

Dr. Chinmayee P. Joshi

De"artment of #N$ head and nec% sur&er', Pramu%h S(ami )edical *olle&e, Shree +rishna os"ital, +aramsad-

Abstract:

*onte.t/

Ri&id bronchosco"' has been time tested modalit' for mana&ement of acute res"irator' distress, es"eciall' in "aediatric cases of forei&n bod' in bronchus- o(eer, there

still "ersists dilemma re&ardin& its a""lication in conditionsother than forei&n bod' bronchus-

ims/

$o e."lore e.tended indications of ri&id bronchosco"' in

"aediatric cases (ith acute res"irator' distress -

Settin&s and Desi&n/

Retros"ectie stud' of ri&id bronchosco"' "erformed in "aediatric cases (ith acute res"irator' distress from Januar'

200 to Jul' 2011 at tertiar' care centre in India-

)ethods and )aterial/

ll 53 "aediatric cases (ho under(ent emer&enc' or electie

ri&id bronchosco"' for acute res"irator' distress bet(eenJanuar' 200 to Jul' 2011 (ere included in the stud'-

Results/

ut of the total 53 cases included in our stud', !5 067

"atients had forei&n bod' as"iration histor' and 2!4067 hadno histor' of forei&n bod' bronchus- o(eer, (hile doin&ri&id bronchosco"' in the latter cases, forei&n bod' (as foundin 5 "atients (hereas 13 had secretions and mucus "lu&s- ll2! "atients had s(ift clinical recoer' after the "rocedure-

*onclusions/

ll "aediatric cases "resentin& (ith acute onset of res"irator'distress (ithout histor' su&&estie of forei&n bod' as"irationshould also be assessed b' a dia&nostic ri&id bronchosco"' if

the' do not im"roe (ithin 43 hours of medical treatment-#arl' dia&nosis and interention is the %e' to successfulmana&ement-

Index terms:

Ri&id bronchosco"', (hee8e associated lo(er res"irator' tract

infection 9:RI7, forei&n bod' bronchus

+e' )essa&es/

If "erformed s%ilfull', ri&id bronchosco"' "roes to be a lifesain& "rocedure in conditions simulatin& forei&n bod'

bronchus in "aediatric "atients- $he unnecessar' dela' in doin&this "rocedure due to its inasie nature ma' (orsen the "ro&nosis and hence it should be a "art of standard "rotocol for mana&ement of "aediatric acute res"irator' distress-

I- I N$RD;*$IN

Dr- <usta +illian, (ho introduced ri&id bronchosco"' to the

(orld, once famousl' =uoted that >ne must hae had thee."erience of seein& a child that at 4"m as"irated a little stone,and that, after the stone has been bronchosco"icall' remoed at"m, ma' ha""il' return home at 3"m after anaesthesia hasfaded a(a'- #en if bronchosco"' (as ten times more difficultas it reall' is, (e (ould hae to "erform it ?ust for hain& these

results@- $his s"ea%s olumes of the "rocedure and its successin treatin& forei&n bod' bronchus-1

Ri&id bronchosco"' is the transoral or transtracheotom' "assa&e of ri&id instruments for dia&nostic or thera"eutic "ur"oses in the tracheobronchial tree- $he "ractice of ri&id

bronchosco"' &reatl' decreased follo(in& the inention of thefle.ible bronchosco"e2- Aut the alue of ri&id bronchosco"' in "aediatric "atients (ith seere atelectasis, "neumonia and(hee8e associated lo(er air(a' infection 9:RI7 has been amatter of &reat confusion- lthou&h bronchosco"' ma' not beindicated as an initial "rocedure to remoe res"irator' tract

secretions, it ma' "roide a beneficial o"tion in cases (hereless inasie methods "roe to be ineffectie in remoin&secretions and mucous "lu&s!- $he ri&id bronchosco"e "roidessu"erior air(a' control es"eciall' in cases of si&nificant

air(a' bleedin&- It is also su"erior to fle.ible bronchosco"' for remoal of forei&n bodies in bronchus- Bor acute central

air(a' obstruction *7, ri&id bronchosco"' is the air(a'stabili8ation "rocedure of choice4-

$he aim of of the stud' (as to direct the focus of sur&eons tothis "rocedure of ri&id bronchosco"' es"eciall' in acuteres"irator' distress in "aediatric "atients-

II- S;AJ#*$S C )#$DS

Bift' ei&ht "aediatric "atients, all less than 14 'ears of a&e,

(ho "resented (ith acute res"irator' distress to our tertiar'care centre bet(een Januar' 200 and Jul' 2011 (ere includedin our stud'- ll cases (ere clinicall' ealuated andinesti&ated b' consultant #N$ sur&eons and Paediatrician in

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emer&enc' de"artment- fter initial resuscitation, blood

inesti&ations and chest ra' P ie( (ere done-

In !5 out of 53 cases (ith "recedin& histor' of forei&n bod'in&estion and radiolo&ical findin& su&&estie of atelectasis,emer&enc' dia&nostic and thera"eutic ri&id bronchosco"' (asconducted- Post "rocedure child (as monitored clinicall' and

radiolo&icall' in I*; (ith antibiotics and su""ortie care

Venturi mas% o.'&en administration, a&e and (ei&ht ad?ustedta"ered steroid7 in association (ith "aediatrician for minimumof 24 hours-

In cases (ithout classical histor' of forei&n bod' in&estion,

"rimar' treatment (as conferred b' "aediatrician in I*; (ithsu""ortie care Venturi mas% o.'&en administration, steroidC antibiotics7- Detoriation or non im"roement of clinicalandEor radiolo&ical condition of child (as considered asindication for electie dia&nostic cum thera"eutic ri&id bronchosco"'- Post "rocedure treatment (as continued as

described aboe-

ll ri&id bronchosco"ies (ere "erformed under a"neah'"erentilation techni=ue of &eneral anaesthesia- Patient "ositioned su"ine (ith e.tension of nec% and "lacement of shoulder ba&- &e matched si8e of ri&id bronchosco"e (as

introduced and tunnelled throu&h trachea, carina and into theres"ectie bronchus- $he force" s"ace is ?ud&ed and (itha""ro"riate instrumentation the forei&n bod' (as remoed inminimum attem"ts to aoid lar'n&eal edema- $racheostom'(as carried out if "rocedure re=uired multi"le attem"ts or there(as "ersistent fall in o.'&en saturation- Such "atients (ere

(eaned off of tracheostom' in F da's-

III- R #S;:$S

ut of total 53 cases of acute res"irator' distress (econsidered all children (ith histor' of forei&n bod' in&estionas <rou" 1 and those (ithout obious histor' of forei&n bod'in&estion as <rou" 2-

Demo&ra"hic data/$able I/ &e statistics

<rou" 1a&e in 'ears7 <rou" 2 a&e in 'ears7

)ean 4-2 -4

$able II/ <ender statistics

<rou" 1 nG!57 <rou" 2 nG2!7

)ales 24 12

Bemales 11 11

$able III/ $'"e of forei&n bod'

<rou" 1 nG!57

Ve&etatie H 22

)etallic 1!

$able IV/ Aronchus inoled

<rou" 1 nG!57Ri&ht 22

*arina and left bronchus 1!

$able V/ $racheostom' re=uired

<rou" 1 nG!57 <rou" 2 nG2!7

es 11

No 2 12

n anal'sin& the retros"ectie data certain obserations noted

are as follo(s

Bi&ure 1/ <ender distribution

It (as noted that of total nG53 cases included in stud', 2! caseshad no histor' of forei&n bod' (hereas !5 cases had "ositiehistor' of forei&n bod' and (hich (as retrieed on ri&id bronchosco"' in all cases -o(eer out of the 2! cases (hich(ere ta%en for bronchosco"' based on clinical sus"icion of

sur&eon, 5 cases (ere such that forei&n bod' (as retrieedeen thou&h no obious histor' of same noted su&&estin& old

and accidental in&estions (hile the rest 13 cases had retainedsecretions- $hese secretions (ere secondar' to infectie "atholo&' in 3 cases and inflammator' in 10 cases- In terms of "ercenta&e 406 cases had no histor' of forei&n bod' but (ere

sub?ected to the "rocedure for dia&nostic "ur"ose and turnedout to be thera"eutic- Brom this 406, 226 "resented forei&n bod' at the time of bronchosco"' and F36 (ere a combinationof secretions of "neumonia !56 and asthma E9:RI 4!6-

In the aboe data (e can see that cases (ithout histor' of forei&n bod' but "resentin& (ith acute res"irator' distress(ere treated b' thera"eutic bronchosco"' b' remoin& theaccidentall' noted forei&n bod' and secretions of "neumonia,

the onl' "atients sub?ected to this inasie "rocedure (ith little benefit (ere asthma and 9:RI- ence ris% benefit ratiofaours to(ards the treatment- Aenefitted "atients (ere 5F6cases ersis 4!6 ris%ed to the "rocedure of bronchosco"' iecases (ith asthma and 9:RI-

)a?or bserations are as follo(s /

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International Journal of Scientific and Research Publications, Volume 4, Issue 12, December 2014 !

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Bi&ure 2/ Past histor' of treatment at other centre on "resentation-

Bi&ure !/ Distribution of "atients under&oin& tracheostom'

Bi&ure 4/ Paediatrician referral of cases and dela's in same-

n anal'sin& radiolo&ical data of the aboe "atients it (asconcluded that unilateral colla"se fi&ure 57 (as a definitieindication for ri&id bronchosco"' but a unilateral focal radioo"a=ue shado( if not resoled (ith hi&her antibiotic and I*;

mana&ement, a chec% bronchosco"' is indicated-

Bi&ure 5/ ;nilateral colla"se of lun&

ther im"ortant findin&s (ere/

$he most common forei&n bod' (ere e&etatie forei&n bod'of (hich "eanuts and seeds of imli ma.imall' encountered-Aoth (ere notorious in mana&ement, as these forei&n bodies

hae h'dro"hilic action and s(ells u"-

$he cases (ithout forei&n bodies (ere the ones "resentin& (ith

mucous "lu&s and thic% secretions bloc%in& the secondar' bronchioles, a meticulous suction (as "erformed for same on bronchosco"'-

$racheostom' (as done for 1F cases out of 53 as a se=uelae to bronchosco"' but (ere (eaned off (ithin aera&e "eriod of Fda's-

IV- DIS*;SSIN

In India, the most commonl' re"orted use of ri&id bronchosco"' is for forei&n bod' remoal-

Dia&nosis lar&el' de"ends on the first "h'sicians to see the "atient because clinical histor' is the most im"ortant element

to ma%e dia&nosis of BA forei&n bod' as"iration7- In theliterature, histor' has been considered an im"ortant dia&nosticmethod-5,,F (itnessed e"isode of cho%in& is considered to bean im"ortant com"onent of the histor' that leads to the correctdia&nosis of as"iration- histor' of cho%in& e"isode canusuall' be obtained from "arents or careta%er- Stridor is a

common s'm"tom in infants- o(eer, the chances of missin&si&nificant structural "atholo&' in the air(a' are hi&h if thestridor is seere, "ersistent, associated (ith a"noea, failure tothrie, an abnormal cr' and a "rior entilated child-#ndosco"ic e.amination of the air(a' is indicated in this&rou" of children-3 ;nilateral or unres"onsie (hee8e ma' also

indicate structural abnormalit' in the lo(er air(a' or een aninhaled forei&n bod' and bronchosco"' is a lo&icalinesti&ation of these s'm"toms- Persistent cou&h is a common "aediatric s'm"tom- If it is refractor' to treatment, bronchosco"' ma' be indicated but the dia&nostic alue is

relatiel' lo( in the absence of other s'm"toms or si&ns, for e.am"le haemo"t'sis, "ersistentl' "roductie cou&h, localised

(hee8e, or radiolo&ical abnormalities- In a child (ithintractable s'm"toms bronchosco"' can be of &reatreassurance, een if normal- Aronchosco"' is indicated for "ersistent atelectasis- If radiolo&ical chan&es "ersist des"ite

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a""arentl' ade=uate treatment, bronchosco"' should be

considered to e.clude a forei&n bod' and obtain s"ecimens for microbiolo&ical and c'tolo&ical e.amination- #.tensieatelectasis in 'oun& children (ill usuall' res"ond to selectie bronchoaleolar laa&e and suction- Inhaled forei&n bodies can be remar%abl' ca"ricious and ma' "resent (ith an' of thes'm"toms discussed aboe- $he "resence of a forei&n bod' in

the tracheobronchial tree cannot be e.cluded (ithout

bronchosco"'- 9hen the histor' is sus"icious bronchosco"'should be "erformed "rom"tl'-

Retrieal of forei&n bodies (ith a fle.ible bronchosco"e ise.tremel' difficult and this is re&arded as one of the fe(absolute indications for ri&id bronchosco"'- Aronchosco"' has become a aluable tool for the inesti&ation of "ulmonar'infections- Aronchoaleolar laa&e has a hi&h 'ield in three

"articular &rou"s of children/ the immunosu""ressed, children(ho fail to res"ond to broad s"ectrum antibiotics, and children(ho "resent (ith s'm"toms su&&estie of an at'"ical "neumonia10,11,12- Aronchoaleolar laa&e can be directed to

areas of radiolo&ical abnormalit'-

In our stud' (e sa( 4! "atients "rimaril' "resented to "aediatrician (ith dela' of 10 da's on an aera&e beforeotolar'n&olo&ist came into mana&in& the cases- $he &olden

"eriod of 43 hours (as lost in F cases (hereas rest ! cases(ere timel' interened and mana&ed- Bortunatel' no fatalcom"lication occurred due to dela' in treatment-

Bi&ure / Protocol for mana&ement of "aediatric cases of acute res"irator' distress-

Bi&ure F / Radiolo&ical "rotocol for mana&ement of "aediatriccases of acute res"irator' distress-

V- *N*:;SIN

$o summari8e, ri&id bronchosco"' should be included in thestandard "rotocol for mana&ement of "aediatric cases of acuteres"irator' distress Bi&ure CF-n "resentation from histor'and clinical si&ns if sus"icious of forei&n bod' strai&ht a(a'head to ri&id bronchosco"' if not then %ee"in& the "robableinfectie and inflammator' res"irator' "atholo&ies as dia&nosis

and mana&e "atient on medical lines- fter 43 hours of medical intensie care mana&ement, "erform a chec% bronchosco"'- ence as a sur&eon (e should remember that allcases of stridor are not forei&n bod' and not all forei&n bod' "resent as stridor ma%in& bronchosco"' an essentialinesti&ation- #arl' dia&nosis on hi&h inde. of sus"icion is the

%e' to re(ardin& results of "aediatric ri&id bronchosco"'

R #B#R#N*#S

1-Kollner B- <usta +illian, father of bronchosco"'- rch tolar'n&ol15L32/5--

2-I%eda S- Ble.ible bronchofibersco"e- nn tol Rhinol :ar'n&ol 1F0L

F/12!-

!-'ers ):, Aeamis JB, Jr- Ri&id bronchosco"' in the t(ent'first centur'-

*lin *hest )ed 2001L22/!554-

4

-

4-#rnst , Beller+o"man D, Aec%er D, )ehta *- *entral air(a'

obstruction- m J Res"ir *rit *are )ed 2004L1/12F3F-

5- *otton #, asuda +- Borei&n bod' as"iration- Pediatr *lin North m134L!1/!F41-

- Alac% R#, Johnson D<, )atla% )#- Aronchosco"ic remoal of as"irated

forei&n bodies in children- J Pediatr Sur& 14L2/324-

F- )antor P*, $u&&le D9, $unell 9P- n a""ro"riate ne&atie

bronchosco"' rate in sus"ected forei&n bod' as"iration- m J Sur&13L153/224-

3-Pran%s' S) , #aluation of the com"romised neonatal air(a'- Pediatr

Clin North Am ! 137:15F1 – 1532.

-Alac% R#, *hoi +J, S'me 9*- Aronchosco"ic remoal of

as"irated forei&n bodies in children- Am J Surg 143 ( 134 ):FF3 – F31.

10-De Alic J, :e Aour&eois ), Araine :, Dehaelaere *, Scheinmann P,Pau&e J- Value of bronchoaleolar laa&e in the mana&ement of seere

acute "neumonia and interstitial "neumonitis in the immunocom"romised

child- Thorax 42( 13F ):F5 – F5.

11-Bran%el :R, Smith D9, :e(iston NJ- Aronchoaleolar laa&e for thedia&nosis of "neumonia in the immunocom"romised child- Pediatrics

31( 133 ):F35 – F33.

12-Sto%es D*, Shene" J:, Parham D, et al- Role of fle.ible bronchosco"'

in the dia&nosis of "ulmonar' infiltrates in "ediatric "atients (ith cancer- J Pediatr 115( 13 ):51 – 5F.

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-

irst Author ! Correspondence Author /

*hinma'ee P- Joshi

)AAS, )S #N$,

De"artment of #N$ head and nec% sur&er',

Pramu%h s(ami medical colle&e,Shree +rishna os"ital, +aramsad-

#mail/ "adh'acM&mail-com

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A Retrospective Study of Rigid Bronchoscopy in 58 Paediatric Cases with Acute Respiratory Distress