Rigid bronchoscopy: a consultant survey

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Abstract

Introduction

Inhalation of foreign bodies represents a potentially fatal emergency in both adults and children. Chest x-ray, in isolation, is neither sensitive nor specific. Rigid bronchoscopy represents the gold standard to diagnose and retrieve paediatric foreign bodies. Cases are encountered infrequently, creating anxieties about their management. Little is known about the confidence in, and maintenance of, rigid bronchoscopy skills by ear, nose and throat teams.

Methods

A 15-question survey was completed by 50 practising otolaryngology consultants in England.

Results

Results show that almost 40% of otolaryngology consultants covering rigid bronchoscopy have not performed bronchoscopy in more than 5 years. Consultants raised concerns about the anaesthetic support and the speed of equipment assembly. Questions on clinical practice showed disparities in practice in the same scenario.

Conclusions

The authors advocate addressing many of the issues raised by the study with a greater availability of simulation courses and regular scheduled intradepartmental teaching days for all professionals involved. National guidelines on criteria for transfer to tertiary centres would improve the consistency of practice.

Related collections

Most cited references 40

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The anesthetic considerations of tracheobronchial foreign bodies in children: a literature review of 12,979 cases.

Christina W Fidkowski, Hui Zheng, Paul G Firth (2010)

Asphyxiation by an inhaled foreign body is a leading cause of accidental death among children younger than 4 years. We analyzed the recent epidemiology of foreign body aspiration and reviewed the current trends in diagnosis and management. In this article, we discuss anesthetic management of bronchoscopy to remove objects. The reviewed articles total 12,979 pediatric bronchoscopies. Most aspirated foreign bodies are organic materials (81%, confidence interval [CI] = 77%-86%), nuts and seeds being the most common. The majority of foreign bodies (88%, CI = 85%-91%) lodge in the bronchial tree, with the remainder catching in the larynx or trachea. The incidence of right-sided foreign bodies (52%, CI = 48%-55%) is higher than that of left-sided foreign bodies (33%, CI = 30%-37%). A small number of objects fragment and lodge in different parts of the airways. Only 11% (CI = 8%-16%) of the foreign bodies were radio-opaque on radiograph, with chest radiographs being normal in 17% of children (CI = 13%-22%). Although rigid bronchoscopy is the traditional diagnostic "gold standard," the use of computerized tomography, virtual bronchoscopy, and flexible bronchoscopy is increasing. Reported mortality during bronchoscopy is 0.42%. Although asphyxia at presentation or initial emergency bronchoscopy causes some deaths, hypoxic cardiac arrest during retrieval of the object, bronchial rupture, and unspecified intraoperative complications in previously stable patients constitute the majority of in-hospital fatalities. Major complications include severe laryngeal edema or bronchospasm requiring tracheotomy or reintubation, pneumothorax, pneumomediastinum, cardiac arrest, tracheal or bronchial laceration, and hypoxic brain damage (0.96%). Aspiration of gastric contents is not reported. Preoperative assessment should determine where the aspirated foreign body has lodged, what was aspirated, and when the aspiration occurred ("what, where, when"). The choices of inhaled or IV induction, spontaneous or controlled ventilation, and inhaled or IV maintenance may be individualized to the circumstances. Although several anesthetic techniques are effective for managing children with foreign body aspiration, there is no consensus from the literature as to which technique is optimal. An induction that maintains spontaneous ventilation is commonly practiced to minimize the risk of converting a partial proximal obstruction to a complete obstruction. Controlled ventilation combined with IV drugs and paralysis allows for suitable rigid bronchoscopy conditions and a consistent level of anesthesia. Close communication between the anesthesiologist, bronchoscopist, and assistants is essential.

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Accidental inhalation of both organic and non-organic foreign bodies continues to be a cause of childhood morbidity and mortality, requiring prompt recognition and early treatment to minimize the potentially serious and sometimes fatal consequences. In the past, the majority of data on foreign body injuries in children came from single-centre retrospective studies, covering a range of about 3-10 years. Recently, several review papers have discussed the main clinical aspects, Country-specific experiences have been presented, and systematic collections of foreign bodies have been started. Fully aware of the difficulty in meta-analysing data, in an observational context, the aim of the present report is: an attempt to synthesize the epidemiological data published in the literature presenting the evidence on foreign body distribution in a review of the meta-analyses of papers focusing on European and North-American data; improve our ability to prevent and to treat these complex and high risk situations.

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All references

Author and article information

Contributors

A Mowat

Journal

Journal ID (nlm-ta): Ann R Coll Surg Engl

Journal ID (iso-abbrev): Ann R Coll Surg Engl

Journal ID (publisher-id): ann

Title: Annals of The Royal College of Surgeons of England

Publisher: Royal College of Surgeons

ISSN (Print): 0035-8843

ISSN (Electronic): 1478-7083

Publication date (Print): April 2024

Publication date (Electronic): 16 October 2023

Volume: 106

Issue: 4

Pages: 377-384

Affiliations

[ ¹ ]The Royal Wolverhampton NHS Trust , UK

[ ² ]Maidstone and Tunbridge Wells NHS Trust , UK

Author notes

CORRESPONDENCE TO Andrew Mowat, E: andrewmowat@ 123456live.com

Article

Publisher ID: rcsann.2023.0067

DOI: 10.1308/rcsann.2023.0067

PMC ID: 10981987

PubMed ID: 37843132

SO-VID: 4df05256-79fd-442c-8fe2-10f9d0d26207

License:

This is an open-access article distributed under the terms of the Creative Commons Attribution 4.0 International License, which permits unrestricted use, distribution, reproduction, and adaptation in any medium, provided the original work is properly attributed.

History

Date accepted : 30 August 2023

Rigid bronchoscopy: a consultant survey

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