1036: DO PATIENT AGE AND PROVIDER TRAINING LEVEL PREDICT FIRST-ATTEMPT SUCCESS FOR DIRECT LARYNGOSCOPY?

Abstract

Learning Objectives: Foreign body aspiration (FBA) is a common cause of unintentional-injury mortality in the United States. Modern bronchoscopy techniques have reduced mortality in children with FBA. We describe a case of FBA in a child with refractory hypoxia where flexible bronchoscopy performed by the intensivist led to recognition and proper treatment. Methods: Patient is a 16 month old male with acute onset of respiratory failure, wheezing, and cyanosis. In the emergency room he received inhaled beta agonists, intravenous steroids, and subcutaneous epinephrine. Respiratory distress worsened and patient was endotracheally intubated. Initial chest x-ray (CXR) revealed bilateral lower lung opacities suggestive of infiltrates. He continued to have persistent desaturations to 60% despite proper intubation and was transferred to our PICU for further management of refractory hypoxia. Upon admission, CXR showed complete opacification of the right hemithorax without evidence of pleural effusion. After endotracheal tube upsizing and recruitment maneuvers, there was interval improvement of the opacification on CXR; however, he continued to require high mean airway pressures with poor oxygenation and labile hemodynamics requiring pressors. Extracorporeal membrane oxygenation (ECMO) was considered given significant hypoxemia after a trial of various ventilator modalities. Flexible bronchoscopy was performed by the pediatric intensivist and a foreign body was visualized completely obstructing the right mainstem bronchus. Rigid bronchoscopy was then performed to remove a large peanut. He was extubated twelve days after admission and subsequently weaned to room air prior to discharge. Results: Patients presenting with wheezing and respiratory distress with persistent hypoxia should be evaluated for FBA, considering initial CXR can be normal in at least 30% of cases, primarily due to the radiolucency of many aspirated objects. Any suspicion of FBA should be promptly evaluated by bronchoscopy. Intensivists trained in flexible bronchoscopy techniques possess a valuable tool to obtain diagnostic information avoiding delays in diagnosis of such patients and initiation of unnecessary therapies, such as ECMO.