Foreign Body Airway Obstruction in Children: Diagnosis, Management & Equipment Preparation

[Dr. Wolfgang Stehr]
In our hospital, we did have pediatric ENT and we do have pediatric surgery and we were a trauma center. We always had pediatric surgeons on call in the house to take care of trauma patients and emergent acute patients. Children with airway foreign bodies, it's oftentimes the toddlers, they eat the nuts, which they're not as supposed to eat and then they aspirate the nut and they come in with a story of the parents sometimes saying, "I think he ate these nuts and he coughed for a while, but now he looks good." Then they end up in the emergency room. The emergency room doctors, they get an X-ray, which usually doesn't show anything, and if they're lucky, they'll listen to the child and hear some whistling in one of the bronchi. Sometimes you actually have the worst-case scenario where you have a child in significant respiratory distress.

[Dr. Gopi Shah]
Absolutely. I think what you describe is pretty common. I agree. It's mostly toddlers, although sometimes they can be quite young, under one, I've seen, and it can be even older kids that don't tell you about an incident that they had. I think you hit the nail in the head, they oftentimes look fine. Fortunately, most of the kids don't come in acute respiratory distress or extremis.

The clinical decision-making can be difficult if there wasn't a witnessed history of choking or maybe it happened and the x-ray most of the time looks fine. We'll get the lateral decubitus, see if there's any ear trapping, if there is a foreign body or something obstructing the bronchi. A lot of times it looks fine, and I think what you said, if they were lucky, the ER physician or maybe the pediatrician or somebody may hear something like wheezing or stridor, subtle stridor or if it's been a while, maybe [unintelligible 00:05:51] sounds on a single side. Again, those clinical physical exam and X-ray findings aren't always there, so I would say the witness history for me is very important as well. Do you ever get a CT, is there ever an indication for you to get a CT for a concern for an airway foreign body?

[Dr. Wolfgang Stehr]
Yes, we would get advanced imaging if there was a chronic history. If there was maybe a remote history of possible aspiration with a coughing event, normal physical exam, and then sometimes development of a pneumonia that then shows the lobar or subsegmental area in the lung that just isn't aerated well, then we would get the CT scan. The wildest thing we've seen there was a pea that actually started to sprout in the airway. You saw this little piece of leaf already growing out of that pea, which then we took out with a bronchoscopy.

[Dr. Gopi Shah]
Wow. I agree that ties into the differential diagnosis or the things that can masquerade or [unintelligible 00:06:58] the red herring or cover the diagnosis of a foreign body that then leads to a pneumonia. A lot of kids will, "Well, they've been treated for reactive airway for the last three months," or, "Oh, they have asthma," here we are intubated, right lung out and there's actually a peanut or something else there. Sometimes in the infants, if there isn't a strong history or maybe there is a little history in the 15-month-old of, "Yes, they coughed a little bit when they were eating a chip," and now they're coming to the ER and there's a runny nose. Sometimes that can be hard to decipher as well. Is it a viral URI, is it mucus plugging or how does it all go? These can be really tricky to tease out sometimes, especially with the history, I think is the most important thing regardless, meaning, if there's a witnessed choking history, they coughed, there was a time where potentially they stopped breathing or turned blue, is going to be your biggest reason to go to the OR to take a look. Now planning for the OR, tell me what your thoughts are and why just planning or thinking about the or, it's like, "All right, here we go."

[Dr. Gopi Shah]
Tell me about the Lean methodology. What is the Toyota Lean System? How'd you learn about it?

[Dr. Wolfgang Stehr]
The organization I worked with actually embraced Toyota Lean as their process improvement system. A simple way to describe it is, if you put together a car and it's your job to put on the wheels, then the step that has to happen before you put on the wheel, you have to put in the brakes. You have your car, you put on the brakes and then you put on the wheel. If somebody does it in the wrong order and you put your wheel on and you maybe forget your brakes, you know something is going wrong when this car rolls off the lot. Same thing in healthcare, there is a correct order for the process and you have to do step A and then you have to do step B and then you have to do step C. Many of those processes can be very standardized in order to make it easier and more efficient and not have to rethink it. It also really helps training the staff on saying, "This is our process, this is how we do it, because it's more efficient and it's safer."

[Dr. Gopi Shah]
Why was this process-- Why did you apply this method specific to airway foreign bodies in children?

[Dr. Wolfgang Stehr]
Look, many articles in the past 10 years have written about there being so much waste in healthcare. There's a number of things we're wasting. We're wasting time, we're wasting equipment, we're wasting motion, we're wasting inventory. The organizations then bring in Lean because they think it can save them money. That is true. Besides saving money, we can really improve safety and quality of the process. We took the Lean methodology and looked at these airway foreign bodies and the equipment that we use to take care of those children. It fits into the process very nicely. We can go through some of the steps if you would like.

[Dr. Gopi Shah]
Absolutely. I would love to hear about the steps.

[Dr. Wolfgang Stehr]
We start with first identifying a goal. What is it we actually want to do. For this, we want to take better care of patients with airway foreign bodies. Then we identify further who are these patients? Are they really all under a year old? Are they really under two years old, or are there some teenagers? We look back at our data. The data actually said, yes, there's a peak early on between 9 and 20 months. Then there's a few other patients that are a little bit older. They're teenagers. They put stuff in their mouths like a nail or sometimes a sewing needle, push pins,

[Dr. Gopi Shah]
Push pins.

[Dr. Wolfgang Stehr]
Exactly.

[Dr. Gopi Shah]
Yes, I've had that too.

[Dr. Wolfgang Stehr]
They need different equipment. Already being able to separate by age or by weight, allows you to have two completely different setups. Then one of the important elements of the Lean process is you go through the 5S steps. The steps are you sort, you set in order, you shine, you standardize and you sustain. What does that mean? Sorting means you open your big cart with all your drawers and you touch every single item that's in there and you make sure you have what you need and you can throw out the stuff you no longer need or nobody has ever used, and then you set in order. Setting in order is exactly what you said. The little alligator grasper and the tines don't meet. That is setting in order, making sure that the equipment that is in your tray actually works. Then shine is, you make sure you have the right way to clean it and you have the right way to maintain it, because sometimes you have your scopes and you look through it and in there, there may still be a tiny little bit of piece of dried blood or something, and that shouldn't be, same with your lenses. The lenses have to be straight, they have to have a full vision. We have to make sure they're maintained. Then we standardize, which means we find a way to take care of this equipment the same way every time, whether you have a traveler in sterile processing or whether you have a new tech or whether you have a visiting surgeon who's doing this procedure. We really try to standardize the process and then come sustain. Sustain then allows us to maintain the equipment so that if I come back in a year, it's still taken care of the same way, and that the right people touch it and those people who touch it know what to do and know what to expect and then the equipment is put together. These are the 5S of the lean process.