Presenter: Int. 羅宇鴻 Supervisor: Dr. 陳欣伶

Foreign Body Aspiration in Children Analysis of diagnostic criteria and accurate time

for bronchoscopy Use of nonaspirin NSAIDs during pregnancy

and the risk of spontaneous abortion

Introduction Methods Results Discussion

Foreign body aspiration Common and potential life-threatening emergency Significant morbidity and mortality in children < 3 y/o ▪ Airway compromise, death, infection, atelectasis..

Delay diagnosis ▪ Parent under-appreciated symptoms ▪ Physicians overlooked clinical s/s and radiological finding

Diagnosis!!

Diagnosis?? History, PE, CXR : not specific.. Bronchoscope : diagnosis & treatment ▪ Complication.. ▪ Should be evaluated carefully

Definition of ideal diagnostic tools This study Retrospective analysis Diagnostic value? Safety of bronchoscopy?

2001.01~2009.12 191 Pt. underwent bronchoscopy : suspect FBA Age, Sex, S/S, duration, Hx., PE, radiological finding,

bronchoscopic finding.. Outcome Sensitivity & specificity

Positive clinical history (CH) Witnessing the aspiration crisis Chocking crisis Paroxysmal cough Cyanosis

Positive symptoms Wheezing Non-productive & productive cough Dyspnea Cyanosis at rest

Positive PEF Decreased breathing sound Wheezing Localized crackles

CXR finding Air trapping, infiltration, atelectasis or radiopaque

FB. Bronchoscopy

Clinical Hx , S/S, PEF

CXR

Severe resp. insufficiency

Bronchoscopy • IV anesthesia • Pediatric ventilating rigid bronchoscope system

• 0-degree optical scope with forceps • Continuous monitor

yes

No Fasting period

Suspect remaining FB?

191 Pt. (117/74) 123 Pt. (65%), FB was confirmed.

Age: 2 m/o to 14 y/o (mean: 3.1 y/o) 74.3% < 3 y/o, 26.7 < 1 y/o

Onset of symptoms to hospital.. Few hours to 45 days Cough: 51% Respiratory compromise: 39.2%

Cough, wheezing & diminished B/S (76 Pt.) 67 Pt. (88.1%) had FBA

191 patients 106 (admitted within 24 hr) ▪ 75: FB(+)

85 (> 24hr) ▪ 48: recurrent infection..etc (2~45 days) ▪ 31 FB (+)

▪ 37: family neglect

Witnessed of FBA 116 Patients

▪ 19: immediately remove FB, due to severe respiratory compromise ▪ 87: FB removed / waiter for fasting

CXR (191 patients) 117 : air trapping 11% : CXR showed normal 5.8% : CXR showed radiopaque FB

FB Rt. Bronchial tree: 43.1%, Lt.: 33.3%

trachea or larynx: 23.6% Organic: 84.5%

Bronchoscopy 29 (15.1%) bronchospasm ▪ 14 self-limited

▪ 15 respiratory support (1.6hr) ▪ 1 FB penetration, pneumothorax

Outcome 122 (63.8%) discharge within 24hr

54 postoperative monitoring in pediatric ICU (1.7 days)

No death nor neurological damage.

FBA in children Common & serious Significant morbidity Bronchoscopy!

Pt’s Age, sex, admitted time Correlated with literature

Foreign Body In a large series, FBs mainly organic Depends on ▪ Culture, social, economic factors, eating hobbits

This study ▪ 85% FBs are organics ▪ Nuts, sunflowers, apple, carrot, beans, corn.

▪ None neurological impairment.. ▪ Rt. > Lt. > trachea

Criteria for decision of bronchoscopy Image study ▪ High false negative ▪ Radiopaque FB: 8.96% ▪ CT were even needed

Delayed diagnosis Bronchial obstruction ▪ Fever, bronchiolitis, recurrent pulmonary infection

31 Pts had diagnosis of: ▪ Asthma, bronchiolitis…etc

Bronchoscopy!! Literature: negative rate: 8.7~19.5% This study: 35% ▪ Increased secretions, granulation tissue, edema, and

hyperemia in trachea or bronchi > 2 diagnostic criteria, adequate to perform

bronchoscopy

Complication of bronchoscopy Laryngeal edema, Bronchospasm, Bleeding,

Hypoxia, Barotrauma, airway injury.. 0.9%~ 25.9% This study ▪ Pneumothorax: 1 ▪ Bronchospasm: 29 ▪ Most are self-limited, and short-term

Risk: FBA > bronchoscopy

Performing bronchoscopy in every patient in whom FBA is suspected with or without positive clinical or radiological findings because of its effectiveness both as a diagnostic and therapeutic method and its low complication rate.

Abstract Method Result Interpretation

Nonaspirin NSAIDs is one of the most commonly used medications during pregnancy. Potential risk? Type? Dosage?

This study Nested case-control study Risk of spontaneous abortion with nonaspirin

NSAIDs (type & dosage)

Study design Data collection Study population Selection of case and controls Exposure Confounding

Study design Nested case-control study design

Data collection Quebec pregnancy registry (since 1997~) ▪ RAMQ database ▪ Med-Echo ▪ Institut de la statistique du Quebec.

Study population Age: 15~45 y/o Continuously insured by the RAMQ drug plan Excluded ▪ Planned abortion ▪ Spontaneous abortion after 20 weeks ▪ Misoprostol, NSAIDs suppositories ▪ Known teratogens

Selection of cases and controls Case: ▪ Clinically detected spontaneous abortion (0~20 weeks)

Control: ▪ 10 controls for each case ▪ Matched to index data & gestational age

Exposure Nonaspirin NSAIDs that were reimbursed by the

RAMQ drug plan during the study period Single exposure / combination Recent exposure (2 weeks) Dose-response relationship ▪ 1~50%, 51~65%, 66~80% & 81%~ (maximum daily dose)

Confounding factors Sociodemographic characteristics Comorbidities ▪ DM, cardiovascular disease, asthma..

Medication Nonaspirin NSAIDs before pregnency Use of healthy services History of abortion

Case / Control 4705 (372, 7.5%) / 47050 (1213, 2.6%) : P < 0.05

Spontaneous abortion Slightly older, urban area,

social assistance↑…

Adjusting for potential confounders.. Nonaspirin NSAIDs ▪ OR:2.43

Exposure nonaspirin before abortion 2w ▪ OR: 3.47

Main finding Explanation and comparison with other

studies Strengths and limitation Conclusion and implication for future

research

Main finding Nonaspirin NSAIDs during early pregnency: 2.4

fold increase of having a spontaneous abortion Not see a dose-response relationship

Explanation and comparison with other studies Li. And colleagues ▪ Risk of spontaneous abortion when nonaspirin NSAIDs

were taken around the time of conception

This study ▪ Even higher when exposure occurred immediately before

the spontaneous abortion ▪ Relieve cramping?

Prostaglandins ? ▪ ↓ uterine synthesis of prostaglandins during gestation

Strengths Large sample size Accurate information Physician-based diagnoses and records. Variable were adjusted Nested case-control designs

Limitation

Strengths Limitation Lack of data ▪ Over-the-counter formulations of NSAIDs ▪ Smoking? BMI?

Actual intake of a medication? Only clinical detected spontaneous abortions

were included Only 36% of pregnant women in Quebec

Conclusion and implication for future research Any type and dosage of nonaspirin NSAIDs during

early pregnancy were more likely to have a spontaneous abortion Nonaspirin NSAIDs should be used with caution

during pregnancy! Mechanism??

?