Presenter: Int. 羅宇鴻 Supervisor: Dr. 陳欣伶
Transcript of 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
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.
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 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??