Natural airway as an alternative to intubation for pediatric endoscopic esophageal foreign body removal
A retrospective cohort study of 326 patients
Pediatric Anesthesia
Submitted August 2024 by Dr Chloe Heath
Read by 214 Journal Watch subscribers
Endoscopic removal of oesophageal foreign bodies (EFB) in children is an urgent or emergency procedure traditionally performed with endotracheal intubation under general anaesthesia. A shift in practice has seen use of a natural airway combined with propofol based anaesthesia, a technique referred to as Monitored Anaesthesia Care (MAC) in select patients.
This single-centre retrospective cohort study looked at flexible endoscopic EFB removal in children (aged 1.6 – 8.2 years) comparing the MAC and endotracheal intubation techniques. Investigators analysed 326 cases using descriptive statistics to compare the safety and efficacy of techniques. Factors related to initial choice of airway technique, perioperative complications and conversion rates (MAC to endotracheal intubation) were examined. In the cohort, 23% were planned for intubation and 77% were planned for MAC with an intubation conversion rate of 0.9% (n = 3). Conversion related to airway reactivity and challenging airway anatomy, with two of the patients requiring hospitalisation for exacerbation of airway reactivity.
Regarding other complications, no patients had reflux of gastric content, dislodgement of the foreign body to the airway or need for cardiopulmonary support. Factors associated with choice of MAC over intubation were:
- Fasting time of > 6 hours
- Coin foreign body
Intubation was conducted for all patients under 2 years of age, all patients with a button battery EFB and was favoured in cases of proximal versus distal EFB. Intubation was associated with a median of 15 minutes extra operating time. Post anaesthesia care unit times were similar between groups (no statistically significant difference).
Commentary and Take Home Messages.
The conduct of MAC in the setting of elective endoscopic oesophageal procedures is well established so there is merit in examining the safety and efficacy of MAC in the management of endoscopic EFB removal. Benefits could include avoiding risk of airway trauma and reducing theatre time to improve cost-effectiveness. However, risks associated with performing procedures under sedation with an unprotected airway must be considered. This study shows that MAC is potentially safe in select paediatric patients undergoing flexible endoscopic removal of EFB, namely those with a coin foreign body, patients fasted > 6 hours, patients with no signs or history of airway reactivity and patients expected to undergo a short uncomplicated procedure. However, no recommendations on best practice can be made.
The study has several key limitations. This is a single-centre retrospective analysis and therefore low quality of evidence. Furthermore, no clinically meaningful outcomes were suggested by findings. No difference in anaesthesia adverse events based on choice of technique or time to recovery were found. Whilst intubation cases were associated with longer operating time, this could be attributed to the more complex nature of the cases associated with higher risk foreign bodies such as button batteries.
Choice of MAC versus endotracheal intubation in this patient cohort remains dependent on expert case by case assessment and risk benefit analysis by the treating anaesthesia care provider. Prospective multi-site studies are needed to guide evidence-based practice and assess clinically meaningful outcomes.
