CHARLES A.

AHENE CONSULTANT ANESTHESIOLOGIST SHEIKH KHALIFA MEDICAL CITY ABU DHABI

None

Short history of removal of inhaled foreign body Epidemiology of foreign body inhalation Diagnosis and management of inhaled foreign bodies Anesthetic management of bronchoscopic removal of inhaled foreign body

Foreign body (FB) inhalation could be lifethreatening Mostly affects children <3years Reported mortality rate of 0-1.8% Types of objects inhaled varies by geographical location, but about 80% are organic:

Nuts Seeds

Prospective studies on anesthesia management lacking Lots of case series, most spanning decades

Anesthesia and surgical practice changes over time Fidowski CW, Zheng H, Firth P. The anesthetic considerations of tracheobronchial foreign bodies in children: A literature review of 12,979 cases. Anesth Analg 2010;111:1016-25

Recent Meta Analysis

19th century treatment

Purges Bleeding Emetics

These treatments were ineffective Mortality rate was high around 23%

First rigid bronchoscopy performed by Gustav Killian (German) in 1897 to remove pig bone from a farmers right main bronchus 1898: Coolidge removed tracheal foreign body at Mass General Chevalier Jackson developed lighted bronchoscope and other instruments for removal of foreign bodies 1966: flexible bronchoscope introduced.

Median age: 1-2 years Mean age: 2.1-3.8 years Boy:Girl=60%/40%

2 Turkish studies report high incidence of adolescent girls aspirating headscarf pins

80% aspirate organic materials: nuts, seeds(sunflower and watermelon)

Aspirated teeth found common in Italian study

Fig 5 Type of foreign body.

Zaytoun G M et al. Otolaryngology -- Head and Neck Surgery 2000;123:311-316

Copyright by American Academy of Otolaryngology- Head and Neck Surgery

90% of FB lodge in bronchial tree 10% lodge in larynx or trachea Most studies report higher incidence of FB in the right bronchus (50%) History of witnessed choking very suggestive of acute aspiration Cough is very sensitive but not specific Cyanosis and stridor are very specific for FB but not sensitive

CXR

Only 20% of FB were radio-opaque 17% had normal CXR Localized emphysema and air trapping Atelectasis Infiltrate Mediastinal shift

Common radiographic findings

Pneumothorax/pneumomediastinum less common (0.1-3.7%)

CT scans Virtual bronchoscopy These are more sensitive diagnostic tools False positive CT scans can result from secretions, tumors, etc Drawbacks to CT scans and virtual bronchoscopy

Excessive exposure to radiation Not always available (equipment or radiologists) Cannot be done in uncooperative children (Will not give GA for CT in suspected FB inhalation)

Rigid bronchoscopy most commonly used Combined rigid and flexible bronchoscopy also used Flexible bronchoscopy alone used in some studies

One study reports 91% success rate with flexible bronchoscopy using sedation and local anesthesia

General history Location of the foreign body Type of FB:

When aspiration occurred Risk of complete airway obstruction high if FB is in trachea Risk of complete airway obstruction low if FB is lodged beyond carina Usual full stomach precautions

Organic FB absorb fluid and swell Oils and nuts cause local inflammation Sharp objects can pierce airway

Shared airway with surgeon

Clear communication essential

Premedication

Induction: spontaneous vs controlled ventilation Survey of pediatric anesthesiologists in 1990s showed majority preferred inhalation induction in the presence of FB in airway. IV induction with spontaneous resp also possible. Spont resp definitely preferred in proximal airway FB

?Atropine, ?Steroids

After induction of anesthesia

Rigid bronchoscope inserted Anesthesia circuit connected to side port of bronchoscope Choice of spontaneous or controlled ventilation Local anesthesia down the airway Avoid coughing and bucking: risk of airway trauma and rupture Muscle relaxants may be required for short periods

384 children with foreign body inhalation Large ENT center in China 3 modes of intra-op ventilation

Spontaneous Manual IPPV Manual jet ventilation TIVA Inhaled anesthesia

2 anesthetic groups

Widely used in suspended laryngoscopy and rigid bronchoscopy Use in foreign body removal not widely advocated This study showed it to be good way to prevent intra-op hypoxia Most serious complication is barotrauma

Vocal cords should be relaxed

Deep anesthesia Topical anesthesia to cords Paralysis

Dropping of foreign body could be lifethreatening Severe cases of obstruction may require ECMO

Early discharge possible in uncomplicated cases Prolonged pulm recovery may require admission Predictive factors for prolonged recovery

Evidence of inflammation on pre-op XRays Prolonged bronchoscopy Worsened post-op CXR Post-op Hypoxemia

Endoscopic management of 504 patients with aspiration of foreign bodies in the tracheobronchial tree.

Our overall complication rate was 8%.

There were no deaths in this series. The variables that were most predictive of complications:
History of previous bronchoscopy, Duration of the procedure Type of foreign body.

Most complications were in the immediate postoperative period and could be managed successfully.

Fig 4 Duration of bronchoscopy (onset of general anesthesia to final withdrawal of bronchoscope).

Zaytoun G M et al. Otolaryngology -- Head and Neck Surgery 2000;123:311-316

Copyright by American Academy of Otolaryngology- Head and Neck Surgery

FB aspiration in children potentially serious Anesthesia for removal of FB could be associated with serious complications Various anesthetic techniques possible

No consensus on optimal choice

Induction technique maintaining spontaneous respirations favored by many Close cooperation with the surgical team necessary to avoid potential hazards