Management of Foreign body aspiration.Speaker : Dr. Pragati Nanda. Moderator : Dr. Subhash Chawla.www.anaesthesia.co.in anaesthesia.co.in@gmail.com

FOREIGN BODY ASPIRATION

Common ,but a life threatening problem.Cause of morbidity and mortality.Can cause chronic lung injury.Challanging for anaesthetist.High degree of suspicion is required for diagnosis.

Foreign Bodies

Foreign body aspirationToddlersOral explorationLack posterior dentitionEasy distractibilityCognitive development (edible?)

Involuntary safety muscular mechanics in adults.

1. soft palate is pulled up and posteriorly,prevent reflux of food into nasal cavities. 2. palatopharangeal folds move medially to form a slit, allow only chewed food to pass. 3. epiglottis moves down and close to glottis.

Foreign Body AspirationVegetable matter in 70-80%Peanuts & other nuts (35%)Carrot pieces, beans, sunflower & watermelon seedsMetallic objectsPlastic objects

Organic f.b are more liable to evoke larangospasm, tracheobronchitis and lung infection. Hence, when patient presents, often has fever. vegitable FB are slippery,hard to grip and friable. They usually get swollen, struk at subglottis, may lead to complete obstruction.

PATHOPHISIOLOGY

Bronchi 80-90%Right mainstem most commonCarinaLess divergent angleGreater diameterTracheaLarynxLarger objects, irregular edgesConforming objects

Relevant AnatomyAirway foreign bodies can become lodged in the larynx, trachea, and bronchus. The size and shape of the object determine the site of obstruction. large, round, or expandable objects produce complete obstruction, and irregularly shaped objects allow air passage around the object, resulting in partial obstruction.

TYPES OF OBSTRUCTION.

1. check valve: air can be inhaled but not exhaled.[emphysema]. 2. ball valve: air can be exhaled but not inhaled.[broncho pul segment collapse]. 3. bypass valve: FB partially obstructs both in insp. and exp. 4. stop valve: total obstruction, airway collapse and consolidation.

PresentationIn general, aspiration of foreign bodies produces the following 3 phases:Initial phase - Choking and gasping, coughing, or airway obstruction at the time of aspiration Asymptomatic phase - Subsequent lodging of the object with relaxation of reflexes that often results in a reduction or cessation of symptoms, lasting hours to weeks Complications phase - Foreign body producing erosion or obstruction leading to pneumonia, atelectasis, or abscess

Foreign Body AspirationHistoryChokingGaggingWheezingHoarsenessDysphoniaCan mimic asthma, croup, pneumoniaA positive history must never be ignored, while a negative history may be misleading

Foreign Body Aspiration

Tachepnia, rib and sternal retraction, cyanosis,n/v.Hypoxic seizures, arrest,hypoxic brain damage.Asymptomatic interval20-50% not detected for one weekInflammation and ComplicationsCoughEmphysemaObstructive atelectasisHemoptysis PneumoniaLung abscessFever

Foreign Body AspirationPhysical examLarynx/cervical tracheaInspiratory or biphasic stridor,aphonia, complete obstruction.Intrathoracic tracheaProlonged expiratory wheeze,comp obs.BronchiUnequal breath soundsDiagnostic triad -

Foreign Body AspirationRadiographyPA & lateral views of chest & neckInspiration & expiration [atelectesis on insp, hyperinflation on exp. In affected bronchus.]Lateral decubitus views [lower lung doesnt collapse if FB present.]Airway fluoroscopy [for intraop evaluation, to locate FB in lung periphery.]25% have normal radiography

X-RAY FINDINGS Obstructive emphysemaNormal x-rayPneumonitisCollapse with mediastinal shiftForeign body. If still a diagnostic delima,CT scan is advised.

Foreign Body Aspiration

Foreign Body Aspiration

Foreign Body Aspiration

Foreign Body Aspiration

IndicationsPerform surgical intervention with rigid bronchoscopy on patients: who have a witnessed foreign body aspiration. those with radiographic evidence of an airway foreign body.those with the previously described classic signs and symptoms of foreign body aspiration. A strong history of suspected foreign body aspiration prompts an endoscopic evaluation, even if the clinical findings are not as conclusive or are not present

ContraindicationsNo contraindications exist to the removal of an airway foreign body from a child. If necessary, health problems can be optimized before surgical intervention. However, even children who are at high risk due to health reasons still need surgical intervention to remove the foreign body.

History of the ProcedureUntil the late 1800s, airway foreign body removal was performed by bronchotomy. The first endoscopic removal of a foreign body occurred in 1897. Chevalier Jackson revolutionized endoscopic foreign body removal in the early 1900s with principles and techniques still followed today. The development of the rod-lens telescope in the 1970s and improvements in anesthetic techniques have made foreign body removal a much safer procedure.

Foreign Body AspirationGoal of treatment Prompt endoscopic removal under conditions of maximal safety and minimal trauma.GA is always technique of choice.Communication and cooperation between anaesthetist and endoscopist is must.

ANAESTHETIC MANAGEMENT

Challanging;Fighting irritable child.Full stomach.Sharing of airway.Difficult to maintain oxygenation and ventilation,as pulmonary gas exchange is already reduced.Difficulty pertaining to pediateric airway.

Usually NOT A DIRE EMERGENCYTrained personnelInstruments assembled and checkedAwait for emptying of stomachFind duplicate FB to test instruments and techniques

Preoperative considerations.

Severity of airway obstruction, gas exchange and level of conciousness.Nature and location of FB,degree and duration of obstruction. fasting status. Delaying intervention must be balanced against potential functional impairment and oxygenation. metoclopramide 0.15mg/kg iv.Atropine 0.02mg/kg iv.

Foreign Body AspirationGeneral anesthesiaSpontaneous ventilationLaryngoscopesBronchoscopesSuctionForcepsRod-lens telescopes

GOALS OF ANAESTHESIA1. Adequate oxygenation.2. Controlled cardiorespiratory reflexes during bronchoscopy.3. Rapid return of airway reflexes.4. Prevention of pulmonary aspiration.5. Meticulous monitoring : spo2,ECG,NIBP,EtCO2.

TECHNIQUEOxygen sevoflurane induction.Monitor, IV line.Ketamine 2mg/kg- safe in peadtric pts,full stomach,leaves cough reflex intact,provides CVS stability and prevents bronchospasm.Atropine 0.02mg/kg- dec secreations and obtund autonomic reflexes during airway instrumentation.Nitrous oxide is avoided,as it inc gas volume,air traping and possible rupture of affected lung.Suxa 1.5 mg/kg if controlled ventilation planned.

Foreign Body AspirationReady to assume airway during inductionLaryngoscopyTopical anesthesia- ligocaine spray 3-4mg/kg.[prevents larangospasm]Examination of upper airwayAtraumatic insertion of bronchoscopeBronchoscopyAttached to ventilating circuit

Foreign Body AspirationBronchoscopySuction opposite bronchusIPPV through side arm mapelson F circuit. Advance to foreign bodyAtraumatically grasp foreign bodyRepeat bronchoscopySuction bronchusMultiple foreign bodies in 5-19%Remove granulation tissueTopical vasoconstrictors for bleeding

Foreign Body AspirationSlipped foreign bodyPush back into bronchus,stablise and remove.Sharp foreign bodyAdvance bronchoscope over FB, to prevent trauma.

Anaesthetic maintainence

oxygen, halo/iso.[ give more time for airway manipulation] Or rpt ketamine.[no OT pollution]Suxa 0.25-0.5mg/kg with atropine 0.02mg/kg.High flows are needed to compensate leak around bronchoscope.Ventilation has to be intrupted while suctioning and removal of foreign body.If foreign body is big/swollen tracheostomy may be needed.

Big FB can be taken out in piecies.Apnea/ oxygen insufflation, is prefered at some crucial time, ideally should not last beyond 1min. After 5 min hypercarbia may lead to dysarrythmias.If ventilation is inadequate with rigid broncoscope,high frequency jet ventilation via bronchoscope or ECMO can be used.For FB embeded in mucosa,wait for 48-72hrs. Let odema subside. Rpt bronchoscopy , if unsuccessful- thoracotomy.

Spontaneous v/s controlled ventilation

SPONTANEOUS VENTILATION. ADV; 1. no dislodgement of FB. 2. unhurried bronchoscopy. 3. relatively safe. DISADV; 1. inc coughing, bucking. 2. inc chances of bronco/ larangospasms and arrythmias.[inadequate depth]. 3. inc resistance bcoz of bronchoscope and suctioning. 4. large FB doesnt come out because of VC movements and closure.

After removal of foreign body, check bronchoscopy is done to ensure full clearence and check impaction site for trauma/ bleeding/granulation.Inj Dexamethasone 0.4-1mg/kg, humidified oxygen and bronchodialators given postop.

Foreign Body AspirationComplicationsLarago/bronchospasm; ms. Relaxation,adequate ventilation.Arrhythmias: hyperventilation , lignocaine. PneumothoraxPneumomediastinum PneumoniaAntibiotics, physiotherapyAtelectasisExpectant management, physiotherapy

If postop stridor or distress: nebulise with racemic Epinephrine.Observe the child in recovery room for signs of subglotic odema, haemorhage, bronchospasm and airway perforation.Postop SPO2 and ECG monitoring.6-8hrs later chest x-ray to assess-lung expantion, exclude pneumothorax, residual FB,mediastinal emphysema from barotrauma.

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*4th leading cause of accidental death in 1-3 yo, 3rd leading cause of accidental death in those below one year Twice as common in boys*Metallic FB have decreased with increased use of disposable diapers less safety pinsPlastics are relatively inert so can remain in the airway for extended periods of time *Size and configuration cause most to end up in peripheral bronchiCarina to left of midline which is most important reason that most are seen in right*Physical exam and xrays can be normal so the history is the most important aspect of diagnosisCoughing and choking are most consistently seen, respiratory distress is relatively rare Often unwitnessed and parents may minimize symptoms with resulting delay in diagnosis Asthma in otherwise healthy child is suspicious as is recurrence of symptoms once therapy is discontinued*Mucosa rapidly adapts to the presence of foreign bodies so signs and symptoms may be absent3 stagesPossible complete airway obstruction during initial phaseAsymptomatic interval occurs when irritation subsides and reflexes fatigue, this accounts for delay in dx*Signs can be subtle5-40% have normal physical examFlexible fiberoptic laryngoscopy can rule out laryngomalacia or other nontraumatic etiologies*Radiopaque FB easily seen with xrayRadiolucent FB (the majority) may have obliterated bronchial air column, atelectasis, mediastinal shifts, or air-trapping in the affected lungInspiratory hypoinflation and expiratory hyperinflation in hallmark of bronchial FBDecubitus films dependent lung should collapse but will remain inflated if FB *Radiopaque spring in right mainstem bronchus*Radiolucent left mainstem obstruction*Left mainstem left lobe consolidationUsually from delayed dx*Pin in trachea*Safety pin in larynx*Not nessicarily a true emergency*Majority of patient have passed acute phase by the time of otolaryngologic evaluationSo is NOT A DIRE EMERGENCY*Age matched appropriate bronchoscopes and a size smaller in case edema or stenosis is encountered*Ready to assume airway during induction if ventilation becomes impaired*Suction opposite bronchus to improve oxygenationSmaller objects pulled through bronchoscopeLarger objects pulled snugly against bronchoscope and removed as one unit*Slipped FB pushed back into bronchus, preferably same one, stabilize, attempt removal againSharp FB advance bronchoscope over FB and sheath to prevent trauma on removal *Persistence of pneumonia or atelectasis symptoms beyond one week must make you consider retained FB