management of foreign body inhalation and bronchoscopy in children

ANESTHESIA FOR FOREIGN BODY INHALATION BRONCHOSCOPY

• By Dr. Vineet Chowdhary

• Moderator- Dr. Neelam Dogra

EPIDEMIOLOGY

• More than 17,000 ED visits for children younger than 14 years (2000)• 5th most common cause of unintentional-

injury mortality in the U.S.• Leading cause of unintentional-injury

mortality in children less than 1 year

INCIDENCE

The maximum incidence of inhalation of foreign bodies occurs in

AGE: 6 months to 3 years:

SEX: Male >female

HISTORY

• During the 19th century, treatment of foreign body aspiration by purges, bleeding, and emetics were largely ineffective.

• Mortality was estimated at 23%.

• This rate plummeted with the development of bronchoscopic techniques for the removal of these foreign bodies.

• In 1897, Gustav Killian, a German otolaryngologist, performed the first bronchoscopy using a rigid esophagoscope to successfully remove a pig bone from a farmer’s right main bronchus.

• Shortly thereafter, Chevalier Jackson developed the lighted bronchoscope and several specialized instruments for the removal of foreign bodies.

• While early clinicians used topical anesthesia, general anesthesia became commonplace for the removal of aspirated objects with increased experience with the rigid bronchoscope and advances in anesthetic delivery.

• The flexible bronchoscope was introduced by Shigeto Ikeda in 1966, and the removal of an airway foreign body using this instrument was reported in the 1970s

WHO IS AT RISK?

In children: because

Natural urge to explore the objects by mouth Tendency to put everything possible into their mouth Lack of molar teeth to crush nuts Crying and playing while eating Lack of parental supervision Immature glottis reflex Incomplete coordination of mouth and tongue

WHO IS AT RISK?In elderly : because

Impaired cough reflex and swallow reflex Mental retardation Alcohol General anesthesia Poor dentition Dental, pharyngeal and airway procedure Loss of consciousness Convulsions Stroke Parkinsonism Maxillofacial trauma Senile dementia

WHERE DOES IT GO?

The larynxTracheaBronchusSmaller airways

80-90 % occurs in bronchus ,mainly right main bronchus and lower lobe

However Aspiration can occur in all lobes, including upper lobes (though with less frequency)

REMEMBER!!

• Objects can fragment and lodge in multiple sites (e.g., sunflower seeds)

• Children can aspirate several different objects concurrently (or sequentially)

• Foreign bodies can erode through the esophagus and cause respiratory symptoms

DANGEROUS OBJECTS• Round

• Balls, marbles• More likely to cause complete

obstruction

• Break apart easily• Compressibility• Smooth, slippery surface

WHY RIGHT SIDE BRONCHUS IS MORE COMMON?

• Larger Diameter

• Angle of divergence from the tracheal axis is smaller (More in line with the trachea)

Airflow through the right bronchus

is greater Situation of carina to left of the

midline of trachea.

WHAT GETS ASPIRATED?

According to sourceEndogenous - vomitus or broken toothExogenous - Pins, Peanut, seeds etc

According to nature of foreign bodyNon-irritating type: plastic, metallicIrritating(organic origin) : peanuts, beans, seeds etc.

FOREIGN BODIES Organic foreign bodies Metallic others

Peanuts( MC in children) Coins Rubber

Beans Nails Wood

Watermelon seeds Screws Pebbles

Animal shells Hair pins Toys

Bones Safety pins

Popcorns

Grapes

PATHOPHYSIOLOGYOrganic foreign bodies (peanuts , Beans and seeds) absorb water

with timeSwelling rapidly change partial to complete bronchial obstructionLong standing foreign body tends to move downward and

outward.Mucosa becomes edematous partly closing over the foreign body

and even completely obliterating the lumen.Foreign body becomes friable and fragments may dislodge into

other bronchus or smaller airways.Foreign body produces inflammatory response and complications

like granulations and stricturesRemoval of foreign body should be done as soon as possible.

However it does not justify hasty, ill planned and poorly equipped bronchoscopy

HISTORY

In Children: A history of a witnessed choking event is highly suggestive of

an acute aspiration.

In Adults: H/O choking after eating or holding a foreign body in mouth

CLINICAL PRESENTATION

Depends upon the Location of foreign body Size of foreign body Nature of foreign body Time since inhalation

• HOWEVER, only 50% of diagnoses occur in the first 24 hours• 80% within first week• Will sometimes take years

CLINICAL PRESENTATION In general, aspiration of foreign bodies produces the following

3 phases: Initial phase - Choking , 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

Complication phase - Foreign body producing erosion or obstruction leading to pneumonia, atelectasis , or abscess

Chronic long standing foreign body often present with misdiagnosis of URI, asthma ,or pneumonia

OFTEN NEED HIGH LEVEL OF SUSPICION TO DIAGNOSE

TRACHEOBRONCHIAL FOREIGN BODY

• Classic triad in only 57%• Wheeze, cough and decreased breath sounds

• 25-40% with normal exam

LARYNGEAL FOREIGN BODY

Present as sudden total or near total obstruction. Initially cough then Hoarseness , Aphonia , Choking and

Dyspnoea .And if total obstruction may cause asphyxia , cyanosis , and

death.

TRACHEAL FOREIGN BODYTracheal foreign bodies present similarly to laryngeal foreign

bodies but without hoarseness or aphonia.Hemoptysis by sharp foreign bodyAudible slap--heard at open mouth of child.Palpatory thud.-on palpation of tracheaAsthmatoid wheeze--wheeze similar to asthma

BRONCHIAL FOREIGN BODY

In case of bronchial foreign body the classical clinical triad consist of :

Paroxysmal Cough Unilateral wheezing

Unilateral diminished breath sounds

VALVE MECHANISM

Three Mechanisms in bronchial obstruction:

Bypass mechanism(Two way valve)

Check valve mechanism (One way valve )

Stop valve mechanism(No way valve)

BYPASS VALVE (2 WAY)MECHANISM

• Partial obstruction

• Ingress and egress both occurs

• No collapse,no emphysema


CHECK VALVE (1 WAY) MECHANISM

• On inspiration enlargement of diameter of bronchus opens a small passage for ingress of air.

• On expiration Foreign body is embedded in swollen mucosa preventing exit of air .

• Air is trapped inside and lung

becomes emphysematous.

(obstructive emphysema)

STOP VALVE (NO WAY) MECHANISM

• Both Ingress and egress stopped.

• Absorbtion of air results in collapse of lung.

(Obstructive atelectasis.)

PHYSICAL FINDINGS (SIGNS)

Decreased breath sounds distal to foreign body Unilateral wheezing TachypnoeaNasal flaring .Inability to speak.Limited chest expansion. Intercostals ,Subcostals,and Suprasternal retractionsImpaired percussion note.

INVESTIGATIONS

1. Chest X ray ( imaging modality of choice )

2. Fluoroscopy & video fluoroscopy

3. Chest CT

4. Virtual Bronchoscopy

CHEST XRAY

Chest radiograph to assess for other potential causes of symptoms, to identify a radio opaque foreign body, or to detect the position of a foreign body on the basis of localized emphysema and air-trapping, atelectasis, infiltrate, or mediastinal shift

Radiopaque materials like metallic Foreign bodies are easily identified on chest X rays

May show less dense objects like teeth, bone, shell, button.Organic materials are not radiopaque but shows radiographic

abnormalities like Hyperinflation due to Air trapping and shifting of the mediastinum

towards the opposite side. AtelectasisA final CXR for checking the presence and position of Foreign body should

be made immediately before bronchoscopy because Foreign bodies often shifts.

SCREW SEEN IN CXR

HYPERINFLATION SEEN ON CXR

ATELACTASIS SEEN ON CXR

Inspiratory film on left, Expiratory film on right ; Foreign body in left mainstem bronchus

Inspiratory film on left ; expiratory film on right ; foreign body in right bronchus

NAIL IN RIGHT MAIN BRONCHUS

• Many chest x-ray may have completely negative findings ,especially within the first 24 hours following aspiration.

• A positive history plus clinical symptoms of aspiration may be sufficient to justify bronchoscopy.

CONSIDER LATERAL DECUBITUS IF CHILD CANNOT COOPERATE• Lateral decubitus views [lower lung doesn’t collapse if FB present.]

COMPLICATIONS OF FOREIGN BODY

Obstructive emphysemaAtelectasisBronchiectasisPneumonia HemoptysisLung abscessSubcutaneous EmphysemaPneumothorax / pneumomediastinumGranulation tissue and hemorrhageCartilage destruction

Emergency Treatment for Aspirated Foreign Bodies

1.Heimlich maneuver2.Back blows3.Chest thrusts4.Finger sweep / grasp

–(finger sweep should be done only if object is visible and will not be pushed deeper)

Note : none of these should be applied if patient is able to speak or cough

HEIMLICH’S MANAEUVER

In erect (sitting/standing) position ,encircle from behind and fist in epigastrium between the xiphoid and umblicus and apply abdomen thrust

BACK BLOWS


CHEST THRUST (STERNAL THRUST)

• For pregnant and massively

obese persons.

• Chest is encircled from

behind and fist is placed on

the midsternum.


INFANT BACK BLOWS

• Rescuer sandwiches infant between one hand supporting neck and the other hand delivering back blows .

INFANT CHEST THRUST

• Rescuer holds infant on thigh in head down position and delivers upto 4 chest thrusts just like chest compressions.

MANAGEMENT

If patient is in distress ->EMERGENCY BRONCHOSCOPY If patient is stable ->PLANNED BRONCHOSCOPY

LARYNGEAL FOREIGN BODY:-> By direct laryngoscopy/BronchoscopyTRACHEAL OR BRONCHIAL FOREIGN BODY:-> Rigid bronchoscopy or

fibreoptic bronchoscope

Chest physical therapyBronchodialatorsTRACHEOSTOMY indicated in

Laryngeal foreign body if Too large and sharp

MEASURES BEFORE BRONCHOSCOPY

A Team EffortGood communication and cooperation between

surgeon and anaesthetistSenior ENT surgeon & expert Anaesthetist.Light and suction checked before procedure.Good venturi systemProper size bronchoscopeTracheostomy trolley should be ready

CHALLENGES

• Fighting irritable child.

• Full stomach.

• Sharing of airway.

• Difficult to maintain oxygenation and ventilation, as pulmonary gas exchange is already reduced.

• Difficulty pertaining to pediatric airway

GOALS OF ANAESTHESIA

1. Adequate oxygenation.

2. A good i.v. access

3. Controlled cardiorespiratory reflexes during bronchoscopy.

4. Rapid return of airway reflexes.

5. Prevention of pulmonary aspiration.

6. Meticulous monitoring : spo2,ECG,NIBP,EtCO2

RIGID BRONCHOSCOPEStandard of care in most centers for evaluationAllows visualization, ventilation, removal with multiple forceps and ready management of mucosal hemorrhageSuccessful in about 95% of casesComplications are rare (about 1%)

Laryngeal and subglottic edema, atelectasis Dislodgement of foreign body into more dangerous

position Hypoxic insults

Port for venturi

Port for circuit

PREOPERATIVE CONSIDERATIONSThe preoperative assessment should determine

• where the aspirated foreign body has lodged

• what was aspirated,

•when the aspiration occurred.

• time of the last meal .

PREMEDICATION

•Sedatives are avoided as it may precipitate total airway obstruction.

•Dexamethasone given prophylactically minimize postoperative stridor and laryngeal edema.

•Anticholinergics (atropine, pyrolate) given to reduce secretions and reflex bradycardia associated with airway instrumentation.

• If patient is not fasting then inj. ondansetron and inj. Metaclopramide can be given.

• In urgent cases, induction by rapid sequence and cricoid pressure. The stomach can be suctioned through a nasogastric tube before the bronchoscope is inserted to minimize the risk of gastric aspiration.

• In delayed presentations in which bronchoscopy is not urgent, a preanesthetic fasting is appropriate.

Mask ventilation is done to maintain oxygen saturation before inserting bronchoscope.

Once the scope introduced beyond the glottis, ventilation by Jet ventilator with oxygen.

During active ventilation the distal end of the bronchoscope is pulled back to the mid of the trachea and the proximal open end is occluded with the thumb or a glass obturator.

Nitrous oxide is avoided, as it increases gas volume, air trapping and possible rupture of affected lung.

Intermittent succinyl choline is administered till the procedure is completed.

Later mask ventilation is done till the patient become fully awake.

• After the extraction of the foreign body and the removal of the rigid bronchoscope, the choice of ventilation during emergence is influenced by pulmonary gas exchange and the degree of airway edema.

• For uncomplicated cases,spontaneous ventilation assisted by mask ventilation as needed may be adequate.

• Intubation during emergence may be indicated for a marginal airway, pulmonary compromise,or residual neuromuscular blockade.

ANAESTHESIA MANAGEMENT1. CONTROLLED VENTILATION2. SPONTANEOUS VENTILATION

ANAESTHETIC CONSIDERATIONS FOR RIGID

BRONCHOSCOPY

• The conversion from spontaneous negative pressure breathing to positive pressure ventilation theoretically risks dislodging an unstable proximal body, causing complete obstruction.

• A survey of 838 paediatric anaesthesiologists found that the majority preferred an inhaled induction when foreign bodies were present in the tracheobronchial tree.

• A cautious IV induction that maintains spontaneous ventilation is also possible

Controlled ventilation :

I.V. induction + muscle relaxant

and ventilation by

• 1) Venturi attachment

• 2) Inflation via side arm of bronchoscope

• 3) Insufflation via a catheter in the trachea

• 4) Insertion of a tube into the end of the bronchoscope intermittently.


ANESTHETIC MAINTENANCE

• Oxygen, halo/iso.[ give more time for airway manipulation] Or repeat ketamine/ propofol

• Suxa 0.25-0.5mg/kg with atropine 0.02mg/kg.• 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 pieces.• Apnea/ oxygen insufflation, is preferred at some crucial

time, ideally should not last beyond 1 min. After 5 min hypercarbia may lead to dysrhythmias.

• If ventilation is inadequate with rigid bronchoscope, high frequency jet ventilation via bronchoscope or ECMO can be used.

• For FB embedded in mucosa, wait for 48-72hrs. Let odema subside. Repeat bronchoscopy , if unsuccessful- thoracotomy.

• Spontaneous Ventilation

a) IV induction : with thiopentone, propofol, ketamine, remifentanil.

Maintanance with halothane or propofol infusion

b) Inhalational induction with sevoflurane/halothane

Maintainance with halothane/isoflurane.


• An advantage of an IV anaesthetic is that it provides a constant level of anesthesia irrespective of ventilation.

• Propofol is especially useful because of its rapid recovery and also good reflex suppression.

• By contrast, hypoventilation and leaks around the rigid bronchoscope may produce an inadequate depth of inhaled anesthesia.

• Pollution of the operating room, due to the combination of leaks around the rigid bronchoscope and high gas flows needed for ventilation, are additional drawbacks of inhalation anesthetics

• Laryngeal foreign bodiesremoved by direct laryngoscopy.

• Tracheal and bronchial foreign bodies are best removed using a rigid bronchoscope.

• Rigid bronchoscopy supersedes any form of conservative approach like using bronchodilators, thoracic percussion and postural drainage.

• However ,Preoperative physiotherapy, and antibiotics is useful in a peripherally situated, organic, foreign body of long standing, in which there is atelectasis of the lung with pneumonia or abscess.

• In the rare event of being unable to remove a foreign body endoscopically, it must be removed by thoracotomy or bronchotomy.

• It is very important after removal of the foreign body, while the child is still anaesthetized, that a second look is taken to remove any remaining small fragments particularly in the case of peanuts.

• Pus and mucus can be aspirated from the distal bronchus - which helps in speeding the resolution of atelectasis or pneumonia.

Intermittent succinyl choline

• Keeps the patient totally quiet during the procedure;

• Bronchial caliber does not vary

• Permits easy introduction of endoscope


DISADVANTAGE OF SPONTANEOUS VENTILATION

• Some times foreign bodies may be too large to be withdrawn through the lumen and it is common to loose the foreign body during the removal, which commonly occur at subglottic region, if the muscle relaxation is not adequate. This is known to occur often with spontaneous ventilation technique and maintenance by halothane.

• With Halothane as primary anaesthetic agent is that it requires higher concentrations of halothane to obliterate airway reflexes which may cause decreased myocardial contractility.

• Increased CO2• Hard to GUARANTEE no movement: therefore additional airway

trauma may occur.

• Prolonged emergence

ADVANTAGES OF SPONTANEOUS VENTILATION

• More effective alveolar ventilation- with difficulty in positive pressure ventilation ,anesthesiologists typically exert more pressure. For the patient with airway compromise, this results in more turbulence in the upper airways and less effective air exchange downstream.

• Better ventilation/perfusion matching

• Better ventilation during bronchoscopy with window closed

• Better ventilation during bronchoscopy with window open

• Foreign body mimic: not every patient believed to have a foreign body, even if stridor is present, actually has one. If there is any doubt, then spontaneous ventilation should be preserved in order to make a diagnosis

• Neuromuscular blockade may worsen the situation by converting a patient with a compromised airway to a patient with no airway

• Multiple placements of forceps in difficult to grasp FB cause gases to be exhausted to the room rather than delivered to the patient during controlled ventilation, unless the window is constantly replaced.

CONTROLLED VENTILATION

• Positive pressure ventilation down the bronchoscope, with intermittent apnea while manipulating the object,may be more suitable for distal foreign body removal.

• The use of optical forceps allows for positive pressure ventilation to be maintained while the foreign body is being manipulated so that periods of apnea can be minimized


ADVANTAGES OF CONTROLLED VENTILATION

• A RSI allows more rapid control of the airway, lessening the chance of aspiration

• Positive pressure ventilation avoids hypoxaemia and also improves oxygenation

• Patient immobility. It is essential to avoid coughing and bucking secondary to the intense stimulation from a rigid bronchoscope deep in the bronchial tree

• The possibility of more rapid emergence since NMB can be monitored throughout the procedure, allowing administration of lower doses of IV anaesthetic


DISADVANTAGES OF CONTROLLED VENTILATION

• Leads to overdistension of the obstructed lung which can embarass the cardiovascular system and may cause rupture of the alveoli resulting in tension pneumothorax.

• Positive airway pressure may cause distal migration and dislodge the foreign body peripherally and may cause failure to remove the foreign body.

IMPORTANT CONSIDERATIONS IN CONTROLLING VENTILATION

• Adequate time is needed for exhalation through the relatively high resistance bronchoscope in order to prevent air trapping and the associated barotrauma.

• Ventilation must be done in concert with the bronchoscopist. Ventilation when the bronchoscope is open will "ventilate" the room

• Excessive suctioning during the procedure can markedly diminish oxygen concentration and also might induce atelectasis.

• Therefore suction must be applied for short periods of time ,which should be followed by lung inflation.


COMPLICATIONS

• Trauma to lips, teeth, base of tongue, epiglottis and larynx

• Severe cardiovascular embarrassment or even cardiac arrest may follow tracheobronchial manipulation and suction;

This is due to a combination of hypoxia and reflex vagal stimulation. Hypoxia aggravates vagal responses and increases the incidence of cardiac arrhythmias.

• Laranygo/bronchospasm- ms. Relaxation,adequate ventilation.

• Pneumothorax, Pneumomediastinum , Pneumonia

• Atelectsasis

• Stridor secondary to subglottic oedema: Nebulized epinephrine 1:1000 should be administered in a dose of 0.5 ml /kg maximum 5 ml per administration. I.V. dexamethasone produces more sustained relief of stridor, but may take 1–2 h to act. Re-intubation may be required.

What About Flexible Bronchoscopy?

Excellent diagnostic tool

Minimal trauma, no general anesthesia

Reports of successful removal as well

American Thoracic Society still recommends rigid bronchoscopy for removal

Flexible bronchoscopy can be performed with local anesthetic topically and sedation in both children and adults

In smaller children who are unable to cooperate, general anesthesia can be given using propofol and sevoflurane with topical lignocaine

TO CONCLUDE

Normal CXR does not rule out Foreign Body

Bronchoscopy should be performed if foreign body aspiration is suspected because it is better to do a negative bronchoscopy rather missing a foreign body.

Not leaving small objects within reach of children.

No consensus from the literature as to which technique is optimal

Be ready and equipped

Don’t turn a non-obstructing FB into an obstructing one

Don’t miss the second FB- go back for another look

Not all FB’s can be removed endoscopically

REFRENCES

Article :Foreign bodies in the larynx and trachea BY J. N. G. Evans

Miller’s anesthesia 7th edition.

Stoelting’s anesthesia and co-existing disease 5th edition.Paediatric bronchoscopy: Steve Roberts MBChB FRCARoger E Thornington MBBS FFA(SA) FRCA

Bronchoscopy by Chevalier Jackson.

PREFERRED ANAESTHETIC TECHNIQUE FOR TRACHEOBRONCHIAL FOREIGN BODY - A OTOLARYNGOLOGIST’S PERSPECTIVE (INDIAN JOURNAL OF ANAESTHESIA 2004)

REVIEW ARTICLECMEThe Anesthetic Considerations of Tracheobronchial Foreign Bodies in Children: A Literature Review of 12,979 CasesChristina W. Fidkowski, MD,* Hui Zheng, PhD,† and Paul G. Firth, MBChB*‡

Thank you

management of foreign body inhalation and bronchoscopy in children

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