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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 aspiration


Toddlers
Oral exploration
Lack posterior dentition
Easy distractibility
Cognitive 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 Aspiration

Vegetable matter in 70-80%


Peanuts & other nuts (35%)
Carrot pieces, beans, sunflower &
watermelon seeds
Metallic objects
Plastic 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 common
Carina
Less divergent angle
Greater diameter

Trachea
Larynx
Largerobjects, irregular edges
Conforming objects
Relevant Anatomy
Airway 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.
Presentation
In 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 Aspiration

History
Choking
Gagging
Wheezing
Hoarseness
Dysphonia

Can mimic asthma, croup, pneumonia


A 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 interval
20-50% not detected for one week
Inflammation and Complications
Cough
Emphysema
Obstructive atelectasis
Hemoptysis
Pneumonia
Lung abscess
Fever
Foreign Body Aspiration
Physical exam
Larynx/cervical trachea
Inspiratory or biphasic stridor,aphonia, complete
obstruction.
Intrathoracic trachea
Prolonged expiratory wheeze,comp obs.
Bronchi
Unequal breath sounds
Diagnostic triad - <50%
Unilateral wheeze
Cough
Ipsilaterally diminished breath sounds
Fiberoptic laryngoscopy
Foreign Body Aspiration
Radiography
PA & lateral views of chest & neck
Inspiration & 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 emphysema
Normal x-ray
Pneumonitis
Collapse with mediastinal shift
Foreign body.
If still a diagnostic delima,CT scan is
advised.
Foreign Body Aspiration
Foreign Body Aspiration
Foreign Body Aspiration
Foreign Body Aspiration
Indications
Perform 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
Contraindications
No 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 Procedure
Until 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 Aspiration

Goal 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 EMERGENCY
Trained personnel
Instruments assembled and checked
Await for emptying of stomach
Find 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 Aspiration

General anesthesia
Spontaneous ventilation
Laryngoscopes
Bronchoscopes
Suction
Forceps
Rod-lens telescopes
GOALS OF ANAESTHESIA

1. 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.
TECHNIQUE
Oxygen 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 Aspiration

Ready to assume airway during


induction
Laryngoscopy
Topical anesthesia- ligocaine spray 3-
4mg/kg.[prevents larangospasm]
Examination of upper airway
Atraumatic insertion of bronchoscope
Bronchoscopy
Attached to ventilating circuit
Foreign Body Aspiration

Bronchoscopy
Suction opposite bronchus
IPPV through side arm mapelson F circuit.
Advance to foreign body
Atraumatically grasp foreign body
Repeat bronchoscopy
Suction bronchus

Multiple foreign bodies in 5-19%

Remove granulation tissue


Topical vasoconstrictors for bleeding
Foreign Body Aspiration

Slipped foreign body


Push back into bronchus,stablise and
remove.
Sharp foreign body
Advance 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 Aspiration

Complications
Larago/bronchospasm; ms.
Relaxation,adequate ventilation.
Arrhythmias: hyperventilation , lignocaine.
Pneumothorax
Pneumomediastinum
Pneumonia
Antibiotics, physiotherapy

Atelectasis
Expectant 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.
THANK YOU.

www.anaesthesia.co.in anaesthesia.co.in@gmail.com