Management of Foreign body aspiration.

1
Management of Foreign body aspiration.

• Speaker Dr. Pragati Nanda.
  Moderator Dr. Subhash Chawla.

www.anaesthesia.co.in anaesthesia.co.in_at_gmail.c
om
2
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.

3
Foreign Bodies

• Foreign body aspiration
• Toddlers
• Oral exploration
• Lack posterior dentition
• Easy distractibility
• Cognitive development (edible?)

4
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.

5
Foreign Body Aspiration

• Vegetable matter in 70-80
• Peanuts other nuts (35)
• Carrot pieces, beans, sunflower watermelon
  seeds
• Metallic objects
• Plastic objects

6

• 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.

7
PATHOPHISIOLOGY

• Bronchi 80-90
• Right mainstem most common
• Carina
• Less divergent angle
• Greater diameter
• Trachea
• Larynx
• Larger objects, irregular edges
• Conforming objects

8

• 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.

9
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.

10

• 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

11
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

12
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

13
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 - lt50
• Unilateral wheeze
• Cough
• Ipsilaterally diminished breath sounds
• Fiberoptic laryngoscopy

14
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

15
X-RAY FINDINGS

• Obstructive emphysema
• Normal x-ray
• Pneumonitis
• Collapse with mediastinal shift
• Foreign body.
  If still a diagnostic
  delima,CT scan is advised.

16
(No Transcript)
17
Foreign Body Aspiration
18
Foreign Body Aspiration
19
Foreign Body Aspiration
20
Foreign Body Aspiration
21

• 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

22

• 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.

23

• 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.

24
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.

25
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.

26

• Usually NOT A DIRE EMERGENCY
• Trained personnel
• Instruments assembled and checked
• Await for emptying of stomach
• Find duplicate FB to test instruments and
  techniques

27
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.

28
Foreign Body Aspiration

• General anesthesia
• Spontaneous ventilation
• Laryngoscopes
• Bronchoscopes
• Suction
• Forceps
• Rod-lens telescopes

29
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.

30
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.

31
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

32
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

33
Foreign Body Aspiration

• Slipped foreign body
• Push back into bronchus,stablise and remove.
• Sharp foreign body
• Advance bronchoscope over FB, to prevent trauma.

34
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.

35

• 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.

36
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.

37

• 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.

38
Foreign Body Aspiration

• Complications
• Larago/bronchospasm ms. Relaxation,adequate
  ventilation.
• Arrhythmias hyperventilation , lignocaine.
• Pneumothorax
• Pneumomediastinum
• Pneumonia
• Antibiotics, physiotherapy
• Atelectasis
• Expectant management, physiotherapy

39

• 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.

40

• THANK YOU.

www.anaesthesia.co.in anaesthesia.co.in_at_gmail.c
om