2.1 Foreign Body Aspiration Flashcards
You are called to see a 17-month-old male child who is currently in
the children’s ward.
He was brought into Accident and Emergency by his mother due to grunting and looking red in the face. Two hours earlier he was eating ‘Bombay mix’ when he had an episode of coughing and went blue. Shortly afterwards he recovered and was well enough to eat a banana and chocolate biscuit.
Past Medical History Full-term normal delivery
Vaccinations up-to-date
No previous anaesthetics
on examination
Playing in the ward
Temperature: 37°C
Spo2: 94% on air
Respiratory rate: 22/min
on auscultation: harsh breath sounds on the left with some basal
crepitations
investigations Chest X-rays provided
- Summarise the Case
- Inhaled foreign body
- Some hypoxia on air
- Stable, not compromised
What are the anaesthetic
concerns?
- Paediatric case
- Risk of aspiration (Wait until fasted—not urgent)
- Possible chemical pneumonia
What are the signs of respiratory distress in children?
- Tachypnoea
* <1 year: 30–40/min
* 1–2 years: 25–35/min
* 2–5 years: 25–30/min
* 5–12 years: 20–25/min
* >12 years: 15–20/min
* Bradypnoea suggests imminent respiratory arrest. - Tripoding or anchoring
Child may sit forward and grasp their
feet or hold on to the side of the bed. - Intercostal and sternal recession
Significant if seen in a child over 6–7 years of age - Nasal flaring
Particularly seen in infants
What are the signs of respiratory distress in children?
- Use of accessory muscles
Look for head bobbing in infants - Inspiratory/ expiratory noises
- Inspiratory/ expiratory noises
Stridor :
high-pitched inspiratory noise,
a sign of upper airway obstruction.
Wheezing:
louder on expiration,
a sign of smaller-calibre lower airway obstruction
Grunting:
exhalation against a partially closed glottis,
a sign of severe respiratory
distress in infants
Explain the CXRs.
- X-ray on inspiration
* Minimal hyperinflation seen on the left lung
* No foreign body (FB) seen - X-ray on expiration
* Hyperinflation of the left lung.
* In both inspiration and expiration images
the diaphragms have not moved.
* FB—not seen on the X-ray.
explain pathophysiology of hyperinflation
(ball-valve mechanism)
- On inspiration both lungs will tend to appear similar
in terms of their degree of aeration.
- On inspiration both lungs will tend to appear similar
The reason for this is that the trachea and bronchi
normally widen on inspiration, allowing passage of air into the affected
lung past the foreign body.
- On expiration the foreign body can obstruct the bronchi
as the diameter of the bronchi decreases slightly on expiration.
- On expiration the foreign body can obstruct the bronchi
The greatest difference in lung aeration will therefore
be seen on the expiration image as air is
exhaled from the normal lung
(right lung) but not from the affected lung (left lung).
it was planned to take this child to theatre for eUA for removal of
foreign body. Would you use any premedication in this child? if yes,
what would you prescribe?
- Atropine/Glycopyrrolate
- Atropine dose 20–40 mcg/kg PO;
max dose 500 mcg
Pros:
reduce secretions, so reduces suctioning during bronchoscopy, vagolytic
Cons: thickening of mucus
- EMLA/Ametop
- EMLA:
2.5% lidocaine and 2.5% prilocaine
(leave it on for 45–60 minutes) - Ametop:
Amethocaine (leave it on for 30–45 minutes);
causes vasodilatation
What is the particular issue with peanuts as a foreign body?
These biological substances fragment and cause irritation and chemical
pneumonia.
Explain the anaesthetic management.
Pre
- Preoperative assessment—
anaesthetic and medical history, allergy and
starvation status - A, B, C
- Explain conduct of anaesthesia and consent parents
- Bronchoscopy should be postponed because child is not compromised
inform
Trained assistant, senior anaesthetist
Check
* Anaesthetic equipment, airway equipment
* Anaesthetic and emergency drugs
Anaesthetic plan
- Inhalational induction with spontaneous ventilation (sevoflurane + oxygen)
2 * Avoid N2o (because of hyperinflated lung)
3.* Prior to bronchoscopy spraying of pharynx and vocal cords with 10%
lignocaine (Max. 3 mg/kg, 1 puff = 10 mg)
4.* Can intubate as it gives surgeon an idea of the size of scope
and avoids unnecessary trauma
- The correct size of scope is one which allows
an audible leak of 20 cm H2o
- The correct size of scope is one which allows
- Maintain spontaneous breathing
with a T piece attached to a side piece
in the bronchoscope
- Maintain spontaneous breathing
- A small dose of neuromuscular blocking agent
or propofol to aid extraction of the
foreign body through the cords
- A small dose of neuromuscular blocking agent
- Once the procedure is finished,
a tracheal tube can be inserted if a
full stomach is considered a problem,
and the patient woken up and
extubated once protective reflexes have returned.
- Once the procedure is finished,
- Analgesia not usually required as the procedure is not painful.
Paracetamol can be given as required.
- Analgesia not usually required as the procedure is not painful.
What are the different types of
bronchoscopes?
- Rigid:
STORZ ventilating bronchoscope,
Venturi scopes
- Rigid:
- Flexible:
Fibreoptic scope
(Dormia basket can be used to extract foreign body)
- Flexible:
What are the complications of bronchoscopy, particularly with
rigid bronchoscopes?
- Trauma to lips, teeth, base of tongue, epiglottis, and larynx.
- Damage to the tracheobronchial tree is rare but causes pneumothorax,
pneumomediastinum, and surgical emphysema. - Haemorrhage is usually minor and settles spontaneously.
The child is in recovery.
The nurse is concerned as he is tachycardic and in
respiratory distress.
What are the differential
diagnoses?
- Residual anaesthetic
- Hypothermia
- Hypovolemia
- Hypercarbia
- Laryngospasm
- Aspiration
- Anaphylaxis
- Barotrauma
What is your
diagnosis?
Barotrauma and right-sided pneumothorax with mediastinal shift
