43. Inhaled Peanut

Question 1

What are the symptoms of foreign body aspiration in a child?

Answer 1

There may be cough, choking, gagging and dyspnoea.

If the obstruction persists, the airway reflexes become fatigued resulting in an ‘asymptomatic period’.

Presentation after this time may be associated with airway erosion or
infection.

Peanuts can cause problems related to obstruction of the airway or
secondary to the oil causing an inflammatory reaction.

Question 2

What clinical signs would you look for?

Answer 2

Non-specific signs of distress – tachycardia, tachypnoea and sweating

Use of accessory muscles of respiration, ‘tripod’ position

Audible wheeze and stridor

Examination of the chest may reveal unilateral signs such as increased
percussion due to air trapping, wheeze and mediastinal shift or signs of
lobar collapse.

There may also be bronchial breathing and crackles
depending on the duration of obstruction

Question 3

How would you manage the case?

Answer 3

Immediate assessment and initial management would follow the ABC
principle.

The need to intervene immediately is then determined. Most foreign
body aspirations can wait until a suitable starvation time has elapsed
providing the child is not too distressed.

Dried beans or peas may require
early intervention as they will expand with time.

Nebulised adrenaline (1:1000 solution at 0.5 ml/kg, max 5 ml) could be used
as a holding measure to help reduce airway oedema (alpha effect).

Heliox is also an option.

Question 4

How would you anaesthetise this child having starved him?

Answer 4

Consultant help should be available.

Calm environment

Insertion of a cannula prior to induction would be ideal, but may be
determined by likelihood of causing more distress to the child.

An inhalational induction with sevoflurane in 100% oxygen followed by
endotracheal intubation to secure the airway would be appropriate.

The surgeon should be on hand

ET tube may then be replaced with a Storz ventilating bronchoscope. A
T-piece can then be connected to the side arm of the bronchoscope.

A muscle relaxant may be used if necessary and lignocaine could be used to
anaesthetise the airway.

In principle, positive pressure ventilation should be avoided until the peanut
has been removed but it may be necessary if the bronchoscope lumen is
narrow and the procedure is long.

Question 5

Why don’t you want to use halothane?

Answer 5

Halothane has advantages and disadvantages over sevoflurane.

Advantages
More potent.
Can achieve higher inhaled concentrations with halothane
vaporiser (5 × MAC) compared with sevoflurane vaporiser
(3 × MAC) – may make it easier to intubate without relaxant

Less likely to lighten quickly resulting in laryngospasm.

Disadvantages
Longer time in stage two anaesthesia.

Slower onset than sevoflurane and slower return of airway
reflexes.

Arrhythmias in children with hypoxaemia and hypercarbia.