Case 66 - foreign body aspiration

Question 1

what is foreign body aspiration and how does it occur?

Answer 1

• lodging of a substance into the trachea or bronchus
• can be life-threatening emergency
• potential for complete airway obstruction
• potential for airway mucosa damage
  
  • inflammation, edema, corrisoin and necrosis (batteries)

Question 2

how does a patient with foriegn body aspiratoin typically present?

Answer 2

is the aspiration tracheal or esophageal?

Tracheal aspiration

• coughing, unilateral deceased breath sounds, wheezing
• tachypneia, tachycardic, resp distress if severe
• CXR
  
  • able to visualize if not radiopaque
  • hyperinflation of obstructed lung = air trapping
  • atelectasis of lung = decreased ventilation

Esophageal aspiratoin

• refusal to feed, increased salivation
• dysphagia
• vomiting

Question 3

what are the preop concerns in a patient with foreign body aspiration?

Answer 3

1) Urgent or emergent Surgery

• assess respiratory status and oxygen saturation
• can this procedure be safely delayed until child is NPO for an appropriate period of time?

2) foreign body aspiration

• type of foreign body (food particle vs inanimate object)
• location
• potential for complete airway obstruction?

Question 4

How will you induce a patient with foriegn body aspiration?

Answer 4

1) ASA standard monitors
2) IV catheter
3) IV or inhalation induction
* if inhalation induction, use 100% oxygen and sevo (less pungent, less airway irritation)
4) admin dexamethasone

• potential airway edema
• 0.5 - 1 mg/kg

Question 5

what is your intra-op maangement/ anesthesia mainteance for foreign body aspiration?

Answer 5

1) Controlled vs Spont Ventilation
* no right answer, personal preference
2) TIVA vs inhaled anes
* no ETT in place, inhaled anes can pollute OR, not a constant flow of anesthetic due to periods of apnea as proceduarlist attempts to remove foreign body
3) ask sx to spray larynx and vocal cords
* decrease risk of coughing and laryngospasm with manipulation of bronchscope as it passes beyond vocal cord
4) avoid N2O
* can worsen air trapping if present
5) monitor ventilatoin
* complete airway obstuction can occur if foreign dislodges to trachea
6) potential for significant airway compromise after foreign body removal

• proceduralist may see excessive airway edema 2/2 foriegn body insult
• consider intubaiton, mech vent, ICU setting

Question 6

what are the pros and cons of controlled vent vs spont vent

Answer 6

Controlled vs Spont Vent

• surgeon will use rigid bronchoscope –> precludes use of ETT
• anes and sx personal preference of either technique

Controlled Vent

Pros

• ensures adequate depth of anesthesia
• prevent patient movement if using neuromusclar blockade
• ensures adequate ventilation and oxygenation with PPV

Cons

• periods of apnea –> o2 desat
• PPV may move foreign body more distally (difficult to remove now)

Spont Vent

Pros

• avoids risk of forcing foreign body into distal airways
• continuous ventilation and oxygen throughout removal of foreign body (avoid apneic period)

Cons

• difficult to maintain adequate anes depth to allow spont vent
• coughing and moving can occur (2/2 lack of neuromusclar blockade)

Question 7

what are your intraop concerns for foreign body ingestion (GI tract)?

Answer 7

Is this urgent, or can this be safely delayed for appropriate NPO status.

1) ETT required

• risk of compelete airway obstruction if foreign body is lost into trachea or hypopharynx after removal
• aspiration risk if urgent procedure –> RSI

2) cautious cricoid pressure
* dislodge foreign body into trachea, cause trauma to esophagus

Question 8

what are the post op concerns in a patient who has aspirated a foreign body?

Answer 8

• residual mucosal edema and viscous secretions –> post op resp distress
• wheezing, stridor –> hypoxia = airway swelling
• patients must be carefully monitored in postoperatively.