Inhaled Foreign Body Flashcards
A 3-year-old male child presents to the emergency department with difficulty in breathing following an episode of coughing while eating breakfast an hour ago. He is otherwise fit and well, has no allergies, was born at term and has had all of his vaccinations. You are asked to review him.
What findings would suggest foreign body obstruction as a cause of his respiratory distress?
History:
* The patient is commonly aged under 3 years old or orally fixated (learning difficulties/behavioural patterns).
- Sudden onset of symptoms.
- Witnessed episode of choking.
- Symptoms appear following a meal.
- Dry cough since the onset of respiratory distress.
- Lack of systemic symptoms e.g. fever and prodromal illness.
Examination
* Hypoxia.
- Signs of respiratory distress e.g. stridor and tachypnoea.
- Wheeze.
- Decreased air entry unilaterally.
Investigations
* Chest X-ray: foreign body if radio-opaque, hyperinflation on expiration and atelectasis.
What is the concern with inhalation of peanuts?
- Peanut oil released from the inhaled nut can lead to bronchial irritation, chemical pneumonitis and further complications such as oedema, an empyema or abscess, in contrast to inorganic foreign bodies.
How would you assess this patient in the emergency department?
- Rapid ABCDE assessment to identify airway patency and any imminent risk of complete airway obstruction or respiratory arrest. Escalation to a consultant anaesthetist/ENT early and as appropriate.
- If there is no immediate threat to the airway, avoid worsening the situation by upsetting the child. Consider a quiet room with child seated on parent’s lap and attempt to develop a rapport.
- Take a history from the parent including a standard anaesthetic history in case the child deteriorates/dislodges the foreign body and you need to get to theatre urgently.
- Examination – the priority is to not upset or cause further distress to the child. If possible, assess:
- Chest movement – effort, symmetry and efficacy.
- Signs of respiratory distress – cyanosis, tracheal tug, recession and drooling.
- Breath sounds e.g. stridor and wheeze (classically monophonic and low in acute obstruction).
- Investigations (if tolerated):
- Respiratory rate and oxygen saturations.
- Heart rate.
- Chest X-ray.
On examination, there is a right-sided wheeze and decreased air entry on the same side. The patient’s oxygen saturations are 94% on room air. The patient is otherwise alert and comfortable. A chest X-ray demonstrates evidence of gas trapping on the right.
How do you proceed?
- Discuss the plan with a senior paediatric anaesthetist and ENT surgeons and alert the appropriate theatre team in order to facilitate the appropriate procedure (likely removal of the foreign body via bronchoscopy).
- If the patient is stable, removal of the foreign body can be delayed until he is appropriately fasted.
- The patient should be kept in a quiet location, carefully monitored until transfer to theatre.
- Do not try and attempt intravenous access, upset the child or try to make them lie down/position them against their will.
- Titrate oxygen to saturations of 94%–98% as tolerated.
- A sign of deterioration can include panic, agitation or loss of compliance. In such a situation, bedside observations may be particularly challenging. A change in behaviour should be urgently assessed by a senior member of the ENT and anaesthetic teams.
How would you anaesthetise this patient?
- Many different techniques - NB maintenance of patient safety, oxygenation and anaesthesia
- Ensure parental consent, WHO checklist, AAGBI monitoring and intravenous access if possible.
- Preparation for anaesthetic should include an experienced paediatric anaesthetist, trained assistant, availability of resuscitation/difficult airway trolleys and appropriate doses of routine and emergency drugs.
- Premedication: avoid sedatives, and consider a weight-appropriate dose of glycopyrrolate to reduce airway secretions.
- ENT surgeons should be scrubbed in theatre.
- Inhalational induction with sevoflurane in 100% oxygen, maintaining spontaneous ventilation to avoid displacing the object further into
the airway and avoid ball-valve trapping. - Direct laryngoscopy to facilitate spraying of cords (above and below)
with local anaesthetic (lignocaine 4 mg/kg) once deep anaesthesia. There is a high risk of laryngospasm; therefore, IV access should be ensured.
How would you anaesthetise this patient?
Continued…
- Options for maintenance of anaesthesia include:
- Sevoflurane in oxygen via the anaesthetic circuit connected to the side port of the bronchoscope ± remifentanil infusion.
- IV propofol infusion ± remifentanil infusion.
- Dexmedetomidine infusion.
- Continue a high inspired concentration of oxygen and avoid nitrous oxide to prolong apnoeic time and avoid potential ball-valve gas expansion.
- Bronchoscopy and instrumentation of the airway are extremely stimulating and therefore some form of opiate carefully titrated is usually required.
- Dexamethasone IV can be given intra- and postoperatively to reduce airway inflammation.
- A prolonged period in recovery is sensible and postoperative care in a suitable nursing environment to closely monitor for airway deterioration.
- Nebulised adrenaline should be carefully considered; systemic absorption is low.
- If any airway soiling present, prophylactic antibiotics may be required.
- Rarely, the patient may require continued postoperative ventilation and transfer to PICU.
In general, what are the indications for bronchoscopy in paediatric patients?
To aid diagnosis
* Tracheo-oesophageal fistula.
* Treatment-resistant pneumonia.
* Failure to wean from ventilation.
For therapeutic purposes
* Removal of foreign body.
* Mucous suctioning.
* Balloon dilation of airways.
* LASER surgery.
