Inhaled Foreign Body

OVERVIEW

• passage of a foreign body into the respiratory tract
• potentially life-threatening

PREOPERATIVE

HISTORY

• 1-3 year old
• coughing with food
• stridor
• respiratory distress
• wheeze
• cyanosis
• collapse
• infection symptoms (pneumonia)

EXAMINATION

• stridor
• decreased SpO2
• increased RR and WOB
• decreased AE on affected side
• rhonchi and wheeze on affected side

INVESTIGATIONS

• CXR (inspiratory and expiratory): in expiratory there may be areas of hyperinflation +/- mediastinal shift

MANAGEMENT

• referral to a centre with appropriate paediatric and ENT skills (lack of experience is cited as a major reason for morbidity)
• starve appropriately
• EMLA for IV access
• pre-medication: 0.25mg/kg PO midazolam, 2.5-5mg/kg PO ketamine, 20mg/kg paracetamol PO
• bronchodilators
• antibiotics and steroids (as indicated)

INTRAOPERATIVE

• IV access
• inhalational induction (sevo -> halo) vs IV induction (controversial)

INHALATIONAL

• advantages: lower risk of F/B moving distally -> easier to remove, allows for rapid assessment of ventilation after removal
• disadvantages: depth of anaesthesia required decreases Q and ventilation, increased resistance to ventilation with scope in -> hypercarbia

IV

• advantages: airway immobilized, balanced anaesthetic, decreases atelectasis
• disadvantages: access may be difficult, may precipitate decompensation

• FiO2 1.0
• topical anaesthesia to vocal cords (1% lignocaine – 4mg/kg)
• antisialagogue (glycopyrulate 5mcg/kg or atropine 20mcg/kg – this is controversial)
• full monitoring
• rigid bronchoscope (Storz ventilating bronchoscope – ventilation + visualisation on insertion, circuit connected to side arm and provides O2 and inhalational agent when eye piece in)
• if it is in the lower airway then muscle relaxation and IPPV may be required as body will be pushed distally until can be grasped (give assisted ventilation via T-piece or high frequency jet ventilation)
• can be long
• management of hypoxia -> re-insert eye piece and deliver O2
• management of F/B in trachea and can’t remove -> push down a main bronchus

POSTOPERATIVE

• dexamethasone 0.5mg/kg IV
• nebulised adrenaline
• physio
• bronchodilators
• antibiotics are often given

COMPLICATIONS

• infection, bleeding, pneumothorax, airway trauma and swelling, tracheal perforation

References and Lniks

• Farrel, P (2004) “Rigid bronchoscopy for foreign body removal; anaesthesia and ventilation” Pediatric Anesthesia 14:84-89
• Verghese, S et al (2001) “Pediatric Otolarngologic Emergencies” Anesthesiology Clinics of North America, Vol 19 (2) pages 237 256