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

CCC 700 6

Critical Care

Compendium

Chris is an Intensivist and ECMO specialist at the Alfred ICU in Melbourne. He is also the Innovation Lead for the Australian Centre for Health Innovation at Alfred Health and Clinical Adjunct Associate Professor at Monash University. He is a co-founder of the Australia and New Zealand Clinician Educator Network (ANZCEN) and is the Lead for the ANZCEN Clinician Educator Incubator programme. He is on the Board of Directors for the Intensive Care Foundation and is a First Part Examiner for the College of Intensive Care Medicine. He is an internationally recognised Clinician Educator with a passion for helping clinicians learn and for improving the clinical performance of individuals and collectives.

After finishing his medical degree at the University of Auckland, he continued post-graduate training in New Zealand as well as Australia’s Northern Territory, Perth and Melbourne. He has completed fellowship training in both intensive care medicine and emergency medicine, as well as post-graduate training in biochemistry, clinical toxicology, clinical epidemiology, and health professional education.

He is actively involved in in using translational simulation to improve patient care and the design of processes and systems at Alfred Health. He coordinates the Alfred ICU’s education and simulation programmes and runs the unit’s education website, INTENSIVE.  He created the ‘Critically Ill Airway’ course and teaches on numerous courses around the world. He is one of the founders of the FOAM movement (Free Open-Access Medical education) and is co-creator of litfl.com, the RAGE podcast, the Resuscitology course, and the SMACC conference.

His one great achievement is being the father of two amazing children.

On Twitter, he is @precordialthump.

| INTENSIVE | RAGE | Resuscitology | SMACC

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