Download airway foreign bodies

10 January 2014
No 01
AIRWAY FOREIGN BODIES
P Slabber
Moderator: Prof B Biccard
Discipline of Anaesthetics
CONTENTS
INTRODUCTION ................................................................................................... 3
FOREIGN BODY ASPIRATION ............................................................................ 3
1. Demographics ............................................................................................... 3
2. Diagnosis ....................................................................................................... 4
(a) History: ....................................................................................................... 4
(b) Physical examination:................................................................................ 4
(c) Special investigations:............................................................................... 4
3. Management ................................................................................................... 7
ANAESTHETIC CONSIDERATIONS FOR REMOVAL OF AIRWAY FB’s ........... 7
PREOPERATIVE ASSESSMENT ......................................................................... 8
Middle of the night or the next morning? .......................................................... 9
Premedication ..................................................................................................... 9
INTRA-OPERATIVE CONSIDERATIONS ............................................................ 9
(a) Induction: IV or inhalational? ..................................................................... 10
(b) Ventilation: SV or PPV? ............................................................................. 11
(c) Maintenance: Volatile or TIVA? .................................................................. 12
(d) Pit falls during removal of the FB .............................................................. 13
POST-OPERATIVE CONSIDERATIONS............................................................ 13
CONCLUSION .................................................................................................... 14
REFERENCES.................................................................................................... 15
Page 2 of 16
AIRWAY FOREIGN BODIES
INTRODUCTION
Aspiration of foreign bodies (FB) by children into the airway is a common problem
faced by anaesthetists. Asphyxiation from inhaled FB is one of the leading causes
of accidental death among children younger than 4 years.(1) When they present for
removal, especially when they are unstable, it often results in a very stressful
period for the attending anaesthetist. Historically the mortality related to FB
aspiration was estimated at 23%(1), largely due to the ineffective methods of
treatment. These included purging, bleeding and the use of emetics.
The first successful bronchoscopy for the removal of a pig bone from a bronchus
was in 1897 and advances in the surgical and anaesthetic domains since then
have resulted in a significant decrease in morbidity and mortality related to the
management of airway FB’s(2). Anaesthetists are frequently involved from the
initial presentation of the patient to casualty. We play an intricate role in the
diagnostic dilemmas and management decisions of these patients and our advice
and expertise are central to patient care. Knowledge obtained from the
preoperative visit is key as correct decisions on anaesthetic techniques can only
be made by an informed anaesthetist which may lead to the difference between a
favourable outcome or not.
FOREIGN BODY ASPIRATION
1. Demographics
In a South African context ingestion of FB’s requiring removal are more prevalent
than aspirated FB. Data from the Red Cross children hospital in Cape Town
indicated a 5% incidence of aspirated FB, compared to 20% incidence of
oesophageal and 40% incidence of nasal FB’s.(3) The vast majority of patients with
aspirated FB’s are children. It is particularly prevalent in the age group between 2
and 4 years with the peak incidence at 3 years.(3) Boys account for 60% of these
cases compared to girls.(1) The type of FB aspirated is linked to the patient’s age
and geographical location.
Frequent reports of headscarf pin aspiration by adolescent girls in Turkey are well
described. (1) In children organic FB’s account for 80% of aspirated FB’s.(1,4) Of
these, nuts especially peanuts are at the top of this list, followed by seeds, beans
and bones. Non organic FB account for 20% of which metal and plastic FB’s are
most prevalent. Aspirated FB will lodge in the bronchial tree in 88% of cases. (1)
The right main bronchus being slightly more common due to anatomical reasons.
The rest (11%) will lodge in the larynx and trachea and a minority (1%) impact in
different parts of the distal airways. Knowledge of the above trends in FB
aspiration will impact on anaesthetic management.
Page 3 of 16
Laryngeal or tracheal FB’s are rare but pose the greatest risk of asphyxia and
carry a mortality rate of 45% prior to reaching a medical facility. (5) Nuts liberate an
irritant oil which result in local inflammation and airway hyper reactivity. Organic
FB’s are often missed on X-ray films and a delayed presentation is associated
with worsening pulmonary function and reserve which will predispose these
patients to perioperative hypoxemia. Organic FB’s are also more prone to
fragmenting during removal and prolonged bronchoscopy might be required.
2. Diagnosis
Rigid bronchoscopy which is often performed to diagnose aspirated FB is not an
innocuous procedure. It carries a major complication rate of 2.4% and mortality
rate of 0.42%.(1) For this reason it is imperative to make the correct diagnosis so to
not expose patients to this dangerous procedure unnecessarily. To make the
correct diagnosis can be difficult and is often based on an index of suspicion.
Clinical presentation is variable and depends on; i) the time of presentation since
aspiration i.e. “when”, ii) size and shape of the object i.e. “what” and iii) site of the
object in the airway i.e. “where”. Unfortunately there is no symptom or sign that is
100% sensitive or specific for FB aspiration. Features on history and examination
which lead to a high index of suspicion are valuable in guiding further special
investigations and subsequent management.(6)
(a) History:
A witnessed aspiration event (usually choking) carries a sensitivity of 77% and a
specificity of 64% and should lead to a high index of suspicion. (1) A history of
coughing, although quite sensitive has a low specificity (40%) and therefore can
result in a significant false positive rate which can lead to unnecessary
bronchoscopy.(1) A history of cyanosis or stridor is very specific but has poor
sensitivity and can result in a significant false negative rate which can lead to
undiagnosed aspirated FB with devastating consequences.(1)
(b) Physical examination:
With an early presentation the clinical examination can range from a completely
normal one to that of a severe acute upper airway obstruction. The presence of
stridor, voice changes, barking cough or decreased level of consciousness can all
indicate laryngeal or tracheal involvement and should heighten our sense of
urgency. The clinical triad of acute coughing/choking, localized wheezing, and
unilateral diminished breath sounds has a specificity of 98%.(6) Although if this
triad is not present it certainly doesn’t exclude the possibility of an aspirated FB.
With a late presentation children typically show signs similar to patients with
pneumonia e.g. fever, tachypnoea and focal chest signs.
(c) Special investigations:
The workup of a stable patient should always include a chest X-ray (CXR). Even
though 89% of FB’s aspirated is known to be radiolucent, the majority (83%) can
show some sign of pathology.(1)
Page 4 of 16
Most abnormal features on CXR are more commonly seen after 24 hours of
presentation compared to early CXR where the sensitivity and specificity is often
low.(7) Indirect signs on CXR include air trapping or localized emphysema (the
most commonly found and specific feature), atelectasis, mediastinal shift and
collapse/consolidation.(7) Pneumothorax or pneumomediastinum are rare findings.
Comparing inspiratory and forced expiratory films will augment the features of air
trapping. The hyper-lucent lung field seen is due to a ball valve obstruction by the
FB leading to air trapping.
Reflex oligaemia due to hypoventilation of the lung field distal to the obstruction
also adds to the hyper lucent lung seen on CXR.(8) Co-operation is often not
possible in small children and the use of lateral decubitus views looking at the
dependent lung for features of air trapping is used to augment this feature. AP and
lateral neck X-Ray is a valuable modality to determine location of upper
aerodigestive tract FB’s. Flat objects e.g. coins typically align in a sagittal plane
when located inside the trachea, but will align in a coronal plane when located
inside the oesophagus (see figure 1).(1) A FB that overlaps the boundaries of the
airway is unlikely to be located inside the airway, unless penetration of the wall of
the airway has occurred.(1) A lateral view (in combination with an AP view) will
often reveal the true location of a FB.
Figure 1. Coin in the oesophagus on AP and lateral views.(1)
Airway fluoroscopy allows dynamic visualization of respiratory airways. It can
display decreased diaphragm movements due to air trapping, narrowed airway
lumens from a FB and mediastinal shift from air trapping. Although the exposure
to radiation is much less compared to CXR, its role for investigating these patients
is not yet established as it doesn’t seem to be as sensitive or specific as CT
scans.(7) In fact, in a small study of 19 patients its specificity for airway FB was
only 17%.(9)
Page 5 of 16
Thoracic computed tomography (CT) and virtual bronchoscopy (VB) are new
modalities to diagnose airway FB. VB is basically a reformatted 3-dimensional CT
image that generates intra luminal views of the airway.(1) CT chest has shown a
100% sensitivity in two studies and therefore showed importantly a zero percent
false negative rate.(10,11) Three out of forty five patients thought to have aspirated a
FB where correctly identified as not having a FB in the airway by CT scan and so
avoided rigid bronchoscopy in those 3 patients.(10)
Secretions and airway obstructive lesions like tumours can cause false positives.
Limitations to these seemingly perfect investigation modalities are: high cost,
limited availability of equipment and staff, requirement of a stable and cooperative child and excessive radiation exposure.(1) An advantage of these
investigations is the ability to delineate the shape and exact location of the FB and
therefore allow surgical planning (choosing the correct instrument prior to
bronchoscopy) and possibly shortening the bronchoscopy and anaesthetic time.(10)
Because of its accuracy some authors suggest that a negative CT and VB in
these patients do not warrant the currently accepted diagnostic gold standard of a
rigid bronchoscopy.(1) A flexible bronchoscope still plays an important role in the
diagnosis and recently the management of airway foreign bodies.
It is more invasive than CT or VB, but much less traumatic or dangerous
compared to diagnostic rigid bronchoscopy. The sensitivity and specificity is
excellent and is reported to be close to 100% (comparable to CT).(7) It is typically
utilized in patients without a clear history or positive radiological findings of FB
aspiration and is able to decrease the negative finding rate of diagnostic rigid
bronchoscopy. (1,7) It can be performed with sedation and topical local
anaesthesia, but general anaesthesia is often necessary in the paediatric
population. Although fewer surgeons utilize this technique for the routine removal
of FB’s, it is better suited for removing small distal FB’s and those located in the
upper lobes of the lung compared to its rigid counterpart. (1) Fewer instruments
(stone baskets are generally used with flexible bronchoscopy) are available to
remove FB’s and less control over the FB during removal are important reasons
why surgeons generally opt for the rigid bronchoscope.
Rigid bronchoscopy is considered the gold standard for diagnosis and
management of suspected airway FB’s. Because of the significant complications
associated with a missed airway FB, diagnostic rigid bronchoscopy is commonly
performed where only a suspicion exists. More appropriately it is recommended
that children undergo rigid bronchoscopy only if they have acute asphyxiation, a
radio-opaque foreign body or convincing clinical and radiological features (clinical
triad and signs of air trapping on X rays).(1) CT, VB or flexible bronchoscope will
be appropriate in all other patients to help clarify the diagnosis and minimize
unnecessary negative rigid bronchoscopies. A simple flow diagram for suspected
airway foreign body diagnoses and management in children has been suggested
(figure 2).(7)
Page 6 of 16
Figure 2. Diagnostic algorithm for suspected bronchial foreign body in children according to Martinot,
1997. (VBS: vesicular breath sounds. BFB+: positive bronchial foreign body).(7)
3. Management
The gold standard method and preferred technique by the majority of surgeons for
the removal of airway FB’s is rigid bronchoscopy. This is largely because of the
advantages a rigid bronchoscope provides in these cases namely, availability of
multiple extraction instruments, good visualization, complete airway and FB
control and an excellent conduit for ventilation.(1)
ANAESTHETIC CONSIDERATIONS FOR REMOVAL OF AIRWAY FB’s
This is broken up into pre-, intra- and post-operative periods. Because the use of
a rigid bronchoscope is almost exclusively used in our setting I will concentrate on
the anaesthetic implications for this technique.
Page 7 of 16
Please note that there is no consensus in the literature yet as to which anaesthetic
techniques are considered optimal so I will discuss below some controversies and
what is considered acceptable practice based on evidence from systematic
reviews and large retrospective cohorts.
PREOPERATIVE ASSESSMENT
It is very important to make a full pre operative assessment of the patient prior to
arrival in the OT. Three main questions that will impact on anaesthetic technique
needs to be answered during the history, clinical examination and special
investigations: (1)
1. Where is the FB located?
Location determines the potential for complete airway obstruction, the most feared
complication although very rare.(1) Laryngeal, tracheal and carinal FB’s therefore
present the highest risk for inadequate oxygenation or complete airway
obstruction.(5) Danger signs would include hypoxia on presentation, stridor, voice
changes and dysphonia or aphonia.(5,13) Oesophageal FB’s are more commonly
encountered than airway FB’s and morbidity and mortality related to their removal
is considerably less as the airway is not shared.(3,13)
2. What was aspirated?
Organic material is often problematic because it can absorb fluid and swell
causing progressive airway obstruction.(1,13) These FB’s are more prone to
fragmenting, but might also need to be crushed intentionally and removed piece
by piece adding to anaesthetic time.(12) Nuts and seeds liberate irritant oils causing
airway inflammation and irritability with the risk of bronchospasm.(5) Spherical
shaped FB’s are prone to complete obstruction of bronchial airways because of
their shape which can lead to distal atelectasis with distal suppuration and
possible spillage of puss into unaffected parts of the lung once it is removed. (13)
They are more difficult to grab and there is the potential to lose grip during
retrieval causing a potentially dangerous situation of complete airway obstruction
or contra lateral bronchial obstruction with resultant hypoxaemia.(13)
3. When did it happen?
Recently aspirated FB’s are more likely to move when the patient coughs and can
potentially lodge in the upper airway with detrimental consequences. (1) Delayed
presentations are often associated with complications such as infection, airway
oedema and formation of granulation tissue (FB is unlikely to move) which make
retrieval more difficult and the anaesthetic time longer.(1) They rarely require
emergency removal.
In the majority of cases fasting (6 hours for solids and 2 hours for clear liquids) is
appropriate unless the urgency of the case outweigh the risk of aspiration.(14)
Page 8 of 16
In a review of 12979 cases for retrieval of airway FB’s there was no reports of
aspiration during bronchoscope, although fatal progression of airway obstruction
was reported in 2 cases.(1) The risk of aspiration is less than the risk of worsening
hypoxia in urgent cases. Nasogastric tube placement in children after induction
but prior to bronchoscopy is appropriate in urgent cases with a significant risk for
aspiration.(1)
Middle of the night or the next morning?
Urgent bronchoscopy should be performed in all cases where airway patency is
deemed threatened.(1) Lack of experience from both surgical and anaesthetic
teams is a contributing factor to poor outcome in patients undergoing
bronchoscopy.(12) In stable patients, a delay in bronchoscopy for removal of airway
FB until the next day failed to show an increase in morbidity during a retrospective
review of 165 patients.(15) The best timing for bronchoscopy is a controversial
issue without adequate guidance available from the literature and is bound to
cause tension between caregivers. I believe that individualization for each case is
necessary and that all factors (patient status, availability of experienced staff and
time of the day) should be considered by surgical and anaesthetic staff in a
conjoint decision that best suites the wellbeing of the patient.
Premedication
Every effort should be made to keep the child calm and prevent coughing spells
prior to induction to avoid FB dislodgement and possibly worsening airway
obstruction.(14) Sedative premedication requires careful consideration though as
sedation can worsen upper airway obstruction and decrease perioperative
respiratory drive when a spontaneous ventilation technique is considered.(14)
Anticholinergic medication (atropine or glycopyrolate) may be used to dry airway
secretions, prevent vagal-induced bradycardia during insertion of the
bronchoscope and attenuate cholinergic-mediated bronchoconstriction during
airway manipulation, but there use is not routine.(5,14) Antibiotic and steroid
medications are indicated to treat infection and laryngeal oedema respectively,
especially in delayed presentations where bronchoscopic manipulation is
expected to be excessive.(1,12,14)
INTRA-OPERATIVE CONSIDERATIONS
The main goals of anaesthesia for rigid bronchoscopy are:
1- OXYGENATION
2- IMMOBILE PATIENT
These goals are based on the most frequent complications seen during rigid
bronchoscopy. Significant morbidity and mortality rates are associated with rigid
bronchoscopy when these goals are not met (suboptimal surgical conditions are
provided.)(1)
Page 9 of 16
Complications include severe laryngeal oedema or bronchospasm,
pneumothorax, hypoxic cardiac arrest, hypoxic brain damage and tracheal or
bronchial laceration.(1,14) Prior to induction it is vital for the surgeon to be in theatre
with the immediate ability to perform rigid bronchoscopy if total airway obstruction
occurs. A minimum of two anaesthetists (one for drug administration and the other
for airway management) is critical to a successful outcome.(12) Communication
between surgeon and anaesthetist is important prior to induction and throughout
the whole procedure.
Pre-operative concerns and planning (step 1,2,3….) should be raised by both
surgeon and anaesthetist and consensus reached before induction.(13) In the ideal
situation intravenous access would be established prior to induction with the use
of topical local anaesthetic to prevent anxiety in a child. However in a distressed
child with difficult veins or in an emergency, establishing IV access immediately
after inhalation induction is acceptable.(12,14) Various successful anaesthetic
techniques are described for airway FB removal. There is no universally accepted
standard method or even evidence based best recipe described. Individualization
for each patient seems to be a good approach taking into consideration the
condition of the patient, location of the foreign body and personal preference or
familiarity with a particular technique.(5)
The 4 main intra-operative anaesthetic issues during bronchoscopy are discussed
below under induction, ventilation, maintenance and pitfalls:
(a) Induction: IV or inhalational?
Both intravenous (IV) and inhalational induction are described in the literature with
successful outcomes. The choice between IV and inhalational induction seems to
be dominated by the location of the FB.(1) In theory, proximal airway FB’s (larynx,
trachea and carina) have the ability to move and completely obstruct the airway
once spontaneous ventilation (SV) is converted to positive pressure ventilation
(PPV) as commonly occur after IV induction.(1,5) For this reason inhalational
induction is advocated when proximal airway FB’s are present even though there
is a lack of evidence to confirm this theory.
Cautious IV induction that maintains spontaneous ventilation is possible, although
technically more challenging to achieve. There are no prospective clinical trials
that compare the complication rates between IV and inhalational induction
techniques. Although hypoxic arrest during the initial stages of anaesthesia and
bronchoscopy does occur, we are not able to draw conclusions from the available
literature whether choice of induction technique affects outcome. (1) Inhalational
induction is preferred by most anaesthetists for the removal of FB’s in
children.(14,16)
Advantages of inhalational induction include; familiarity with its use in paediatric
patients, avoidance of the need to attain IV access in the awake child, high
success rate with maintaining spontaneous ventilation, haemodynamic stability
Page 10 of 16
and the ability to titrate and quickly reverse the volatile once signs of airway
obstruction appear. Inhalational induction also doesn’t appear to increase the risk
of aspiration in these patients compared to IV induction.(12) Evacuating the
stomach with a nasogastric tube after induction but prior to bronchoscopy is
considered acceptable practice.(1)The optimal method of induction is not
definitively established and probably does not change the outcome in the majority
of cases (where FB’s are lodged distal to the carina).
Maintaining spontaneous ventilation during the induction of a patient with a
proximal FB is commonly practiced though.(1) After induction but prior to
bronchoscopy the use of topical local anaesthesia is indicated in all cases, except
when the condition of the patient is critical or when a local anaesthetic allergy
exists. Lignocaine 1% (maximum safe dose is 4mg/kg) sprayed onto the larynx
and into the trachea reduces the cardiovascular and tussive response to
bronchoscopy.(12,14) It will allow a lighter level of anaesthesia to be tolerated during
bronchoscopy, which is often the case with spontaneously breathing patients.
b) Ventilation: SV or PPV?
Considerable controversy exists as to how to conduct ventilation during rigid
bronchoscopy.(14) It is difficult to demonstrate superiority of one type of ventilation
technique over the other from the current literature. Both SV and PPV has been
used successfully by various authors and it seems that there are no significant
difference in major outcomes like mortality.(1,5,12,17) SV has the advantage of
continued ventilation and oxygenation despite interruptions with the anaesthetic
breathing circuit.(5) Although due to the underlying lung pathology (atelectasis
and/or pneumonia) and high resistance to breathing through the bronchoscopes
lumen the episodes and severity of desaturation is comparable between SV and
PPV techniques.(18) The major disadvantage of SV is the high incidence of
coughing and/or bucking during bronchoscopy because of inadequate depth of
anaesthesia.(18)
Traditionally it was thought that with the use of PPV, the FB can be pushed more
distally making retrieval more difficult for the surgeon. The most feared
complication is total proximal airway occlusion, was also thought to occur when
PPV created a ball valve effect in the proximal airways preventing inspiration.
These are overstated and unsubstantiated fears. If it is relevant, it remains a very
rare phenomenon.(1,5,18) Most FB’s that require removal are lodged and PPV is
unlikely to change the position. Because airway trauma and rupture are significant
and potentially fatal complications the immobility of the patient during
bronchoscopy is vital.(1) Adequate depth of anaesthesia so to render the patient
immobile (without the use of muscle relaxants) is often not achieved with
techniques that maintain SV. The significant conversion rate from SV to PPV
during bronchoscopy to attain optimal surgical conditions (immobility) demonstrate
this fact.(17,18)
Page 11 of 16
Taking into consideration that two main goals are oxygenation and immobilization
during bronchoscopy and the fact that PPV is often required to achieve these
goals with a high success rate, its routine use cannot be frowned upon and should
probably be investigated in larger prospective clinical trials. The use of muscle
relaxants (mivacurium or suxamethonium) is the most reliable way of achieving
immobility and is utilized most often on a “as needed” basis, but will commit the
anaesthetist to the use of PPV.(1) SV during proximal airway FB’s (proximal to
carina) is currently advocated.(1) PPV often result in leakage of air around the
bronchoscope with inadequate ventilation.
One way to overcome this problem is by manually closing the mouth and nose,
although this will restrict the surgeon’s ability to manipulate the bronchoscope. (1)
An alternative solution to this problem is the use of jet ventilation. Manual jet
ventilation via a side port of the bronchoscope is described and was shown to
have fewer episodes of hypoxaemia compared to PPV with a T-piece during FB
retrieval.(19) Its use in children is not advocated, especially when experience with
the use of it is lacking as barotrauma is a common complication.(12) Its use is
valuable when inadequate oxygenation or ventilation during PPV cannot be
achieved with the T-piece due to a significant leak around the bronchoscope.
(c) Maintenance: Volatile or TIVA?
Halothane was commonly used during bronchoscopy because of its ability to
provide very deep inhalational anaesthesia during SV. The one major side effect
was the high incidence of cardiac arrhythmias in these patients because
halothane sensitizes the myocardium to catecholamines especially in the
hypercarbic state as you would often find in patients with airway FB’s. (1)
Sevoflurane has been shown in multiple trials to be similar in efficacy but has a
much lower incidence of arrhythmias compared to halothane during
bronchoscopy.(20) Traditionally only volatile anaesthetic agents were used for
maintenance of anaesthesia during bronchoscopy for airway FB removal.
Nowadays the use of total intravenous anaesthesia (TIVA) is becoming popular
for these procedures due to the advantages it offers.(1) TIVA provides a constant
depth of anaesthesia irrespective of ventilatory mode (SV or PPV), but also during
manipulation of the bronchoscope in and out of the airways and there is also less
theatre pollution with volatile anaesthetic.(1,5) The success of this technique to
provide a haemodynamically stable and immobile patient depends on giving the
correct dosage of IV drug and also operator experience with the technique. (21,22)
There are several variations of IV drugs used (propofol, remifentanil,
dexmeditomidine, midazolam) and combinations of these drugs described, but
there is no clear evidence to suggest a superior drug or combination. Dosages in
the range of 0.2 μg/kg/min of remifentanil and 100–250 μg/kg/min of propofol
provide adequate surgical conditions.(21)
Page 12 of 16
The ability to maintain SV with the use of a remifentanil infusion is described and
together with the use of sevoflurane and topical local anaesthesia, it is an effective
and save method to use during bronchoscopy.(23)
(d) Pit falls during removal of the FB.
Airway compromise is most likely during manipulation of the FB by the
bronchoscopist. Dropping the FB during removal in the trachea or getting it stuck
at the larynx is a complication that is well described and that have accounted for
multiple intra-operative deaths.(1,12) Clear communication between surgeon and
anaesthetist is vital during the period of removal of the FB. Incomplete vocal cord
relaxation can contribute to the inability to remove the FB and immediate paralysis
with the use of suxamethonium is then required. If ventilation suddenly becomes
impossible during removal of the FB, the possibility of tracheal obstruction should
be considered first. A dropped FB in the trachea needs to be either removed
immediately or pushed back down the trachea into the same bronchus it was
located in to provide ventilation.
If the FB is displaced into the contra lateral bronchus (healthy lung) there is a
possibility of complete airway obstruction and severe hypoxaemia due to oedema
and inflammation at the original bronchial site.(1) In rare circumstances the inability
to remove a FB can result in inadequate ventilation and will need to be optimized
to provide oxygenation. Slow prolonged breaths with adequate pressure after
endotracheal intubation can provide ventilation past a partially obstructed
airway.(1) Extracorporeal membrane oxygenation can be a life saving modality if
available during such cases.(24)
POST-OPERATIVE CONSIDERATIONS
Significant pulmonary compromise (hypoxaemia) and upper airway obstruction
from laryngeal oedema should be anticipated after FB removal, especially in
delayed presentations where bronchoscopy was difficult and prolonged. Nursing
the child with the affected lung down can help prevent contamination of the
unaffected lung. Supplemental oxygen and adrenalin nebulisation can be used
post-operatively for airway oedema.
Uncomplicated bronchoscopy and FB removal will allow the majority of patients to
be discharged on the same day.(12) Predictive factors for a prolonged recovery
period include the presence of infiltrates on preoperative CXR, delayed
presentation, non resolving signs on post operative CXR and prolonged duration
of bronchoscopy.(1)
Page 13 of 16
CONCLUSION
FB aspiration is common in children. A combination of a good history, physical
examination and special investigations should eliminate the need for diagnostic
rigid bronchoscopy as anaesthesia for this procedure is associated with significant
morbidity and mortality. There is no consensus from the literature as to which
anaesthetic technique is considered optimal.
Keeping in mind the two main goals of oxygenation and patient immobility an
individual plan for each patient based on FB type and location, surgeon
preferences and personal familiarity with an anaesthetic technique must play a
role in the final method chosen for anaesthesia. Clear communication and
experienced team members are essential to a good outcome as intra-operative
findings or events might significantly change the initial plans.
Page 14 of 16
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