|Year : 2007 | Volume
| Issue : 1 | Page : 20-23
Management of tracheobronchial foreign body aspirations in paediatric age group - A 10 year retrospective analysis
Vijaykumar T Kalyanappagol1, NH Kulkarni2, LH Bidri3
1 M.D.;D.A., Senior Consultant, Dr. Bidari's Ashwini Institute of Child Healthand Research Centre, Bijapur, India
2 M.S.(ENT)SeniorConsultant, Dr. Bidari's Ashwini Institute of Child Healthand Research Centre, Bijapur, India
3 DCH SeniorConsultant, Dr. Bidari's Ashwini Institute of Child Healthand Research Centre, Bijapur, India
|Date of Acceptance||03-Jan-2006|
|Date of Web Publication||20-Mar-2010|
Vijaykumar T Kalyanappagol
14, Vijayhousing Colony, NearKhedcollege, Bijapur-586101
A retrospective analysis of management of tracheobronchial tree in paediatric age group was done over a period of 10 years. These children were aged 0 month to 12 years and male children were predominant. Bronchoscopy performed under general anaesthesia in 316 cases of suspected foreign body inhalation, out of which 206 were positive for the same. There were no post operative complications in any case.
Keywords: Foreign body, Bronchoscopy, Tracheobronchial tree
|How to cite this article:|
Kalyanappagol VT, Kulkarni N H, Bidri L H. Management of tracheobronchial foreign body aspirations in paediatric age group - A 10 year retrospective analysis. Indian J Anaesth 2007;51:20-3
|How to cite this URL:|
Kalyanappagol VT, Kulkarni N H, Bidri L H. Management of tracheobronchial foreign body aspirations in paediatric age group - A 10 year retrospective analysis. Indian J Anaesth [serial online] 2007 [cited 2013 Dec 7];51:20-3. Available from: http://www.ijaweb.org/text.asp?2007/51/1/20/61109
| Introduction|| |
Foreign body aspiration is a common problem in children  and accounts for an important cause of morbidity and mortality.  It is potentially life threatening event and may also cause chronic lung injury if not properly managed.  The diagnosis and the treatment of the problem requires awareness and highest degree of suspicion of signs and symptoms of foreign body aspiration.  This study analyses the clinical and radiological profile of foreign body aspiration and its management as it requires complete co-operation an good communication between endoscopist and anaesthesiologist.
| Materials and methods|| |
Medical records of all patient subjected to bronchoscopy from June 1995 - June 2005 in children hospital were studied retrospectively. The following data was collected, age, sex, availability of history of foreign body aspiration, type and location of the foreign body and radiological findings. All children were evaluated by paediatrician and bronchoscopy was done by Storz rigid bronchoscope.
| Anaesthesia management|| |
General anaesthesia is always the technique of choice for the removal of a tracheobronchial foreign body in a fighting irritable child, distally lodged invisible foreign body and if prolonged bronchoscopy procedure is contemplated. The problems of in many of these children is that of full stomach and the necessity for the both the surgeon and the anaesthesiologist to share the same airway. Nitrous oxide should be withheld to limit further pulmonary inflation and potential rupture. Rigid ventilating bronchoscope equipped with an optical telescope and fibrooptic light source has been used, in all of our patients.
| Goals of anesthesia|| |
After securing good IV access, all children were preoxygenated for 3 minutes, inj. atropine sulphate 0.02 mgkg -1 was administered IV to decrease secretions and to obtund autonomic reflexes during airway instrumentation. Children were induced with either ketamine hydrochloride 2 mgkg -1 intravenously or oxygen in halothane 2-3% by face mask. For muscle relaxation succinyl choline 1.5 mgkg- 1 was administered and topical lidocaine 3-4 mgkg -1 was sparayed in larynx and tracheobronchial tree to prevent laryngospasm. Once the child was apnoeic, the surgeon introduced an appropriate sized bronchoscope and intermittent positive pressure ventilation was continued through the side port of the bronchoscope. Anaesthesia was maintained with repeat dose of ketamine or by oxygen and halothane. Succinyl chloride 0.25-0.5 mgkg -1 was repeated whenever necessary with atropine sulphate 0.02 mgkg -1 . Following the removal of the foreign body, a check bronchoscopy was done to ensure full clearance of foreign body and impact site for trauma,bleeding and granulation. Inj. Dexamethasone (0.4-1 mgkg -1 ) IV, humidified oxygen and bronchodilators were given prophylactically in all the cases and nebulized racemic epinephrine was given wherever necessary to prevent post operative stridor and distress. Patient were monitored continuously by pulse oxymetry and ECG.
- Adequate oxygenation
- Controlled cardiorespiratory reflexes during bronchoscopy.
- Rapid return of upper airway reflexes.
- Prevention of pulmonary aspiration.
- Meticulous monitoring with the help of SpO 2 , NIBP, ECG, EtCO 2
A chest X-ray was taken at 6-8 hours postbronchoscopy to assess lung expansion and exclude a pneumothorax and residual foreign body.
| Results|| |
Total of 316 bronchoscopies were performed, out of which 206 were positive for foreign body accounting for 2/3 of all suspected cases. [Table 1] Most of our patients were below the age of 3 years. Four patients were below the age of 6 months in whom there was high index of suspicion of a foreign body aspiration.[Table 2] Boys were predominant with male to female ratio of 2:1[Table 2]. Common site for foreign body lodgement was right main bronchus followed by left main bronchus [Table 3]. The commonest foreign body was ground nut. [Table 4]. The major presenting symptoms were cough, fever, breathlessness [Table 5]. Common signs were tachypnoea, unilateral diminished breath sounds and rhochi/crepitations. [Table 5]. The commonest radiological feature was obstructive emphysema [Table 6]. There were no complications during and after procedure.
| Discussion|| |
Anaesthesia for rigid bronchoscopy in infants and children is a challenging procedure for a paediatric anaesthesiologists, since it is often difficult to maintain the airway for adequate ventilation and oxygenation in patients whose pulmonary gas exchange is already reduced. Since the mid 1970s, Chavelier Jackson bronchoscopes have been replaced by newer types of bronchoscopes with a breathing sidearm. The use of Hopkins glass rod telescopes through the bronchoscope lumen has further reduced the airway patency and ventilation during bronchoscopy, especially in young children. Thus it has become extremely important to have a close dialogue with the bronchoscopist for the process of planning of the anaesthesia.  In our study the Storz rigid bronchoscope with a ventilating sidearm, was used for most of the paediatric bronchoscopies because, it provides excellent visibility.
Foreign body aspiration in children occurs commonly in children between 1 and 3 years of age and consists most frequently of peanuts, seeds and other food particles and less frequently of plastic and metal particles.  Our analysis of tracheobrochial foreign body confirms the findings of other studies that majority of the children presenting with foreign body aspiration were under the age of 3 years. [5,[,, In our study 80% of children were below the age of 3 years. The natural urge to explore the objects by mouth, lack of molar teeth to crush nuts, crying and playing while eating and lack of parental supervision contributes to this hazard in this age group. The male to female ratio in our study was 2:1 which is in concurrence with previous data. , In present study peanut was the commonest foreign body which is similar to study done by others. ,,, It occurs commonly in the right main bronchus than the left and less frequently in the larynx and trachea,  this is because of anatomical position of right main bronchus, as it is more vertical and has larger diameter leading to more airentry than the left bronchus. In our study the common site for foreign body lodgement was right main bronchus followed by left main bronchus which is also found in study done by others. ,, Eight of our patients had bilateral foreign bodies. In our study unilateral diminished breath sounds were the commonest sign and the commonest radiological feature was obstructive emphysema.
In addition to the usual pre-operative assessment, physical examination should focus on the location and degree of airway obstruction and gas exchange. A review of the latest chest radiograph is helpful in determining the location of the foreign body and for evidence of secondary pathologic changes such as atelectasis, airtrapping or pneumonia. If a significant hyperinflation of one lung or lobe exists, nitrous oxide should be withheld, because of the potential danger of further increasing gas volume and possible rupture of the affected lung.  So in our study we avoided nitrous oxide. In the case of acute respiratory distress and hypoxemia with laryngeal foreign body, anaesthesia is induced with halothane and oxygen by mask, while the patient is monitored with precordial stethoscope, pulse oximeter and electrocardiogram. Anaesthesia is deepened swiftly, while the ventilation is assisted with bag and mask. As soon as child is anasthetized, laryngoscopy is performed with the patient in semirecumbent position.Unless the foreign body is visible in the airway, the trachea is intubated without delay with styleted endotracheal tube, one size smaller than the tube appropriate for the patient's age. Muscle relaxant is not given because of the degree of total airway obstruction.The tube is gently pushed down in to a main bronchus to bypass the foreign body in the trachea and to establish a life saving gas exchange. Fortunately, it is rare for an anaesthesiologists to encounter a foreign body in the larynx and trachea with dyspnea and life threatening hypoxia.  We came across such situations twice and successfully removed the foreign body without any complications.
In a child with a most stable condition an intravenous induction with an IV induction agents (eg. Sodium thiopental, Ketamine or propofol) is used.  In our study Ketamine hydrochloride is the preferred drug in paediatric age group as it is safe in children in an emergency situation were they may be with full stomach. It leaves cough reflexes intact and it also provides cardiovascular stability and prevents bronchospasm.  At the conclusion of procedure, patients should be returned to consiousness quickly with the airway reflexes intact to protect the recently instrumented airway. 
Muscle relaxation, if desired can be achieved by following any one of the number of convential techniques include succinylcholine by bolus or intermittent doses or non-depolarising relaxants; of the later, shorter acting agents (eg. mivacurium or atracurium). may be used to avoid excessive neuromuscular blockade at the end of a brief bronchoscopy. Muscle relaxation necessitate controlled ventilation, but also allows delivary of less anaesthesia, prevents coughing, trauma and facilitates removal of foreign bodies through the vocal cords.  In our study succinyl choline was used for the satisfactory muscle relaxation.
A variety of ventilatory techniques can be used during rigid bronchoscopy, following hyperventilation with 100 percent oxygen to denitrogenate the lungs and to lower PaCO 2. Oxygen can be delivered by insufflation at high flow rates (10-15 litre/min) by apnoeic oxygenation without actually ventilating the patient. Although satisfactory oxygenation can be achieved for long periods, apnoea should not extend beyond 5 minutes because of carbon dioxide accumulation. Oxygen and anaesthetic gases can be delivered through the sidearm of the bronchoscope by intermittent ventilation. Ventilation is possible as long as eyepiece is in place,but must be interrupted whenever removal of foreign body or suctioning is performed. During long procedure, carbon dioxide accumulates and predisposes the patient to dysrhythmias, particularly in the presence of light anaesthesia. Intermittent hyperventilation lowers PaCO 2 and deepens the anaesthesia. High flows of fresh gases are needed to compensate for the leak around the bronchoscope. Oxygen can also be delivered by a Sanders system which uses the Venturi principle to deliver oxygen by jet ventilation. The presence of an eyepiece is not advisable with this technique.So continous uninterrupted ventilation is possible.  We used side arm bronchoscope with intermittent ventilation with satisfactory anaesthesia.
On completion of the examination, the bronchoscope is removed from the trachea and the anaesthesiologist institutes bag and mask ventilation with 100 percent oxygen. The trachea is intubated as needed to provide pulmonary toilet to protect the airway from aspiration of gastric contents or to manage pulmonary insufficiency. After the bronchoscopy, the child is observed in a anaesthesia recovery room for stridor, respiratory distress or other signs suggestive of subglottic edema, damaged teeth, haemorrhage, bronchospasm and airway perforation. A chest radiograph should be obtained following bronchoscopy to exclude the presence of pneumothorax or mediastinal emphysema from barotraumas.  Detail clinical history, X-ray chest with proper surgical and anaesthetic management are essential to ensure a high degree of success rate.
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[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]