Airway Foreign Body

Background:

Foreign Body in Airway

• This may be the result of aspiration of food or other household items.

• Foods with oils (such as un-roasted nuts) may lead to significant inflammation at the site where the foreign body is lodged

• Foreign body may be jagged and can puncture the airway or become wedged making extraction difficult

• Partial obstruction of the airway may result in a "ball valve” effect leading to air trapping on the affected lung

Patient Considerations

• These cases are frequently an emergency. It is essential to extract the foreign body before the patient decompensates

• Patients are frequently full stomach

Disease Specific Considerations

• Risks/Benefits of proceeding vs risk of aspiration

  • This should be discussed with the surgeon and patient’s family

• Damage foreign body may cause to airway (roasted v. unroasted almonds, sharp objects, ball valve effect)

Anesthetic Management:

• Case Planning

  • Thorough Pre-Anesthetic Evaluation including identification and optimization of comorbid conditions (as allowed)

  • R/B/A discussion of proceeding with parents and surgeon

• Specific or Unique Room Set-Up Requirements

  • Airway

    • R/B/A of open airway v. RSI

    • RSI may protect against additional aspiration but may hinder FB extraction by abolishing spontaneous respiration

      • Oral Endotracheal Tube may hinder rigid bronchoscopy and prevent successful FB extraction

    • Open airway with cautious positioning and readily available suction is frequently required

      • Be prepared to intubate emergently if reflux of gastric contents is identified.

• Drugs/Infusions

  • Steroids

    • Dexamethasone (0.2-0.5mg/kg)

  • PONV Prophylaxis

  • Ondansetron (0.1-0.15mg/kg) -max 4mg

  • Emergence Delirium Prophylaxis

    • Dexmetomedine (0.5mcg/kg)

  • Many options/combinations for maintenance

    • Inhalational

    • A 4.0-5.0 uncuffed OETT in the side of mouth allows insufflation of volatile anesthetic while the surgeon is working

    • Precedex

      • Bolus or infusion

    • Ketamine

      • 0.5-1mg/kg boluses

    • Remifentanil

    • Propofol

      • Start at 100mcg/kg/min and titrate to effect

• Monitors

  • Standard ASA monitors

  • EtCO2 unreliable during open airway

    • SpO2 and Chest Movement must be observed to confirm oxygenation/ventilation

• Blood Availability

  • Usually not required

• PICU Bed Availability

  • May be needed in case of prolonged procedure leading to airway edema, aspiration and/or pneumothorax

• Anesthetic Considerations

  • Laryngoscopy is VERY stimulating, anesthetic depth should be deep enough to tolerate this, considering that removal of stimulation may lead to deep anesthesia and apnea

  • Maintain spontaneous ventilation is goal

  • Role of apneic oxygenation

    • Healthy patients can tolerate prolonged apnea if 100% O2 is insufflated during bronchoscopy

  • PaCO2 will continue to rise in the absence of effective ventilation

  • Possible tension pneumothorax if severe air trapping

    • Have a plan for decompression

  • Induction

    • R/B/A of open airway v. RSI

    • Case frequently requires mask induction and open airway with maintenance of spontaneous ventilation

  • Positioning

    • Frequently supine with bed turned 90*

  • Maintenance

    • Drugs as above

  • Hemodynamic/Physiologic goals

    • Avoid aspiration

    • Maintain spontaneous ventilation

    • Minimize increases in PA pressures

• Surgical Considerations (such as neuromonitoring, muscle relaxation, anticipated blood loss)

  • If wedged deep or fragmented, may be prolonged extraction

  • Surgeon may manipulate head/neck to align airway so rigid scope may reach bronchus

• Emergence/Disposition

  • Full stomach patients may be intubated after FB removal and awakened in OR

  • Patients with significant airway trauma or edema may require post-op ventilation

• Post-Op Pain Management

  • Very stimulating intra-op, usually not painful post-op

• Case-Specific Complications

  • Total airway obstruction

    • If FB lodges in trachea it may need to be pushed back into a mainstem bronchus

  • Pulmonary Hypertension

    • Both hypoxia and hypercarbia increase PVR.

  • Patients with pre-existing pulmonary HTN or cardiac defects may not tolerate this

  • Laryngospasm

  • May occur due to light anesthesia and/or surgical manipulation of vocal cords

  • Bronchospasm

    • Difficult to treat with open airway

    • Have a low threshold for administering small boluses of IV epinephrine

  • Stridor

  • Edema from surgical manipulation can cause obstruction

    • Generous steroid administration may help mitigate this

    • Racemic epinephrine may be given to decrease edema

  • Fistula formation

    • Foreign bodies can cause tracheaoesophageal fistulae via mechanical pressure, puncture or caustic trauma

  • Pulmonary Hemorrhage

    • Foreign body erosion into the pulmonary vasculature may result in catastrophic hemorrhage