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Year : 2007  |  Volume : 51  |  Issue : 6  |  Page : 501-504 Table of Contents     

A retrospective study of anaesthetic management of foreign bodies in airway- a two & half years experience

1 M.D.,Lecturer,Anaesthesia, Govt. Dental College, Aurangabad, India
2 M.D.,D.A.,Professor ofAnaesthesia, Govt. Dental College, Aurangabad, India

Date of Acceptance25-Oct-2007
Date of Web Publication20-Mar-2010

Correspondence Address:
Jyoti V Kulkarni
7, Bharat Nagar, Shahnoorwadi, Aurangabad-431005.(M.S.)
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Source of Support: None, Conflict of Interest: None

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A retrospective analysis of medical records of 76 children of suspected foreign bodies (FB) in airway posted for rigid bronchoscopy under general anaesthesia was done. Patients were 9 months to 11 years old. Seventy eight percent patients were between the age of 9 months to 4 years & 22% patients were above the age of four years. Seventy one percent patients were male and 29% patients were female. In 16% (n=12) patients no FB was found while in 82.7% (n=63) patients vegetative FB like peanut, custard apple, gram and turdal, tamarind seed, garlic, chilli, coconut piece and non-vegetative foreign body i.e. ear-ring was found in 1 case.
In 17 % patients foreign body was located in subglottic region, in 59 % patients FB was in right main bronchus and in 24% patients it was in left main bronchus. In 33 % patients bronchoscopy was done within 72 hours of appearance of symptoms while in 51% patients bronchoscopy was done after 72 hours to one week of appearance of symptoms. In 16% patients bronchoscopy was done after one week. Twenty percent patients required tracheostomy and 3% patients required bronchodilators, nebuliza­tion and ventilatory support in immediate post operative period. All patients were managed under general anaesthesia using ketamine, suxamethonium, oxygen and halothane. All patients were ventilated through side arm of ventilating bronchoscope.All patients were discharged from hospital & no death was reported.

Keywords: F.B. (Foreign body), General anaesthesia, Bronchoscopy

How to cite this article:
Kulkarni JV, Bhagat H P. A retrospective study of anaesthetic management of foreign bodies in airway- a two & half years experience. Indian J Anaesth 2007;51:501-4

How to cite this URL:
Kulkarni JV, Bhagat H P. A retrospective study of anaesthetic management of foreign bodies in airway- a two & half years experience. Indian J Anaesth [serial online] 2007 [cited 2021 Jun 25];51:501-4. Available from: https://www.ijaweb.org/text.asp?2007/51/6/501/61187

   Introduction Top

Foreign body (FB) aspiration is an important cause of paediatric morbidity and mortality. It is common in infants and small children [1],[2] . Anaesthetic management for removal of FB is still a challenge. Sharing of airway by both anaesthesiologist and surgeon poses difficulty in ventilation. Associated oedema and inflammatory changes in tracheobronchial tree predispose these pa­tients to severe bronchospasm [2] .

We conducted a retrospective analysis of 76 cases of suspected FB aspiration posted for rigid bronchos­copy under general anaesthesia, to identify trends ac­cording to patient's age, sex, type of FB, location of FB in respiratory tract and outcome of patient. We have also discussed different techniques of anaesthesia and ventilation for rigid bronchoscopy.

   Methods Top

In this study we have under taken a retrospective analysis of medical records of all 76 children posted for rigid bronchoscopy for suspected FB aspiration in Govt. Medical College & Hospital, Aurangabad between Janu­ary-2004 to June-2006. We noted age, sex, definitive history of aspiration, findings of X ray chest and dura­tion from appearance of symptoms to bronchoscopy. Preoperative symptomatic treatment received by patient, details of anaesthesia and monitoring were recorded. Type of FB, location of FB, need for tracheostomy, post bronchoscopy complication and their management were also noted.

   Results Top

After analysing records of 76 patients of suspected foreign body aspiration we got following results. In 67 % patients there was definite history of aspiration. 78% patients were between the age of 9 months to 4 years & 22% patients were above the age of four years. 71% patients were male and 29% patients were female [Table 1]. Preoperatively patients received symptomatic treat­ment like bronchodilator, nebulization, oxygen supplemen­tation & antibiotics, depending upon the presentation. Consent from parents/guardias was obtained before the procedure. All patients were monitored with pulse oxime­ter throughout the procedure.

Ventilating bronchoscope was used for the proce­dure. All children received atropine 0.02 mg.kg -1 as pre­medication, 100 % preoxygenation was done. Patients were induced with ketamine 2 mg.kg -1 and suxamethonium 2mg.kg -1 was given. After regression of fasciculations patients were ventilated on mask with 100 % oxygen for 1 minute and then bronchoscopy was allowed. In all patients O 2 , halothane and intermittent doses of suxamethonium were given for maintenance of anaesthesia. Hydrocortisone 2 mg.kg -1 was given IV followed by dexamethasone 600 ggm.kg -1 .24hrs -1 in 4 divided doses to prevent postoperative laryngeal oedema. Nasal oxygen was administered in postoperative period to prevent hypoxia. Bronchospasm was treated with xanthine derivatives and salbutamol nebulization.

In 63(82.7%) patients vegetative foreign bodies like peanut, custard apple, gram and tur dal, tamarind seed, garlic, chilli, coconut piece were found [Figure 1] & [Figure 2] and non-vegetative foreign body ear-ring was found in 1 case. Peanut was the FB in maximum cases (39%), custard apple seed was another common foreign body (24%) observed particularly in the winter season when custard apples are available in market. Due to its big size tama­rind seed was usually aspirated by older children above the age of 4 years. Negative bronchoscopy was observed in 12 (16%) patients in which 10% patients were suffer­ing from acute respiratory distress and 5% patients had chronic respiratory pathology [Table 2].

In 17 % patients foreign body was located in sub­glottic region, in 59 % patients FB was in right main bronchus and in 24 % patients it was in left main bron­chus [Table 3]. In 33 % patients bronchoscopy was done within 72 hours of appearance of symptoms while in 51 % patients bronchoscopy was done, after 72 hours to one week of appearance of symptoms. In 16% pa­tients bronchoscopy was done after one week[Table 4]. Twenty percent patients required tracheostomy and 3% patients required bronchodilators, nebulization and ven­tilatory support in immediate post operative period.

   Discussion Top

Aspiration of foreign bodyinto tracheobronchial tree occurs in all age groups, but infants and small children suffer most commonly [1],[2],[3] . Presentation of FB aspira­tion is a triad of coughing, choking and wheeze [2] . In pres­ence of persistent wheeze, predominantly unilateral with unexplained persistent fever in spite of treatment, FB aspiration should be suspected. Positive history of aspi­ration may not be present in all patients. [3] In our study also 78 % patients were between the age of 9 months to 4 years. The anatomic relation of the larynx, shouting, crying, playing while eating and lack of parental supervi­sion contribute to hazard of aspiration [2] . Also the habit ofpatting objects into mouth and to chewon whenteething leads to aspiration [4] . Right main bronchus was the com­monest site of foreign body [1],[2],[3] .

Not only vegetative FBs but also non-vegetative FBs are aspirated by children. Vegetative FBs are known to produce chemical bronchitis, mucosal oedema result­ing in acute obstructive emphysema or atelectasis which call for immediate attention [5],[6]. These FBs get swell by hygroscopic action and may disintegrate in fragments which occlude segmental bronchi [5] . In metallic FBs mucosal irritation occurs but bronchial occlusion takes longer duration [4] . Inert FBs with smooth surface cause little irritation of mucosa [4] . Peanut and dal were the for­eign bodies observed in other studies [1],[2],[3] . Custard apple seed is another foreign body in our study might be due to availability of custard apple, (Seetaphal) in Marathwada region on large scale particularly in winter season. X­ray chest may be normal in many cases. Most common x-ray finding is unilateral emphysema or hyperinflation particularly if FB is located in bronchus. Air trapping occurs and mediastinal shift to unobstructed side may be present [6] . Collapse of lung on one side is seen in FBs of longer duration [Figure 3] & [Figure 4]. Computer tomography of thorax & isotope scan demonstrate changes in venti­lation & perfusion may help in diagnosis [6] .

For successful bronchoscopy a close association and team work of anaesthesiologist, endoscopist and assistants is essential to ensure safety of the procedure. Although the procedure should be done as early as pos­sible but not without adequate preparation of patient [1] . O 2 supplementation, use of bronchodilators, nebuliza­tion, antibiotics and antipyretics should be used as per symptoms of patient. Rigid bronchoscopy may lead to bronchospasm or cardiac dysrhythmias and interference with ventilation [7] . The anaesthetic technique which pro­vides adequate analgesia and, muscle relaxation is pre­ferred. Rapid recovery is desirable to enable the patient to cough out secretions or accumulated blood. An inha­lational induction is preferred most of the times because IPPV may push FB distally into smaller airways or may cause ball valve effect resulting in distal airway trap­ping. Use of inhalational agents like halothane as a sole agent permits instrumentation but it is difficult to main­tain depth of anaesthesia for prolonged period [7], Desaturation may need to convert it in assisted ventila­tion. Use of IV inducing agent propofol followed by suxamethonium is most popular technique [7] . Thiopentone sodium or ketamine can be used for induction of anaes­thesia [3] . Suxamethonium was used as muscle relaxant, oxygen & halothane were used to ventilate patient. We used ventilating bronchoscope, patients were ventilated through side port of bronchoscope with oxygen & hal­othane. Due to shorter duration of procedure non-depo­larizing muscle relaxants were not required.

There are three techniques for ventilation of pa­tient during bronchoscopy. Apnoeic oxygenation with small catheter alongside of bronchoscope, conventional ventilation through side arm of ventilating bronchoscope, and use of venturi injector or high frequency jet ventila­tor [8] . We used ventilating bronchoscope for ventilation of all patients during bronchoscopy.

Apnoeic oxygenation - In this technique small catheter is introduced into larynx and connected to ana­esthesia machine, 6 to 10 L.min -1 O 2 flow has to be main­tained. Major disadvantage of this technique is increase in PaCO 2 level. In first minute PaCO 2 increases by 6mmHg and after that 3 to 4 mm Hg/min. This limits the duration of bronchoscopy. This technique is not recom­mended for more than 10 minutes 7 . To avoid CO 2 re­tention it is advisable to hyperventilate the patient to maintain PaCO 2 at 30 mm of Hg. No control over ven­tilation, loss of protective reflexes and theatre pollution are the disadvantages of this technique.

Ventilating bronchoscope :- Patient is ventilated through side port of bronchoscope with oxygen. Chest movements can be observed, high FiO 2 is required to ventilate patient. If desaturation occurs bronchoscope can be withdrawn into the trachea and patient is venti­lated with 100 % oxygen. Repeated instrumentation may lead to laryngeal oedema and needs deeper plane of anaesthesia.

Use of venturi :- Low frequency manual jet ven­tilation is used. In this system O 2 from high pressure source at 50 psi is delivered via pressure regulator and an in line toggle switch with 1 to 1 ½ inch 18 to 16 gauge needle located in the side port of ventilating broncho­scope. Visible chest movements indicate adequate ven­tilation.Advantage of this technique is that we can main­tain adequate ventilation for unlimited time in apnoeic and relaxed patient without rise in PaCO2.Ventilation is not interrupted during instrumentation. Disadvantages of venturi are chances of aspiration of blood and debris in tracheobronchial tree, 100 % oxygenation is not pos­sible due to entrainment of room air, ventilation is inad­equate in non-compliant lung and chances of barotrauma.

High frequency jet ventilation can be used for venti­lation during bronchoscopy. Respiratory rate ranging be­tween 150 to 300/min provides adequate ventilation. Due to small tidal volume no chest movement is observed. As no intratracheal pressure generated during HFJV possibili­ties of barotrauma is not there.Age, size of the needle and pressure generated in the trachea are shown in [Table 5].

To summarise, proper preoperative preparation and closed association of anaesthesiologists, endoscopists and assistants will give good results. Use of controlled ventilation with muscle relaxants and inhalational anaes­thesia provides an even and adequate depth of anaes­thesia for rigid bronchoscopy.Even though use of ven­turi for ventilation of patient is the safest and comfort­able but ventilation with side port of ventilating broncho­scope can provide safe and adequate anaesthesia for rigid bronchoscopy which we observed in our study.[9]

   References Top

1.Srppnath J, Mahendrakar V. Management of tracheobronchial FBs: a retrospective analysis. Indian Journal of Otolaryngol­ogy & Head and Neck Surgery 2002;54:127-131.  Back to cited text no. 1      
2.Sehgal A, Singh V, Chandra J & Mathur NN. Foreign body aspiration. Indian Pediatrics 2002; 39:1006-1010.  Back to cited text no. 2      
3.Patel A. Anaesthesia for endoscopic surgery. Anaesthesia & Intensive care medicine 2005;6-7:15-20.  Back to cited text no. 3      
4.Evans JNG. Foreign bodies in larynx & trachea. Text book of Otolaryngology by Ian Mackay T.R.Bull -6 th Edition 1997; 6/ 25/1 To 6/25/11.  Back to cited text no. 4      
5.Agarwal, Parashar V, Parashar S, Sen U, Rai K. Management of FB in tracheobronchial tree. In paediatric age group-A brief review. Indian Journal ofAnaesthesia 2001;45:348-350.  Back to cited text no. 5      
6.Narwahi S, Bora M K, et al. FB in bronchus-An unusual pre­sentation. Indian Journal of Otolaryngology 2005;57:161-162.  Back to cited text no. 6      
7.Aitkenhead AR, Smith G. Text book of Anaesthesia, IIIrd Edi­tion-Ch-38- Anaesthesia for Thoracic Surgery 622-623.  Back to cited text no. 7      
8.Anaesthesia for thoracic surgery. Ch.24- Clinical Anesthesiol­ogy, IIIrd edittion- Cl/Edward Morgen J, Maged S.Mikahail, Michael J.Murray 2002;544-545.  Back to cited text no. 8      
9.Thomas Jgal. Bronchospasm Ch.16. Complications in Anaesthesiology, Nikolaus Gravenstein, Rober R.Kirby, IInd Edition 206-210.  Back to cited text no. 9      


  [Figure 1], [Figure 2], [Figure 3], [Figure 4]

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5]


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