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| CLINICAL INVESTIGATION |
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| Year : 2007 | Volume
: 51
| Issue : 6 | Page : 501-504 |
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A retrospective study of anaesthetic management of foreign bodies in airway- a two & half years experience
Jyoti V Kulkarni1, HP Bhagat2
1 M.D.,Lecturer,Anaesthesia, Govt. Dental College, Aurangabad, India
2 M.D.,D.A.,Professor ofAnaesthesia, Govt. Dental College, Aurangabad, India
| Date of Acceptance | 25-Oct-2007 |
| Date of Web Publication | 20-Mar-2010 |
Correspondence Address:
Jyoti V Kulkarni
7, Bharat Nagar, Shahnoorwadi, Aurangabad-431005.(M.S.)
India
 Source of Support: None, Conflict of Interest: None  | Check |
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 Mar 8];51:501-4. Available from: https://www.ijaweb.org/text.asp?2007/51/6/501/61187 |
 Introduction | |  |
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 | | |
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 | | |
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 | | |
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 | | |
| 1. | Srppnath J, Mahendrakar V. Management of tracheobronchial FBs: a retrospective analysis. Indian Journal of Otolaryngology & Head and Neck Surgery 2002;54:127-131.  |
| 2. | Sehgal A, Singh V, Chandra J & Mathur NN. Foreign body aspiration. Indian Pediatrics 2002; 39:1006-1010. |
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| 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. |
| 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. |
| 6. | Narwahi S, Bora M K, et al. FB in bronchus-An unusual presentation. Indian Journal of Otolaryngology 2005;57:161-162. |
| 7. | Aitkenhead AR, Smith G. Text book of Anaesthesia, IIIrd Edition-Ch-38- Anaesthesia for Thoracic Surgery 622-623. |
| 8. | Anaesthesia for thoracic surgery. Ch.24- Clinical Anesthesiology, IIIrd edittion- Cl/Edward Morgen J, Maged S.Mikahail, Michael J.Murray 2002;544-545. |
| 9. | Thomas Jgal. Bronchospasm Ch.16. Complications in Anaesthesiology, Nikolaus Gravenstein, Rober R.Kirby, IInd Edition 206-210. |
[Figure 1], [Figure 2], [Figure 3], [Figure 4]
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]
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