Management of Patients

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Management of Patients With Airway Foreign
Bodies The Anesthesiologists Perspective Dr.
Robert Hoskin MD Ph.D Department of
Anesthesia Royal Columbian Hospital New
Westminster, BC Canada January 2010
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• Overview
• Spectrum of presenting symptoms from chronic to
  emergent
• Preparation
• Communication
• Constant Re-evaluation
• Individualize approach to each patient
• Anesthetic Considerations
• Shared Airway
• Possible Full Stomach
• Spontaneous vs controlled ventilation
• Airway Edema
• Unstable

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• Presentation of Aspirated Foreign Bodies
• Spectrum of symptoms depending on size and
  location of FB
• Peripheral Airway FBs may take weeks to months
  to cause symptoms
• Chronic lobar pneumonia
• Unilateral wheeze
• Chronic Cough
• Hemoptysis

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• Presentation of Aspirated Foreign Bodies
• Most Foreign Body aspirations occur in children
  less than 3 years old
• Right lung gt Left lung
• 1/3 of parents were unaware of the aspiration
  incident, or recalled an event occurring gt1 week
  prior to presentation

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• Presentation of Aspirated Foreign Bodies
• Spectrum of symptoms depending on size and
  location of FB
• FBs in trachea or at the cords may cause
• Dyspnea
• Stridor
• Aphonia
• Coughing
• Cyanosis
• Total Obstruction

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• Presentation of Aspirated Foreign Bodies
• Supraglottic Foreign Body- Inspiratory Wheeze
• Infraglottic Foreign Body- Expiratory Wheeze

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• Presentation of Aspirated Foreign Bodies
• Spectrum of symptoms depending on size and
  location of FB
• Identity of FB may or may not be known
• Coins
• Small toys
• Beads
• Peas, beans, nuts, candies, raisins, grapes,
  seeds, etc.

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• Presentation of Aspirated Foreign Bodies
• Spectrum of symptoms depending on size and
  location of FB
• Foreign Bodies may impede airflow in 4 ways
• Check valve air may be inhaled but not
  exhaled
• Ball Valve air may be exhaled but not inhaled
• Bypass valve partial obstruction of
  inhalation and exhalation
• Stop Valve total blockage

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• Presentation of Aspirated Foreign Bodies
• Spectrum of symptoms depending on size and
  location of FB
• There may be more than one Foreign Body!

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• Presentation of Aspirated Foreign Bodies
• Spectrum of symptoms depending on size and
  location of FB
• FBs can move partial obstruction can become
  total obstruction suddenly and unexpectedly.

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• Pre-Operative Assessment
• Severity of Airway Obstruction
• Gas Exchange
• Level of Consciousness
• Fasting Status
• Nature and location of Foreign Body
• History
• Radiographic Exam
• Physical Exam
• Unilateral wheeze
• Air Entry
• Aphonia, stridor

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• X-Ray Findings in Airway Foreign Bodies
• Many Airway FBs are radiolucent
• Many CXRs are normal, especially in first 24
  hours
• Secondary Evidence on CXR
• Atelectasis, Air Trapping with mediastinal shift
• Pneumonia
• Inspiratory/Expiratory Films

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• Pre-Operative Preparation
• Fasting if patient stability permits
• Anticholinergic medication
• Sedation- relatively contraindicated
• IV access
• Preparation of OR
• Anesthesia equipment
• Endoscopy equipment and Endoscopist

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• Anesthetic Considerations
• Positive Pressure Ventilation may push FB further
  peripherally
• So usual approach is to maintain spontaneous
  ventilation

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• Anesthetic Considerations
• Inhalation induction with Sevoflurane in 100 O2
• Avoid N2O
• May induce sitting up if patient very agitated or
  in severe respiratory distress
• Induction may be slow if mainstem bronchus is
  obstructed

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• Anesthetic Considerations
• Once appropriate depth of anesthesia is reached,
  endoscopist may proceed
• Constant communication between endoscopist and
  anesthesiologist
• Anesthesia circuit may be attached to sidearm of
  rigid bronchoscope to allow insufflation of
  Sevo/O2

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• Anesthetic Considerations
• Ventilation via sidearm of Rigid Scope
• Caution to avoid hyperinflation if scope occludes
  airway
• Same channel in scope for ventilation and
  instrumentation Gas flow may be impeded by
  forceps, etc. in channel
• Contamination of room air may be a concern
  especially during PPV
• Patient may become hypoxic if scope is pushed
  distally in bronchial tree during attempts to
  grasp a FB

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• Intraoperative Concerns
• Unable to measure ETCO2- hypercarbia may develop
• Loss of airway
• Laryngospasm
• Bronchospasm
• Regurgitation
• Arrhythmias
• Fragmentation of FB
• Pneumothorax
• Loss of spontaneous ventilation
• Airway edema
• Airway trauma, bleeding, perforation . . .

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• Intraoperative Concerns
• During attempted removal, FB may become hung up
  on vocal cords or in trachea
• Sudden new total airway obstruction
• Solution endoscopist may need to use scope to
  push FB down a mainstem bronchus to allow
  ventilation of one lung
• Regroup, re-oxygenate, re-attempt removal

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• Postoperative Management
• Treatment of bronchospasm with bronchodilators
• Treatment of airway edema with racemic
  epinephrine
• CXR and physical exam looking for
• Resolution of preoperative findings (unilateral
  wheeze, etc.)
• Development of new complications e.g.
  pneumothorax
• Edema and infection may take days to normalize
• Some Foreign Bodies require repeated procedures
  before normal air entry is restored

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• Words of Wisdom
• Normal CXR does not rule out Foreign Body
• All that wheezes is not asthma
• Practice with a duplicate Foreign Body
• Be ready and equipped
• Dont turn a non-obstructing FB into an
  obstructing one
• Dont miss the second FB- go back for another
  look
• Not all FBs can be removed endoscopically

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• Overview
• Spectrum of presenting symptoms from chronic to
  emergent
• Preparation
• Communication
• Constant Re-evaluation
• Individualize approach to each patient
• Anesthetic Considerations
• Shared Airway
• Possible Full Stomach
• Spontaneous vs controlled ventilation
• Airway Edema
• Unstable