Airway Foreign Bodies 2010 Management of Patients With Airway Foreign Bodies The Anesthesiologist’s Perspective Dr. Robert Hoskin MD Ph.D Department of.

Airway Foreign Bodies 2010

Management of PatientsWith Airway Foreign Bodies

The Anesthesiologist’s Perspective

Dr. Robert Hoskin MD Ph.D

Department of AnesthesiaRoyal Columbian Hospital

New Westminster, BC Canada

January 2010











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


Presentation of Aspirated Foreign Bodies

•Spectrum of symptoms depending on size and location of FB

•Peripheral Airway FB’s may take weeks to months to cause symptoms:

–Chronic lobar pneumonia

–Unilateral wheeze

–Chronic Cough

–Hemoptysis



• Most Foreign Body aspirations occur in children less than 3 years old

• Right lung > Left lung

• 1/3 of parents were unaware of the aspiration incident, or recalled an event occurring >1 week prior to presentation



• Spectrum of symptoms depending on size and location of FB

• FB’s in trachea or at the cords may cause

– Dyspnea

– Stridor

– Aphonia

– Coughing

– Cyanosis

– Total Obstruction



• Supraglottic Foreign Body- Inspiratory Wheeze• Infraglottic Foreign Body- Expiratory Wheeze




• Identity of FB may or may not be known:

– Coins – Small toys– Beads– Peas, beans, nuts, candies, raisins, grapes, seeds, etc.




• 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




There may be more than one Foreign Body!There may be more than one Foreign Body!




• FB’s can move: partial obstruction can become total obstruction suddenly and unexpectedly.


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


X-Ray Findings in Airway Foreign Bodies

• Many Airway FB’s are radiolucent• Many CXR’s are normal, especially in first 24 hours• Secondary Evidence on CXR:

– Atelectasis, Air Trapping with mediastinal shift

– Pneumonia

– Inspiratory/Expiratory Films






Pre-Operative Preparation

• Fasting if patient stability permits• Anticholinergic medication• Sedation- relatively contraindicated• IV access• Preparation of OR

– Anesthesia equipment

– Endoscopy equipment and Endoscopist


Anesthetic Considerations

• Positive Pressure Ventilation may push FB further peripherally

• So: usual approach is to maintain spontaneous ventilation



• 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



•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






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


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 . . .


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


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


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• Don’t turn a non-obstructing FB into an obstructing one• Don’t miss the second FB- go back for another look• Not all FB’s can be removed endoscopically


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

Airway Foreign Bodies 2010 Management of Patients With Airway Foreign Bodies The Anesthesiologist’s Perspective Dr. Robert Hoskin MD Ph.D Department of.

Documents

airway foreign bodies

fb slide

presentation slide

location of fb foreign

endoscopist slide

stridor slide

obstructed slide

location of foreign