Airway Foreign Body (FB)

 

 

Considerations

 

  • Emergency, full stomach/aspiration risk 

  • Pediatric patient considerations

  • Potential for airway obstruction & respiratory complications:

    • Ball-valve effect & barotrauma

    • Bronchospasm, laryngospasm

    • Edema

    • Post obstructive pneumonia/sepsis

  • Rigid or flexible bronchoscopy, esophagoscopy:

    • Shared airway

    • Immobility required

    • Ventilatory strategies, spontaneously-breathing method preferred 

 

 

Goals

 

  • Maintain spontaneous ventilation (avoid hyperinflation/barotrauma, FB dislodgement/airway obstruction)

  • Provide adequate analgesia for rigid bronchoscopy (avoid coughing/airway trauma)

  • Effective teamwork with ENT throughout

  • Prevent airway complications

 

 

Conflicts

 

  • Uncooperative patient vs. spontaneous ventilation

  • Deep anesthesia vs. spontaneous ventilation

  • Shared airway vs. ventilation/oxygenation/deep anesthesia

 

 

Optimization

 

  • Establish IV 

  • ENT STAT, call for OR & second anesthesiologist or anesthesia assistant 

  • Hold child in position of comfort if upper airway FB or with affected lung down if lower airway FB

  • Bronchodilators 

  • Humidified O2, heliox

  • Aspiration prophylaxis (can delay case for 8 hrs if child stable)

  • Dexamethasone to reduce swelling 

  • Glycopyrrolate to dry secretions 

  • Spontaneously breathing induction methods: 

    • Total IV anesthesia:  

      • Titrate to RR 12-16 or 50% of baseline before stimulation of the child

    • Inhalational with sevoflurane

  • Once anesthesized, perform staged stimulation/laryngoscopy & topicalization with lidocaine

    • Staged approach example steps: 

      1. Jaw thrust 

      2. Insert oral airway 

      3. Do direct laryngoscpy & spray with lidocaine

 

 

Complications 

 

  • Bronchospasm

  • Laryngospasm on awakening

  • Inadequate ventilation

  • Pneumothorax, BPF (ball valve)

  • Unable to ventilate, hypoxemia

  • Complete airway obstruction:

    • Push FB into a mainstem bronchus

  • Hypertension, tachycardia, tachyarrhythmias

  • Pulmonary hemorrage

  • Post obstructive pneumonia