causes , management and precaution during foreign body ingestion and inhalation

1. ANESTHESIA FOR FOREIGN BODY
INHALATION BRONCHOSCOPY
• By Dr. Vineet Chowdhary
• Moderator- Dr. Neelam Dogra

2. EPIDEMIOLOGY
• More than 17,000 ED visits for children
younger than 14 years (2000)
• 5th most common cause of unintentional-injury
mortality in the U.S.
• Leading cause of unintentional-injury
mortality in children less than 1 year

3. INCIDENCE
The maximum incidence of inhalation of foreign bodies occurs
in
AGE: 6 months to 3 years:
SEX:
Male >female

4. HISTORY
• During the 19th century, treatment of foreign body aspiration
by purges, bleeding, and emetics were largely ineffective.
• Mortality was estimated at 23%.
• This rate plummeted with the development of bronchoscopic
techniques for the removal of these foreign bodies.
• In 1897, Gustav Killian, a German otolaryngologist, performed
the first bronchoscopy using a rigid esophagoscope to
successfully remove a pig bone from a farmer’s right main
bronchus.

5. • Shortly thereafter, Chevalier Jackson developed the lighted
bronchoscope and several specialized instruments for the removal
of foreign bodies.
• While early clinicians used topical anesthesia, general anesthesia
became commonplace for the removal of aspirated objects with
increased experience with the rigid bronchoscope and advances in
anesthetic delivery.
• The flexible bronchoscope was introduced by Shigeto Ikeda in 1966,
and the removal of an airway foreign body using this instrument
was reported in the 1970s

6. WHO IS AT RISK?
 In children: because
 Natural urge to explore the objects by mouth
 Tendency to put everything possible into their mouth
 Lack of molar teeth to crush nuts
 Crying and playing while eating
 Lack of parental supervision
 Immature glottis reflex
 Incomplete coordination of mouth and tongue

7. WHO IS AT RISK? In elderly : because
 Impaired cough reflex and swallow reflex
 Mental retardation
 Alcohol
 General anesthesia
 Poor dentition
 Dental, pharyngeal and airway procedure
 Loss of consciousness
 Convulsions
 Stroke
 Parkinsonism
 Maxillofacial trauma
 Senile dementia

8. WHERE DOES IT GO?
The larynx
Trachea
Bronchus
Smaller airways
80-90 % occurs in bronchus ,mainly right main bronchus and lower
lobe
However Aspiration can occur in all lobes, including upper lobes
(though with less frequency)

9. REMEMBER!!
• Objects can fragment and lodge in multiple sites
(e.g., sunflower seeds)
• Children can aspirate several different objects
concurrently (or sequentially)
• Foreign bodies can erode through the esophagus
and cause respiratory symptoms

10. DANGEROUS
OBJECTS
• Round
• Balls, marbles
• More likely to cause complete
obstruction
• Break apart easily
• Compressibility
• Smooth, slippery surface

11. WHY RIGHT SIDE BRONCHUS IS MORE
COMMON?
• Larger Diameter
• Angle of divergence from the tracheal axis is smaller (More in
line with the trachea)
 Airflow through the right bronchus
is greater
 Situation of carina to left of the
midline of trachea.

12. WHAT GETS ASPIRATED?
According to source
Endogenous - vomitus or broken tooth
Exogenous - Pins, Peanut, seeds etc
According to nature of foreign body
Non-irritating type: plastic, metallic
Irritating(organic origin) : peanuts, beans, seeds etc.

13. FOREIGN BODIES
Organic foreign bodies Metallic others
Peanuts( MC in children) Coins Rubber
Beans Nails Wood
Watermelon seeds Screws Pebbles
Animal shells Hair pins Toys
Bones Safety pins
Popcorns
Grapes

14. PATHOPHYSIOLOGY
Organic foreign bodies (peanuts , Beans and seeds) absorb water
with time
Swelling rapidly change partial to complete bronchial obstruction
Long standing foreign body tends to move downward and
outward.
Mucosa becomes edematous partly closing over the foreign body
and even completely obliterating the lumen.
Foreign body becomes friable and fragments may dislodge into
other bronchus or smaller airways.
Foreign body produces inflammatory response and complications
like granulations and strictures
Removal of foreign body should be done as soon as possible.
However it does not justify hasty, ill planned and poorly equipped
bronchoscopy

15. HISTORY
In Children:
A history of a witnessed choking event is highly suggestive of
an acute aspiration.
In Adults:
H/O choking after eating or holding a foreign body in mouth

16. CLINICAL PRESENTATION
 Depends upon the
 Location of foreign body
 Size of foreign body
 Nature of foreign body
 Time since inhalation
• HOWEVER, only 50% of diagnoses occur in the first 24
hours
• 80% within first week
• Will sometimes take years

17. CLINICAL PRESENTATION
In general, aspiration of foreign bodies produces the
following 3 phases:
Initial phase - Choking , gasping, coughing, or airway
obstruction at the time of aspiration
Asymptomatic phase - Subsequent lodging of the object with
relaxation of reflexes that often results in a reduction or
cessation of symptoms, lasting hours to weeks
Complication phase - Foreign body producing erosion or
obstruction leading to pneumonia, atelectasis , or abscess
Chronic long standing foreign body often present with
misdiagnosis of URI, asthma ,or pneumonia

18. OFTEN NEED HIGH
LEVEL OF SUSPICION TO
DIAGNOSE
TRACHEOBRONCHIAL FOREIGN BODY

19. • Classic triad in only 57%
• Wheeze, cough and decreased breath sounds
• 25-40% with normal exam

20. LARYNGEAL FOREIGN BODY
 Present as sudden total or near total obstruction.
 Initially cough then Hoarseness , Aphonia , Choking and
Dyspnoea .
And if total obstruction may cause asphyxia , cyanosis , and
death.

21. TRACHEAL FOREIGN BODY
Tracheal foreign bodies present similarly to laryngeal foreign
bodies but without hoarseness or aphonia.
Hemoptysis by sharp foreign body
Audible slap--heard at open mouth of child.
Palpatory thud.-on palpation of trachea
Asthmatoid wheeze--wheeze similar to asthma

22. BRONCHIAL FOREIGN BODY
In case of bronchial foreign body the classical clinical triad
consist of :
 Paroxysmal Cough
 Unilateral wheezing
 Unilateral diminished breath sounds

23. VALVE MECHANISM
Three Mechanisms in bronchial obstruction:
 Bypass mechanism(Two way valve)
 Check valve mechanism (One way valve )
 Stop valve mechanism(No way valve)

24. BYPASS VALVE (2 WAY)MECHANISM
• Partial obstruction
• Ingress and egress both occurs
• No collapse,no emphysema
TRACHEOBRONCHIAL

25. CHECK VALVE (1 WAY) MECHANISM
• On inspiration enlargement of diameter of bronchus opens a
small passage for ingress of air.
• On expiration Foreign body is embedded in swollen mucosa
preventing exit of air .
• Air is trapped inside and lung
becomes emphysematous.
(obstructive emphysema)

26. STOP VALVE (NO WAY) MECHANISM
• Both Ingress and egress stopped.
• Absorbtion of air results in collapse of lung.
(Obstructive atelectasis.)

27. PHYSICAL FINDINGS (SIGNS)
Decreased breath sounds distal to foreign body
 Unilateral wheezing
Tachypnoea
Nasal flaring .
Inability to speak.
Limited chest expansion.
Intercostals ,Subcostals,and Suprasternal retractions
Impaired percussion note.

28. INVESTIGATIONS
1. Chest X ray ( imaging modality of choice )
2. Fluoroscopy & video fluoroscopy
3. Chest CT
4. Virtual Bronchoscopy

29. CHEST XRAY
Chest radiograph to assess for other potential causes of symptoms,
to identify a radio opaque foreign body, or to detect the position of
a foreign body on the basis of localized emphysema and air-trapping,
atelectasis, infiltrate, or mediastinal shift
Radiopaque materials like metallic Foreign bodies are easily
identified on chest X rays
May show less dense objects like teeth, bone, shell, button.
Organic materials are not radiopaque but shows radiographic
abnormalities like
 Hyperinflation due to Air trapping and shifting of the
mediastinum towards the opposite side.
 Atelectasis
A final CXR for checking the presence and position of Foreign body
should be made immediately before bronchoscopy because
Foreign bodies often shifts.

30. SCREW SEEN IN CXR

31. HYPERINFLATION SEEN ON CXR

32. ATELACTASIS SEEN ON CXR

33. Inspiratory film on left, Expiratory film on right ;
Foreign body in left mainstem bronchus

34. Inspiratory film on left ; expiratory film on right ;
foreign body in right bronchus

35. NAIL IN RIGHT MAIN
BRONCHUS

36. • Many chest x-ray may have completely negative
findings ,especially within the first 24 hours following
aspiration.
• A positive history plus clinical symptoms of aspiration may
be sufficient to justify bronchoscopy.

37. CONSIDER LATERAL
DECUBITUS IF CHILD CANNOT
COOPERATE
• Lateral decubitus views [lower lung doesn’t collapse if FB present.]

38. COMPLICATIONS OF FOREIGN BODY
Obstructive emphysema
Atelectasis
Bronchiectasis
Pneumonia
Hemoptysis
Lung abscess
Subcutaneous Emphysema
Pneumothorax / pneumomediastinum
Granulation tissue and hemorrhage
Cartilage destruction

39. Emergency Treatment for Aspirated
Foreign Bodies
Note : none of
these should be
applied if patient
is able to speak
or cough
1.Heimlich maneuver
2.Back blows
3.Chest thrusts
4.Finger sweep / grasp
–(finger sweep should be done only if object is
visible and will not be pushed deeper)

40. HEIMLICH’S MANAEUVER
In erect (sitting/standing) position ,encircle from behind and fist
in epigastrium between the xiphoid and umblicus and apply
abdomen thrust

41. BACK BLOWS
TRACHEOBRONCHIAL FOREIGN BODY

42. CHEST THRUST (STERNAL THRUST)
• For pregnant and massively
obese persons.
• Chest is encircled from
behind and fist is placed on
the midsternum.
TRACHEOBRONCHIAL

43. INFANT BACK BLOWS
• Rescuer sandwiches infant between
one hand supporting neck and the
other hand delivering back blows .

44. INFANT CHEST THRUST
• Rescuer holds infant on thigh in
head down position and delivers
upto 4 chest thrusts just like
chest compressions.

45. MANAGEMENT
If patient is in distress ->EMERGENCY BRONCHOSCOPY
If patient is stable ->PLANNED BRONCHOSCOPY
LARYNGEAL FOREIGN BODY:-> By direct laryngoscopy/Bronchoscopy
TRACHEAL OR BRONCHIAL FOREIGN BODY:-> Rigid bronchoscopy or
fibreoptic bronchoscope
Chest physical therapy
Bronchodialators
TRACHEOSTOMY indicated in
 Laryngeal foreign body if Too large and sharp

46. MEASURES BEFORE
BRONCHOSCOPY
A Team Effort
Good communication and cooperation between
surgeon and anaesthetist
Senior ENT surgeon & expert Anaesthetist.
Light and suction checked before procedure.
Good venturi system
Proper size bronchoscope
Tracheostomy trolley should be ready

47. CHALLENGES
• Fighting irritable child.
• Full stomach.
• Sharing of airway.
• Difficult to maintain oxygenation and ventilation, as
pulmonary gas exchange is already reduced.
• Difficulty pertaining to pediatric airway

48. GOALS OF ANAESTHESIA
1. Adequate oxygenation.
2. A good i.v. access
3. Controlled cardiorespiratory reflexes during
bronchoscopy.
4. Rapid return of airway reflexes.
5. Prevention of pulmonary aspiration.
6. Meticulous monitoring : spo2,ECG,NIBP,EtCO2

49. RIGID BRONCHOSCOPE
Standard of care in most centers for evaluation
Allows visualization, ventilation, removal with multiple forceps and
ready management of mucosal hemorrhage
Successful in about 95% of cases
Complications are rare (about 1%)
 Laryngeal and subglottic edema, atelectasis
 Dislodgement of foreign body into more dangerous position
 Hypoxic insults
Port for
venturi
Port for circuit

51. PREOPERATIVE CONSIDERATIONS
The preoperative assessment should determine
• where the aspirated foreign body has lodged
• what was aspirated,
•when the aspiration occurred.
• time of the last meal .
PREMEDICATION
•Sedatives are avoided as it may precipitate total airway obstruction.
•Dexamethasone given prophylactically minimize postoperative stridor
and laryngeal edema.
•Anticholinergics (atropine, pyrolate) given to reduce secretions and
reflex bradycardia associated with airway instrumentation.

52. • If patient is not fasting then inj. ondansetron and inj.
Metaclopramide can be given.
• In urgent cases, induction by rapid sequence and cricoid
pressure. The stomach can be suctioned through a
nasogastric tube before the bronchoscope is inserted to
minimize the risk of gastric aspiration.
• In delayed presentations in which bronchoscopy is not
urgent, a preanesthetic fasting is appropriate.

53. Mask ventilation is done to maintain oxygen saturation before
inserting bronchoscope.
 Once the scope introduced beyond the glottis, ventilation by
Jet ventilator with oxygen.
During active ventilation the distal end of the bronchoscope is
pulled back to the mid of the trachea and the proximal open
end is occluded with the thumb or a glass obturator.
Nitrous oxide is avoided, as it increases gas volume, air
trapping and possible rupture of affected lung.
Intermittent succinyl choline is administered till the procedure
is completed.
Later mask ventilation is done till the patient become fully
awake.

54. • After the extraction of the foreign body and the removal
of the rigid bronchoscope, the choice of ventilation during
emergence is influenced by pulmonary gas exchange and
the degree of airway edema.
• For uncomplicated cases,spontaneous ventilation assisted
by mask ventilation as needed may be adequate.
• Intubation during emergence may be indicated for a
marginal airway, pulmonary compromise,or residual
neuromuscular blockade.

55. ANAESTHESIA MANAGEMENT
1. CONTROLLED VENTILATION
2. SPONTANEOUS VENTILATION

56. ANAESTHETIC CONSIDERATIONS FOR
RIGID
BRONCHOSCOPY
• The conversion from spontaneous negative pressure breathing
to positive pressure ventilation theoretically risks dislodging an
unstable proximal body, causing complete obstruction.
• A survey of 838 paediatric anaesthesiologists found that the
majority preferred an inhaled induction when foreign bodies
were present in the tracheobronchial tree.
• A cautious IV induction that maintains spontaneous ventilation
is also possible

57. Controlled ventilation :
I.V. induction + muscle relaxant
and ventilation by
• 1) Venturi attachment
• 2) Inflation via side arm of bronchoscope
• 3) Insufflation via a catheter in the trachea
• 4) Insertion of a tube into the end of the bronchoscope
intermittently.
TRACHEOBRONCHIAL FOREIGN BODY

58. ANESTHETIC MAINTENANCE
• Oxygen, halo/iso.[ give more time for airway
manipulation] Or repeat ketamine/ propofol
• Suxa 0.25-0.5mg/kg with atropine 0.02mg/kg.
• Ventilation has to be intrupted while suctioning and
removal of foreign body.
• If foreign body is big/swollen tracheostomy may be
needed

59. • Big FB can be taken out in pieces.
• Apnea/ oxygen insufflation, is preferred at some crucial
time, ideally should not last beyond 1 min. After 5 min
hypercarbia may lead to dysrhythmias.
• If ventilation is inadequate with rigid bronchoscope, high
frequency jet ventilation via bronchoscope or ECMO can
be used.
• For FB embedded in mucosa, wait for 48-72hrs. Let odema
subside. Repeat bronchoscopy , if unsuccessful-thoracotomy.

60. • Spontaneous Ventilation
a) IV induction : with thiopentone, propofol, ketamine,
remifentanil.
Maintanance with halothane or propofol infusion
b) Inhalational induction with sevoflurane/halothane
Maintainance with halothane/isoflurane.
TRACHEOBRONCHIAL FOREIGN BODY

61. • An advantage of an IV anaesthetic is that it provides a
constant level of anesthesia irrespective of ventilation.
• Propofol is especially useful because of its rapid recovery
and also good reflex suppression.
• By contrast, hypoventilation and leaks around the rigid
bronchoscope may produce an inadequate depth of
inhaled anesthesia.
• Pollution of the operating room, due to the combination
of leaks around the rigid bronchoscope and high gas flows
needed for ventilation, are additional drawbacks of
inhalation anesthetics

62. • Laryngeal foreign bodiesremoved by direct
laryngoscopy.
• Tracheal and bronchial foreign bodies are best removed
using a rigid bronchoscope.
• Rigid bronchoscopy supersedes any form of conservative
approach like using bronchodilators, thoracic percussion
and postural drainage.
• However ,Preoperative physiotherapy, and antibiotics is
useful in a peripherally situated, organic, foreign body of
long standing, in which there is atelectasis of the lung with
pneumonia or abscess.

63. • In the rare event of being unable to remove a foreign body
endoscopically, it must be removed by thoracotomy or
bronchotomy.
• It is very important after removal of the foreign body, while
the child is still anaesthetized, that a second look is taken to
remove any remaining small fragments particularly in the case
of peanuts.
• Pus and mucus can be aspirated from the distal bronchus -
which helps in speeding the resolution of atelectasis or
pneumonia.

64. Intermittent succinyl choline
• Keeps the patient totally quiet during the procedure;
• Bronchial caliber does not vary
• Permits easy introduction of endoscope
TRACHEOBRONCHIAL FOREIGN BODY

65. DISADVANTAGE OF SPONTANEOUS
VENTILATION
• Some times foreign bodies may be too large to be withdrawn
through the lumen and it is common to loose the foreign body
during the removal, which commonly occur at subglottic region, if
the muscle relaxation is not adequate. This is known to occur often
with spontaneous ventilation technique and maintenance by
halothane.
• With Halothane as primary anaesthetic agent is that it requires
higher concentrations of halothane to obliterate airway reflexes
which may cause decreased myocardial contractility.
• Increased CO2
• Hard to GUARANTEE no movement: therefore additional airway
trauma may occur.
• Prolonged emergence

66. ADVANTAGES OF SPONTANEOUS
VENTILATION
• More effective alveolar ventilation- with difficulty in positive
pressure ventilation ,anesthesiologists typically exert more
pressure. For the patient with airway compromise, this results in
more turbulence in the upper airways and less effective air
exchange downstream.
• Better ventilation/perfusion matching
• Better ventilation during bronchoscopy with window closed
• Better ventilation during bronchoscopy with window open
• Foreign body mimic: not every patient believed to have a foreign
body, even if stridor is present, actually has one. If there is any
doubt, then spontaneous ventilation should be preserved in order
to make a diagnosis

67. • Neuromuscular blockade may worsen the situation by
converting a patient with a compromised airway to a
patient with no airway
• Multiple placements of forceps in difficult to grasp FB
cause gases to be exhausted to the room rather than
delivered to the patient during controlled ventilation,
unless the window is constantly replaced.

68. CONTROLLED VENTILATION
• Positive pressure ventilation down the bronchoscope,
with intermittent apnea while manipulating the
object,may be more suitable for distal foreign body
removal.
• The use of optical forceps allows for positive pressure
ventilation to be maintained while the foreign body is
being manipulated so that periods of apnea can be
minimized
TRACHEOBRONCHIAL FOREIGN BODY

69. ADVANTAGES OF CONTROLLED
VENTILATION
• A RSI allows more rapid control of the airway, lessening the
chance of aspiration
• Positive pressure ventilation avoids hypoxaemia and also
improves oxygenation
• Patient immobility. It is essential to avoid coughing and bucking
secondary to the intense stimulation from a rigid bronchoscope
deep in the bronchial tree
• The possibility of more rapid emergence since NMB can be
monitored throughout the procedure, allowing administration
of lower doses of IV anaesthetic
TRACHEOBRONCHIAL FOREIGN BODY

70. DISADVANTAGES OF CONTROLLED
VENTILATION
• Leads to overdistension of the obstructed lung which can
embarass the cardiovascular system and may cause
rupture of the alveoli resulting in tension pneumothorax.
• Positive airway pressure may cause distal migration and
dislodge the foreign body peripherally and may cause
failure to remove the foreign body.

71. IMPORTANT CONSIDERATIONS IN
CONTROLLING VENTILATION
• Adequate time is needed for exhalation
through the relatively high resistance
bronchoscope in order to prevent air trapping
and the associated barotrauma.
• Ventilation must be done in concert with the
bronchoscopist. Ventilation when the
bronchoscope is open will "ventilate" the room

72. • Excessive suctioning during the procedure can markedly
diminish oxygen concentration and also might induce
atelectasis.
• Therefore suction must be applied for short periods of
time ,which should be followed by lung inflation.
TRACHEOBRONCHIAL FOREIGN BODY

73. COMPLICATIONS
• Trauma to lips, teeth, base of tongue, epiglottis and larynx
• Severe cardiovascular embarrassment or even cardiac arrest may follow
tracheobronchial manipulation and suction;
This is due to a combination of hypoxia and reflex vagal stimulation. Hypoxia
aggravates vagal responses and increases the incidence of cardiac
arrhythmias.
• Laranygo/bronchospasm- ms. Relaxation,adequate ventilation.
• Pneumothorax, Pneumomediastinum , Pneumonia
• Atelectsasis
• Stridor secondary to subglottic oedema: Nebulized epinephrine 1:1000
should be administered in a dose of 0.5 ml /kg maximum 5 ml per
administration. I.V. dexamethasone produces more sustained relief of
stridor, but may take 1–2 h to act. Re-intubation may be required.

74. What About Flexible Bronchoscopy?
Excellent diagnostic tool
Minimal trauma, no general anesthesia
Reports of successful removal as well
American Thoracic Society still recommends rigid
bronchoscopy for removal
Flexible bronchoscopy can be performed with local anesthetic
topically and sedation in both children and adults
 In smaller children who are unable to cooperate, general
anesthesia can be given using propofol and sevoflurane with
topical lignocaine

75. TO CONCLUDE
Normal CXR does not rule out Foreign Body
Bronchoscopy should be performed if foreign body aspiration is
suspected because it is better to do a negative bronchoscopy rather
missing a foreign body.
Not leaving small objects within reach of children.
No consensus from the literature as to which technique is optimal
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

76. REFRENCES
Miller’s anesthesia 7th edition.
Stoelting’s anesthesia and co-existing disease 5th edition.
Paediatric bronchoscopy:
Steve Roberts MBChB FRCA
Roger E Thornington MBBS FFA(SA) FRCA
Bronchoscopy by Chevalier Jackson.
 PREFERRED ANAESTHETIC TECHNIQUE FOR TRACHEOBRONCHIAL
FOREIGN BODY - A OTOLARYNGOLOGIST’S PERSPECTIVE (INDIAN
JOURNAL OF ANAESTHESIA 2004)
REVIEW ARTICLE
CME
The Anesthetic Considerations of Tracheobronchial Foreign Bodies in Children: A
Literature Review of 12,979 Cases
Christina W. Fidkowski, MD,* Hui Zheng, PhD,† and Paul G. Firth, MBChB*‡
Article :Foreign bodies in the larynx and trachea BY J. N. G. Evans

77. Thank you