A case of sub-glottic foreign body in a child

A case of subglottic
foreign body in a child
PRESENTED BY: DR SWAYAM SAHU
MODERATED BY: LT COL MUNISH KUMAR

HISTORY
- 9 years old male child
- 3rd born of non-consanguinous marriage
- Resident of Bihar
- Informant: Father, reliability good

HISTORY
- Presenting complaints:
- Breathlessness since 1 month
- Progressive abdominal distension
- Worsening of breathlessness since last 3 days

HISTORY
- Apparently asymptomatic until eight months of age
- Recurrent fever
- Weakness
- Failure to thrive
- Civil Hosp:
- Anemia
- Workup: diagnosed to have beta thalassemia major

HISTORY
- On frequent blood transfusion
- From 8 m to 6 years of age: once monthly
- From 6 years to 9 years of age: once in a fortnight

HISTORY
- No history of:
- Jaundice
- Bleeding
- s/o bone pain
- Painful episodes in chest/ finger
- Leg ulcers
- Skin hyperpigmentation
- Seizures/ focal deficits
- Deafness/ visual deficits

HISTORY
- No history of:
- Choking
- Sudden onset cough/ breathlessness

HISTORY
- Treatment history
- Initially managed at AH(R&R) in Sep 2011.
- Was advised HLA typing, Hb Electrophoresis, regular blood transfusion, but lost
to follow up.

HISTORY
- Antenatal History
- No history of
- Gestational Diabetes Mellitus
- Hypertension
- Thyroid disorder
- Fever with rashes
- Exposure to radiation

HISTORY
- Birth History
- Booked case
- Full term normal vaginal delivery
- Cried immediately after birth
- Birth weight: 4 kg
- Was started on breast feeding soon after birth

HISTORY
- Post natal period uneventful
- No history of NICU admission
- Immunised as per protocol

HISTORY
- Developmental History:
- Gross motor: Neck holding – 04m
Sit with support – 06m
Stand with support – 10m
Run – 2 years

HISTORY
- Fine motor: Palmar grasp – 07m
Pincer grasp – 09 m
- Language: Cooing: - 03m
Two words – 01y

HISTORY
- Social: Smile – 02 m
Recognise mother – 03 m
Waving – 10 m
Child still hadn’t joined school

HISTORY
- Family History:
- No history of blood related disorders in family
- Socioeconomic history:
- Lower middle class as per Kuppuswamy scale
- Closed sanitation

Examination
- Child lying on couch, tachypnoeic, in visible distress
- Anthropometry:
- Weight: 25 kg
- Height:118 cm
- Vitals:
- HR: 116/ min, regular
- BP: 99/64 mm Hg
- RR: 34/ min, regular
- SpO2: 94% in room air
- Afebrile

Examination
- Pallor present
- Icterus present
- No signs of cyanosis/ clubbing/ pedal oedema/ lymphh node enlargement

Examination
- Systemic Examination:
- Per abdomen: Inspection
- Grossly distended
- Skin over abdomen normal
- Umbilicus everted
- No visible pulsations/ dilated veins
- Hernial sites normal
- Genitalia normal

Examination
- Per abdomen: Palpation
- Liver palpable 4 cm below right costal margin
- Gross splenomegaly 18 cm extending downwards to right iliac fossa: notch felt
on medial side
- No free fluid
- Auscultation: Sluggish bowel sounds heard

Examination
- CNS:
- GCS: E4V5M6
- Fully conscious, oriented to time, place and person
- No signs of meningeal irritation
- Cranial nerves normal
- Power in all four limbs normal

Examination
- CVS:
- S1, S2 normal
- No murmurs heard

Examination
- Respiratory system: Inspection
- Tachypnoea present ( 34/min)
- Subcostal and intercostal retractions present
- Use of accessory muscles of respiration present
- Inspiratory stridor present

Examination
- Respiratory system: Auscultation
- Bilateral conductive sounds present
- Occasional rhonchi present

Investigations
- Hb: 7.2 gm/dl
- TLC: 6400/cmm
- DLC: Polymorph – 33%, Lymphocytes – 39%
- Platelets: 1.41 lacs/cmm
- BUN/ S. Creat: 12mg/dl / 0.2 mg/dl
- AST/ ALT: 35U/ 45U
- Total Proteins: 6.8 mg/dl
- S. Albumin: 3.2 mg/ dl
- Iron/ TIBC: 77/ 326

Working Diagnosis
- 9 year old male child, case of beta thalassemia major, with transfusion dependent
anaemia from 08m of age, with progressive breathlessness, gross abdominal
distension, admitted for splenectomy in view of massively enlarged spleen and
increasing demand of blood transfusion

Progress in Hospital
- Child admitted in PICU on 20/07/19, after transfer from CHCC, placed on DIL.
- Patient managed with oxygen by nasal cannula @4L/ min and nebulisation with
Asthalin 6 hourly, Tab Desferrioxamine 600 mg OD, and Tab FA 5 mg OD
- On 21/07/19, patient was transfused with 300ml of PRBC, along with Inj Lasix 40 mg
stat

- Patient’s breathlessness worsened further, and developed stridor on 22/07/19
morning.
- ENT consultation was requested in view of laryngeal oedema and laboured
breathing
- Patient was placed on Airvo with Flow of 30L/min and FiO2 of 0.5; saturation
maintained was 94-98%
- Auscultation revealed bilateral rhonchi. Vitals were stable. GCS – E4V5M6

- Pre-op investigations:
- Hb: 8.4 gm/dl
- TLC: 6730/cmm
- DLC: Polymorph – 65%, Lymphocytes –21%
- Platelets: 1.27 lacs/cmm
- BUN/ S. Creat: 10mg/dl / 0.2 mg/dl
- AST/ ALT: 32U/ 43U
- Total Proteins: 7.4 mg/dl
- S. Albumin: 3.6 mg/ dl
- Na/K: 135 mEq/L / 4.3 mEq/L

- 2D Echo
- Mild LV Dysfunction
- LVEF – 50%
- No PAH

- ENT consult
- FOL done under LA cover
- Revealed subglottic foreign body with subtotal occlusion of trachea
- Both vocal cords were mobile
- In view of persisting stridor, and visible crust/ foreign body at subglottic region,
bronchoscopy under GA in OT was planned at 1800h
- Written and informed high risk consent was taken along with consent for
tracheostomy

- Patient accepted under ASA IV E
- Shifted to OT at 1830h
- Standard physiologic monitoring attached to the patient
- HR: 126/ min
- BP: 110/60 mm Hg
- RR: 32/ min
- SpO2 : 92 %

- Pre-medication
- Inj Glycopyrollate 0.1 mg IV
- Inj Fentanyl 20 mcg IV
- Patient was pre-oxygenated for 5 minutes with 100% O2
- Induction
- Inj Ketamine 30 mg IV
- Sevoflurane inhalational

- Inj Scholine 25 mg IV given
- Patient handed over to ENT team for FB removal through bronchoscope
- FB was found just below the VC, and was hard and flaky in consistency
- FB couldn’t be removed with flexible bronchoscope
- Planned for rigid bronchoscopy

- Intermittent oxygenation was done with face mask, child regained spontaneous
ventilation.
- 2-3 attempts to remove the FB were done with rigid bronchoscope and forceps.
- Child started desaturating with fall in HR from 110/min to 64/min.
- Endotracheal intubation was attempted, but not possible because of the FB.
- Decision was made to perform emergency surgical tracheostomy.

- Difficult tracheostomy
- Short Neck
- Large thyroid
- After multiple attempts, emergency tracheostomy done with size 3.5mm
tracheostomy tube.
- However, child developed ventricular tachycardia, and no peripheral pulses were
plapable

- CPR was initiated
- DC cardioversion was done first with 50 J, and 3 subsequent shocks with 100J of
energy.
- Inj adrenaline 400 mcg was administered three times.
- Heart rhythm reverted back to sinus rhythm after 5th DC shock with 150 J.

- Subsequently, tracheostomy tube was changed from size 3.5 mm to 4.0 mm, and
then 4.0 mm to 4.5 mm, and finally 4.5 mm to 5.0 mm size.
- Right radial artery was cannulated for BP monitoring
- Right femoral vein was cannulated for inotropic support with Noradrenaline.
- ABG: pH : 6.8
PO2: 57 mm Hg
PCO2: 136 mm Hg

- Immediate Post-op:
HR: 140/min
BP: 114/62 mm Hg
SpO2: 99% with FiO2 of 1.0
EtCO2: 70+ cm H20

- Lung fields checked by bedside USG:
- Bilateral air entry equal with no fluid in pleura
- ECHO showed normal functioning heart
- Prior to shifting from OT,
- Inj Lasix 2 mg IV
- Inj Fentanyl 10 mcg IV
- Inj Ketamine 20 mg IV
- Inj Atracurium 10 mg IV
- Child maintained vitals without inotropic support

- Urinary bladder was catheterised
- Planned to shift to PICU for post-op ventilation
- Prior to shifting:
HR: 136/min
BP: 102/58 mm Hg
SpO2: 99% at FiO2 1.0
Pupils: 2 mm bilateral with sluggish reaction

- After shifting to PICU:
HR: 144/min
BP: 140/90 mm Hg
RR: 34/min
SpO2: 97% with FiO2 1.0
Afebrile
- Child was put on ventilator in PC-SIMV mode.
- PEEP: 6 – 10 cmH2O, PIP: 18 cm H2O, FiO2: 1.0, RR – 40/min
- Frequent changes to these settings to decrease rising PCO2

- VBG:
pH: 7.088
PO2: 57.6 mm Hg
PCO2: 80.05 mm Hg
HCO3-: 20.5 mEq/l
- Noradrenaline started @0.2 mcg/kg/min
- Required regular suctioning (blood tinged scretions)
- BP kept on falling, respiratory distress kept worsening
- Adrenaline was added, and ventilator settings titrated.

- Chest Xray was done
- f/s/o pulmonary oedema and cardiomegaly
- Inotrope requirement kept on increasing

- At about 0530 hrs the child developed progressive desaturation with bradycardia.
- CPR started with chest compression and tracheostomy tube ventilation.
- The CPR continued as per protocol with 3 Inj Adr. IV @ 0.1 ml/kg. and other
ionotropes.

- Cardioversion attempted.
- HR- nil, no spontaneous respiratory efforts, no electrical activity on ECG after 45
min of CPR.
- The child was declared dead at 0615 hrs on 23-07-2019.

Cause of Death
- Pulmonary oedema
- Acute airway obstruction
- Thalassemia major

Discussion
- Tracheobronchial foreign body aspiration (FBA)
- Life-threatening event
- Obstructs the airway, thereby impairing oxygenation and ventilation
- Responsible for more than 17,000 emergency department visits in children
younger than 14 years in the United States.
- Responsible for about 4,800 deaths in 2013.

Discussion
- 80 percent of pediatric FBA episodes occur in children younger than three years
- peak incidence between one and two years of age
- smaller diameter of their airway, which is prone to obstruction
- older children and adults, neurologic disorders, loss of consciousness, and alcohol
or sedative abuse predispose to FBA

Discussion
- The majority of aspirated FBs in children are located in the bronchi
- Larynx – 3 percent
- Trachea/carina – 13 percent
- Right lung – 60 percent (52 percent in the main bronchus, 6 percent in the
lower lobe bronchus, and <1 percent in the middle lobe bronchus)
- Left lung – 23 percent (18 percent in the main bronchus and 5 percent in the
lower bronchus)
- Bilateral – 2 percent
Burton EM, Brick WG, Hall JD, et al. Tracheobronchial foreign body aspiration in children. South Med J 1996; 89:195.

Signs and symptoms
- Children who present with severe respiratory distress, cyanosis, and altered mental
status
- True medical emergency
- Demands prompt recognition, life support, and rigid bronchoscopic removal of
the foreign body (FB)

Signs and symptoms
- More commonly, children with FBA present with partial airway obstruction.
- Most common symptom is cough, followed by tachypnea and stridor, often with
focal monophonic wheezing or decreased air entry.
- Regional variation in aeration is an important clue to the diagnosis
- Classic triad of wheeze, cough, and diminished breath sounds is not universally
present
Singh H, Parakh A. Tracheobronchial foreign body aspiration in children. Clin Pediatr (Phila) 2014; 53:415.

Signs and symptoms
- More commonly, children with FBA present with partial airway obstruction.
- Most common symptom is cough, followed by tachypnea and stridor, often with
focal monophonic wheezing or decreased air entry.
- Regional variation in aeration is an important clue to the diagnosis
- Classic triad of wheeze, cough, and diminished breath sounds is not universally
present.
- Presence of the triad has high specificity (96 to 98 percent) for the diagnosis of
FBA, but the sensitivity is low (27 to 43 percent).
Singh H, Parakh A. Tracheobronchial foreign body aspiration in children. Clin Pediatr (Phila) 2014; 53:415.
Zhijun C, Fugao Z, Niankai Z, Jingjing C. Therapeutic experience from 1428 patients with pediatric tracheobronchial foreign
body. J Pediatr Surg 2008; 43:718.

Signs and symptoms
- Laryngotracheal FBs
- Laryngotracheal FBs are uncommon (5 to 17 percent of FBs) but are
particularly likely to be life-threatening.
- stridor, wheeze, and dyspnea, and sometimes hoarseness.
- most likely to present with acute respiratory distress, which must be addressed
promptly .
Esclamado RM, Richardson MA. Laryngotracheal foreign bodies in children. A comparison with bronchial foreign
bodies. Am J Dis Child 1987; 141:259.
Wiseman NE. The diagnosis of foreign body aspiration in childhood. J Pediatr Surg 1984; 19:531.

Signs and symptoms
- Large bronchi
- The usual symptoms are coughing and wheezing.
- Hemoptysis, dyspnea, choking, shortness of breath, respiratory distress,
decreased breath sounds, fever, and cyanosis may also occur .
- The right main bronchus is the most common location (45 to 55 percent of
FBs), followed by left bronchus.
Mu L, He P, Sun D. Inhalation of foreign bodies in Chinese children: a review of 400 cases. Laryngoscope 1991; 101:657.

Signs and symptoms
- Lower airways
- Children with these FBs may have little acute distress after the initial choking
episode.

Signs and symptoms
- History of choking
- Witnessed episode of choking, defined as:
- the sudden onset of cough and/or dyspnea and/or cyanosis in a
previously healthy child,
- has a sensitivity of 76 to 92 percent for the diagnosis of FBA
Blazer S, Naveh Y, Friedman A. Foreign body in the airway. A review of 200 cases. Am J Dis Child 1980; 134:68.
Even L, Heno N, Talmon Y, et al. Diagnostic evaluation of foreign body aspiration in children: a prospective study. J Pediatr Surg 2005; 40:1122.
Mu L, He P, Sun D. The causes and complications of late diagnosis of foreign body aspiration in children. Report of 210 cases. Arch Otolaryngol
Head Neck Surg 1991; 117:876.

Signs and symptoms
- choking phase occurs immediately after the episode and lasts a few seconds
to several minutes.
- acute episode usually is self-limited and may be followed by a symptom-free
period.
- must not be misinterpreted as a sign of resolution since it may delay the
diagnosis
Lemberg PS, Darrow DH, Holinger LD. Aerodigestive tract foreign bodies in the older child and adolescent. Ann Otol Rhinol Laryngol 1996;
105:267.

Signs and symptoms
- a history of choking may not be recalled during initial evaluation; detailed
and repeated questioning of all caregivers may be necessary to stimulate
recall of the choking episode.
- In one review of 200 cases of FBA, 19 percent presented more than one
month after aspiration, even though a history of choking was present in 88
percent.

Signs and symptoms
- Delayed diagnosis
- Patients who present days or weeks after the aspiration often develop
symptoms due to complications related to the presence of the FB, such as
infection and inflammation of the airway.
- Patients with occult FBA may improve with antibiotic therapy. However, the
infiltrate on chest radiograph usually does not resolve, and recurrence of
pneumonia is common.

Evaluation
Life threatening
FBA
Suspected
FBA

Evaluation
- Life-threatening FBA
- complete airway obstruction (ie, is unable to speak or cough)
- dislodgement using back blows and chest compressions in infants, and the
Heimlich maneuver in older children

Evaluation
- Life-threatening FBA
- In contrast, these interventions should be avoided in children who are able to
speak or cough since they may convert a partial to a complete obstruction.
- For the same reason "blind" sweeping of the mouth should be avoided.
Ciftci AO, Bingöl-Koloğlu M, Senocak ME, et al. Bronchoscopy for evaluation of foreign body aspiration in children. J Pediatr Surg 2003; 38:1170.

Evaluation
- Suspected FBA
- All children with suspected FBA who are stable should undergo a focused
history and physical examination.
- specifically asked about a history of a choking episode in the hours or days
prior to symptom onset.
- physical examination should evaluate for wheezing, stridor, and regional
variation in breath sounds, which may be subtle and difficult to detect
Ciftci AO, Bingöl-Koloğlu M, Senocak ME, et al. Bronchoscopy for evaluation of foreign body aspiration in children. J Pediatr Surg 2003; 38:1170.

Evaluation
- Moderate or high suspicion of FBA:
- if none of the above features are present
- normal results of plain radiographs are sufficient to provisionally exclude FBA.
- should be observed, with follow-up in two to three days, and further
evaluation (eg, bronchoscopy), if symptoms persist or progress.

Evaluation
- Low suspicion of FBA:
- Witnessed FBA, regardless of symptoms.
- History of choking, with any subsequent symptoms or suspicious characteristics
on imaging.
- Young child with suggestive symptoms without other explanation, especially if
there are suspicious characteristics on imaging.

Imaging
- First step in the evaluation is to perform plain radiography of the chest.
- Subsequent steps depend on the degree of clinical suspicion for FBA.
- May include computed tomography (CT) or bronchoscopy

Imaging
- In children with lower airway FBA, the most common radiographic findings in lower
airway FBA:
- Hyperinflated lung (lucency distal to the obstruction) – caused by partial airway
obstruction with air trapping.
- Atelectasis – This is usually caused by complete obstruction of an airway, since air
is resorbed from the distal alveoli over time.

Imaging
- Mediastinal shift – The mediastinum tends to shift away from the lung field
containing the foreign body .
- Pneumonia – Infection often develops distal to an obstructed airway. Therefore, a
consolidated infiltrate is also a possible finding.

Imaging
- Mediastinal shift – The mediastinum tends to shift away from the lung field
containing the foreign body .
- Pneumonia – Infection often develops distal to an obstructed airway. Therefore, a
consolidated infiltrate is also a possible finding.
- If a laryngotracheal FB is suspected based on symptoms (stridor, wheeze, and dyspnea,
and sometimes hoarseness) a neck radiograph should be performed. These should include
posteroanterior and lateral views, with the arms and shoulders positioned inferiorly and
posteriorly to optimize the image of the larynx and trachea. Even if the FB is radiolucent,
these films may suggest the diagnosis if they show a subglottic density or swelling.
Wiseman NE. The diagnosis of foreign body aspiration in childhood. J Pediatr Surg 1984; 19:531.

Imaging
- Computed tomography:
- possible diagnostic option for patients who are asymptomatic or symptomatic
but stable, who have normal or inconclusive plain radiographs but an ongoing
clinical suspicion of FB aspiration.

Imaging
- Computed tomography:
- possible diagnostic option for patients who are asymptomatic or symptomatic
but stable, who have normal or inconclusive plain radiographs but an ongoing
clinical suspicion of FB aspiration.
- The sensitivity of CT for FBA is almost 100 percent and specificity is 66.7 to 100
percent.
- Unlike plain radiography, CT usually can detect radiolucent foreign bodies
such as vegetables.

Bronchoscopy
- Tracheobronchial tree should be examined in all cases with a moderate or high
suspicion of FBA
- Using rigid bronchoscopy so that the object can be safely removed.

Bronchoscopy
- Flexible rather than rigid bronchoscopy may be used:
- for diagnostic purposes in cases in which the diagnosis is unclear,
- or if the FBA is known but the location of the object is unclear

Foreign body removal
- rigid bronchoscopy is the procedure of choice to identify and remove the object.
- Unsuccessful attempts to remove the FB:
- may push it into a distal position, making them more difficult to retrieve.
- dislodgement of all or part of the FB, or a fragment of the FB, into the
mainstem bronchus of the contralateral lung are potentially lethal
complications if the originally involved bronchus remains obstructed by
inflammation or residual FB.

- Occasionally, a FB that has been retained for several weeks will cause such
intense airway inflammation and infection that it cannot be removed.
- In such cases, antibiotics should be administered, guided by gram stain and
cultures obtained at bronchoscopy.
- In addition, a three- to seven-day course of systemic corticosteroids
(methylprednisolone [or equivalent] 1 to 2 mg/kg per day either by mouth or
intravenously) may help reduce inflammation.
Cataneo AJ, Reibscheid SM, Ruiz Júnior RL, Ferrari GF. Foreign body in the tracheobronchial tree. Clin Pediatr (Phila) 1997; 36:701.

- Occasionally, a FB that has been retained for several weeks will cause such
intense airway inflammation and infection that it cannot be removed.
- In such cases, antibiotics should be administered, guided by gram stain and
cultures obtained at bronchoscopy.
- In addition, a three- to seven-day course of systemic corticosteroids
(methylprednisolone [or equivalent] 1 to 2 mg/kg per day either by mouth or
intravenously) may help reduce inflammation.
- FB may be removable at a second rigid bronchoscopy.

Anaesthesia for FB Removal in a child
- Children in respiratory distress, or with suspected laryngeal or tracheal foreign
body aspiration (FBA) should be taken urgently to the operating room for
bronchoscopy
- For children who are stable and at low risk of progression of airway obstruction,
the procedure may be scheduled during optimal operating room staffing
conditions and after routine preoperative fasting
Mani N, Soma M, Massey S, et al. Removal of inhaled foreign bodies--middle of the night or the next morning? Int J Pediatr
Otorhinolaryngol 2009; 73:1085.

- Full stomach concerns should not delay procedures for children thought to be at
risk of progression of airway obstruction.
- multiple reports of progression from partial to complete airway obstruction, from
movement or swelling of the foreign body, or swelling of the tracheobronchial
mucosa.
- For patients with full stomachs, a large bore gastric tube can be placed and
suctioned after induction of anesthesia to reduce the volume of stomach
contents.

- Induction of anesthesia for rigid bronchoscopy:
- The goal should be to maintain spontaneous ventilation, particularly for
children with proximal (ie, laryngeal or tracheal) FBA.
- The use of positive pressure ventilation may theoretically move a foreign body
in the tracheobronchial tree and convert a partial obstruction to a complete
obstruction.
- Patients require deep general anesthesia to tolerate rigid bronchoscopy

- Mode of ventilation during rigid bronchoscopy
- Spontaneous ventilation during the maintenance of anesthesia minimizes the
chance that an unstable foreign body will be moved more distally.
- In addition, the ability to ventilate with positive pressure around an airway
obstruction is not guaranteed.
- However, positive pressure ventilation via the ventilating port of the
bronchoscope is often required during rigid bronchoscopy, either because of
hypoventilation at the required depth of anesthesia or because NMBAs are
administered.

Complications
- When FBA is diagnosed soon after the event, there is usually little damage to the
airway or lung parenchyma.
- The longer the FB is retained, the more likely are complications (eg, atelectasis,
postobstructive pneumonia).
- A FB that causes chronic or recurrent distal infection may lead to bronchiectasis

A case of sub-glottic foreign body in a child

Recommended

Recommended

More Related Content

What's hot

What's hot (20)

Similar to A case of sub-glottic foreign body in a child

Similar to A case of sub-glottic foreign body in a child (20)

Recently uploaded

Recently uploaded (20)

A case of sub-glottic foreign body in a child

Editor's Notes