Rigid bronchoscopy for foreign body removal: anaesthesia and ventilation

Abstract

Foreign body aspiration is a leading cause of death in children 1-3 years old, although mortality is low for children who reach the hospital. Presenting symptoms of an inhaled foreign body depends on time since aspiration. Immediately after inhalation the child starts to cough, wheeze, or have laboured breathing. If the early signs are missed, the child usually presents with fever and other signs and symptoms of chest infection. A plain chest X-ray has relatively low sensitivity and specificity for inhaled foreign body. The gold standard for diagnosis and management of this condition is rigid open tube bronchoscopy under general anaesthesia. For late presentations, time should be taken to fast the child and complete a thorough evaluation before bronchoscopy. The procedure should be performed in a well-equipped room with at least two anaesthesiologists, one with paediatric experience, in attendance. Most experienced anaesthesiologists prefer inhalational rather than intravenous induction of anaesthesia and a ventilating bronchoscope rather than intubation. Equally good results have been reported with spontaneous ventilation or positive pressure ventilation; jet ventilation is not advocated for foreign body removal in children.

The anaesthetic consideration of tracheobronchial foreign body aspiration in children

“…Some organic foreign materials may swell due to fluid absorption after aspiration and the partial blockage can become total in time. Also, sharp tipped objects may perforate the airways they enter (8,11). Taking history leads to correct diagnosis (5).…”

“…Therefore, if an aspiration incident has been witnessed or suspected, basic life support maneuvers based on the guidelines of the European Resuscitation Council and the American Heart Association should be commenced while the local ambulance services are called (6,11). It is imperative that the requisite preparations be completed before bronchoscopy, to be undertaken as early as possible.…”

“…If the patient is in a stable condition, it has been recommended that bronchoscopy be performed in day time operating hours with experienced anaesthesiologists and surgeons under optimal conditions (8,(11)(12)(13). Despite recent preference in some centers for using the fiber-optic bronchoscope, use of the rigid bronchoscope remains the gold standard (7,11,14,15). Although the fiber-optic bronchoscopy has the disadvantages of limited suction and instrumentation, and the lack of ventilatory capability and airway control, it has advantages in being less invasive, and in not requiring general anaesthesia.…”

“…Steroids (dexamethasone 0.4-1 mg/kg i.v.) can be used to treat the inflammation and to prevent the likelihood of airway oedema incurred by bronchoscopy (11,22,23). Resorting to the multiple anaesthetic methods during the removal of the foreign body has been reported in the literature.…”

“…With this approach, positive pressure ventilation can be applied to reverse of atelectasis, to correct oxygenation and to overcome the airway resistance. Some anaesthesiologists prefer spraying the epiglottis, larynx and the cords with 1% topical lidocaine before the procedure to reduce the haemodynamic and airway reactions to the introduction of the bronchoscope into the airways, reducing the need for general anaesthetic use and the risks of laryngospasm (11,24). Use of manual jet ventilation during bronchoscopy in nonobstructed lung prevents the hypoxaemia that can arise despite spontaneous or controlled ventilation.…”