The Anesthetic Considerations of Tracheobronchial Foreign Bodies in Children

Abstract

Asphyxiation by an inhaled foreign body is a leading cause of accidental death among children younger than 4 years. We analyzed the recent epidemiology of foreign body aspiration and reviewed the current trends in diagnosis and management. In this article, we discuss anesthetic management of bronchoscopy to remove objects. The reviewed articles total 12,979 pediatric bronchoscopies. Most aspirated foreign bodies are organic materials (81%, confidence interval [CI] = 77%-86%), nuts and seeds being the most common. The majority of foreign bodies (88%, CI = 85%-91%) lodge in the bronchial tree, with the remainder catching in the larynx or trachea. The incidence of right-sided foreign bodies (52%, CI = 48%-55%) is higher than that of left-sided foreign bodies (33%, CI = 30%-37%). A small number of objects fragment and lodge in different parts of the airways. Only 11% (CI = 8%-16%) of the foreign bodies were radio-opaque on radiograph, with chest radiographs being normal in 17% of children (CI = 13%-22%). Although rigid bronchoscopy is the traditional diagnostic "gold standard," the use of computerized tomography, virtual bronchoscopy, and flexible bronchoscopy is increasing. Reported mortality during bronchoscopy is 0.42%. Although asphyxia at presentation or initial emergency bronchoscopy causes some deaths, hypoxic cardiac arrest during retrieval of the object, bronchial rupture, and unspecified intraoperative complications in previously stable patients constitute the majority of in-hospital fatalities. Major complications include severe laryngeal edema or bronchospasm requiring tracheotomy or reintubation, pneumothorax, pneumomediastinum, cardiac arrest, tracheal or bronchial laceration, and hypoxic brain damage (0.96%). Aspiration of gastric contents is not reported. Preoperative assessment should determine where the aspirated foreign body has lodged, what was aspirated, and when the aspiration occurred ("what, where, when"). The choices of inhaled or IV induction, spontaneous or controlled ventilation, and inhaled or IV maintenance may be individualized to the circumstances. Although several anesthetic techniques are effective for managing children with foreign body aspiration, there is no consensus from the literature as to which technique is optimal. An induction that maintains spontaneous ventilation is commonly practiced to minimize the risk of converting a partial proximal obstruction to a complete obstruction. Controlled ventilation combined with IV drugs and paralysis allows for suitable rigid bronchoscopy conditions and a consistent level of anesthesia. Close communication between the anesthesiologist, bronchoscopist, and assistants is essential.

Cinical Presentation of Foreign Body Aspiration in Children -An Observational Study

“…Children in this age group are more vulnerable because of development of ability to stand and move around, tendency to use their mouth to explore the surroundings, lack molars, incomplete coordination between chewing and swallowing and lack of close supervision. FB aspiration was predominant in male children i.e.70.4% , as corroborative with other studies [4,5,7]. Although there was clear witness of aspiration of FB by an adult in 58 (81.7%) children and another 4 (5.6%) children had circumstantial evidence in our study, aspiration of FB was not witnessed in 9 (12.6%) children.…”

“…Majority of children i.e 80.3%, were below 3 years of age, with mean age of 27.32 months. Similar observations were made in other studies [4][5][6]. Children in this age group are more vulnerable because of development of ability to stand and move around, tendency to use their mouth to explore the surroundings, lack molars, incomplete coordination between chewing and swallowing and lack of close supervision.…”

“…Peanut was the most common vegetable FB in 42 (59.1%) patients. Fidkowski et al [4], Boufersaoui et al [5], Kaur et al [11] had similar finding. Groundnut/peanut was the most common airway FB in winter months because it is quite cheap and commonly eaten commodity and is usually given to appease crying children by their ignorant parents realising little of it's potential of airway aspiration.…”

“…Sinha et al [14], Fidkowski et al [4], Kaur et al [11] had similar finding. Whereas Naragund et al [7] found no significant difference between FB aspiration in right and left bronchus [7], Liu et al found predominance of FB aspiration in left bronchus in 60% children [15].…”

“…Similarly Kaur et al observed cough in 92% cases, respiratory distress in 80% cases and wheeze in 64% cases [11]. A history of cough is highly sensitive but not very specific for aspiration of FB as observed by Fidkowski et al [4]. They also found that a history of cyanosis and stridor is very specific for FB aspiration but is not very sensitive 4 .…”