|Year : 2023 | Volume
| Issue : 1 | Page : 56-58
Anesthetic concerns during rigid bronchoscopy for the management of a friable vegetative foreign body in an infant
Diksha Gaur1, Geetanjali T Chilkoti1, Zainab Ahmad2, Steffi Dua3, Nikhil Gaur1, Nandita Kanwar4, Ashok Kumar Saxena5
1 Department of Anesthesiology, Critical Care and Pain Medicine, University College of Medical Sciences, Guru Tegh Bahadur Hospital, New Delhi, India
2 Department of Anesthesiology, Critical Care and Pain Medicine, All India Institute of Medical Sciences, Bhopal, Madhya Pradesh, India
3 Department of Anesthesiology, Critical Care and Pain Medicine, All India Institute of Medical Sciences, New Delhi, India
4 Department of Anesthesiology, Critical Care and Pain Medicine, RNT Medical College, Udaipur, Rajasthan, India
5 Department of Anesthesiology, Critical Care and Pain Medicine, University College of Medical Sciences, New Delhi, India
|Date of Submission||13-Jan-2023|
|Date of Decision||06-Apr-2023|
|Date of Acceptance||05-May-2023|
|Date of Web Publication||25-May-2023|
Dr. Diksha Gaur
Maurya Enclave, Pitampura, New Delhi - 110 034
Source of Support: None, Conflict of Interest: None
Tracheobronchial foreign-body (FB) aspiration is a commonly encountered entity in the pediatric population. FB aspiration (FBA) is an emergency condition requiring early recognition and management, and the primary treatment is the surgical removal of FB under anesthesia. Herein, we report a unique case of an infant developing prolonged severe respiratory distress due to obstruction following a vegetative FBA and shall also discuss the related anesthetic concerns.
Keywords: Foreign-body aspiration, rigid bronchoscopy, tracheobronchial foreign body
|How to cite this article:|
Gaur D, Chilkoti GT, Ahmad Z, Dua S, Gaur N, Kanwar N, Saxena AK. Anesthetic concerns during rigid bronchoscopy for the management of a friable vegetative foreign body in an infant. J Ind Coll Anesth 2023;2:56-8
|How to cite this URL:|
Gaur D, Chilkoti GT, Ahmad Z, Dua S, Gaur N, Kanwar N, Saxena AK. Anesthetic concerns during rigid bronchoscopy for the management of a friable vegetative foreign body in an infant. J Ind Coll Anesth [serial online] 2023 [cited 2023 Oct 1];2:56-8. Available from: https://www.jicajournal.in//text.asp?2023/2/1/56/377593
| Introduction|| |
Tracheobronchial foreign-body (FB) aspiration, especially peanut during the winter season, is commonly encountered in the pediatric age group. Approximately 70.2% of cases of FB aspiration (FBA) are within 5 years of age, and most are within 2–3 years of age. FBA has been reported to be the fifth-most common cause of accidental mortality in infants. Male children present more frequently with FBA. It is an emergency condition, and delay in its recognition and treatment can result in severe morbidity and mortality.
The aspirated FB is located most commonly in the right mainstem bronchus (55%–70%). Other sites include the left bronchus (20%–30%) and the trachea (7%).
Under anesthesia, although spontaneous ventilation has been the most accepted technique to prevent the FB from migrating and ultimately obstructing the airway, the literature suggests that both spontaneous and controlled ventilation are acceptable with similar outcomes.
We report an unusual case of a vegetative FB in an infant and shall discuss the anesthetic challenges in this case.
| Case Report|| |
An 11-month-old, 8 kg weight, female patient was brought to the casualty of our tertiary care teaching hospital with a history of choking, difficulty in breathing, and vigorous coughing while eating peanuts 2 days back. Since then, the child had been coughing persistently and breathing rapidly and noisily. There was no history of fever, allergies, asthma, or any past medical or surgical illness.
On general physical examination, the child was frequently coughing and had stridor (expiratory) with suprasternal retractions and use of accessory muscles. However, there was no cyanosis or hoarseness of voice. Vitals were – heart rate (HR) – 122 b/min, respiratory rate (RR) – 32 b/min, blood pressure (BP) – 96/58, and SpO2 – 88% (on room air) and 95% (on O2 by Hudson's face mask). On respiratory system examination, mild sternal retractions were present on inspection. On auscultation, bilateral air entry was decreased bilaterally (more on the left side), bilateral wheeze was present, and SpO2 – 90% (on room air) and 95% (on 02 by face mask). The rest of the systemic examination was within the normal limits.
The chest X-ray posteroanterior view done in casualty showed hyperinflated lung fields (air trapping on the left side) [Figure 1]. The provisional diagnosis of the left side FB (peanut) aspiration with severe respiratory distress (ball-valve effect) was made. The patient was accepted for FB removal through rigid bronchoscopy under ASA Grade III E.
The anesthetic technique chosen was general anesthesia using inhalational induction and controlled ventilation.
Following informed consent and high-risk consent, the fasting status of the patient was ensured, and the child was shifted to the operation theater.
The ASA-recommended minimum mandatory monitoring, including continuous Electrocardiographi (Lead II), HR, SpO2, ETCO2, and intermittent noninvasive BP, was instituted. Baseline vitals were HR – 152 b/min, RR – 42 b/min, BP – 96/58, and SpO2 – 85% on O2 by face mask. Preoxygenation with 100% oxygen was done, following which SpO2 increased to 95%.
Inhalational induction with 8% sevoflurane was done, following which a 24 G intravenous (IV) cannula was inserted into the dorsum of the left hand. Injection fentanyl 20ug IV and injection atracurium 4 mg IV were administered after confirming ventilation. Direct laryngoscopy was done by inserting a rigid ventilating bronchoscope 5 mm (Karl Storz™) with a telescope by the surgeon. A large FB almost completely obstructing the carina was seen [Figure 2]. The long axis of the FB (peanut) was lying in the horizontal plane at the carina, completely obstructing both the bronchus and leading to a “cannot ventilate situation.” During this time, the SpO2 dropped to 20%–30%. Atropine was kept ready but not required.
|Figure 2: FB located at the carina causing a subtotal obstruction. FB: Foreign body|
Click here to view
The surgeon quickly inserted a suction catheter, and on active manipulation, the FB turned vertical [Figure 3], exposing the right bronchus, thus making partial ventilation through the right bronchus possible. During this time, the SpO2 increased to 50%–60%. However, still, ventilation was possible only through the right bronchus. Thereafter, FB was removed with great difficulty by forceps in pieces. Following complete FB removal, SpO2 improved to >90%. Injection dexamethasone 4 mg IV was administered.
|Figure 3: FB manipulated marginally with centralized suction. FB: Foreign body|
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Anesthesia was reversed with injection neostigmine 0.5 mg IV and injection glycopyrrolate 0.1 mg IV. The trachea was extubated when the patient was awake. Postextubation, the child was awake crying, and the chest-bilateral air entry presented with added conducted sounds in the right apex. The child was discharged from the ward on day 4 in stable condition.
| Discussion|| |
In the present case report, we observed subtotal airway obstruction by a peanut at the level of the carina in an infant. The smaller-sized airway in an infant, the vegetative nature of FB, controlled ventilation, and surgeons' manipulation attributed to near subtotal respiratory obstruction leading to a near “cannot ventilate situation” in the present case.
Promptness is essential to avoid possible serious complications such as pneumonia, atelectasis, and bronchiectasis with FBA. The most important elements in diagnosing FBA are awareness, adequate history taking, and thorough clinical examination. Rigid bronchoscopy is the treatment for FB removal. Given the shared use of the airways by the surgeon and the anesthesiologist, bronchoscopy is a challenging procedure requiring experienced teams with an efficient method of intercommunication and well planning of the anesthesia and bronchoscopy ahead of the procedures.
Peanut FB is a common and hazardous FB. Its oil leads to airway inflammation and edema. It expands with moisture and may fragment into multiple pieces. It is located most commonly in the right mainstem bronchus (55%–70%), left bronchus (20%–30%), and trachea (7%). Carinal FB has been reported less often and is more dangerous, leading to bilateral bronchus obstruction. This is a tricky position for FB impaction in children as it swells, and due to a small-sized airway, it may lead to subtotal or complete airway obstruction leading to a near “cannot ventilate situation.”
Spontaneous ventilation has been advocated conventionally, but was found to be associated with the risk of coughing, involuntary movement of the patient, laryngeal spasm, and trauma. Controlled ventilation abolishes these reflexes and facilitates the removal of FB. However, there is a theoretical risk of migration of FB like in the present case. Various reviews have shown no advantage of spontaneous ventilation over controlled ventilation, and the literature has revealed a high rate of conversion to controlled ventilation. Another study of 13,000 patients reports that there is no apparent reason to avoid muscle relaxants during rigid bronchoscopy. Our patient, when presented, was already in severe respiratory distress with respiratory muscle fatigue due to the 2-day-long history. Thus, we preferred controlled ventilation.
| Conclusion|| |
We observed subtotal airway obstruction by peanut as FB at the level of the carina in an infant. The attributing factors for subtotal airway obstruction are the smaller-sized airway in an infant, the vegetative nature of FB, controlled ventilation, and surgeons' manipulation, thus adopting gentle ventilation and caution while FB manipulation.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form, the legal guardian has given his consent for images and other clinical information to be reported in the journal. The guardian understands that names and initials will not be published and due efforts will be made to conceal patient identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3]