Heimlich's maneuver-assisted bronchoscopic removal of airway foreign body.

Aspiration of foreign bodies (FBs) by children can lead to serious illness and sometimes even death. Bronchoscopic removal of the FB is necessary to prevent from any catastrophic event. Sometimes bronchoscopic removal is not possible due to the larger size of the FB, sharp FB, or long duration FB. Tracheostomy is normally used for the removal of such FBs. The aim of this case report is to highlight the use of Heimlich maneuver for the removal of such FBs before opting invasive procedures. In the present case, a 5-year-old child was presented with history of FB aspiration 5 h back. After multiple failed bronchoscopic attempts to remove the FB it was decided to use Heimlich maneuver in the supine position. A single attempt of Heimlich maneuver expelled the FB into the oral cavity, which was removed by Magill's forceps. On repeated bronchoscope check, there was no remnant of FB. Child's further course of stay in hospital was uneventful. In conclusion, Heimlich maneuver may be useful in patient with failed bronchoscope removal of airway FBs before proceeding for tracheotomy or other invasive procedures.

INTRODUCTION

Foreign body (FB) aspiration has mainly been reported in children, but can occur in any age group, mostly while eating in intoxicated states. The course of illness after a FB lodges in the air passages depends upon the characteristics of the FB and its length of stay. Aspiration of FBs by children can lead to serious illness and sometimes even death.[1] On diagnosis, immediate bronchoscope removal of FB is necessary to prevent any catastrophic event.

Heimlich maneuver is used to create pressure within the lungs which in turn helps to expel the lodged FB in the airway into the oral cavity which is further removed by hooking movement of fingers or by any instrument.[2] Here we present a case where a FB stuck at a level of subglottis during bronchoscopic extraction that was further removed with help of Heimlich maneuver while the patient was under general anesthesia in the supine position.

CASE REPORT

A 5-year-old, 18-kg male child was presented in the emergency department with a history of cough and labored breathing. Groundnut aspiration was suspected by his parents. Otorhinolaryngology consultation was obtained and it was planned for emergency bronchoscopic removal of the FB. He had taken breakfast 5 h back. His parents denied any other medical comorbidities or surgical treatment in the past. On examination, he was 107 cms in height, conscious, and well oriented. He was in labored breathing with the use of accessory muscles. Respiratory examination revealed decreased breath sounds on the right side of the chest along with wheezing. He was mallampati Class II with full range of neck movements. A preoperative chest radiograph showed obstructive emphysematous changes and electrocardiography (ECG) showed normal sinus rhythm. After explaining the procedure and risk involved, written informed consent was taken. In the operation room standard ECG, noninvasive blood pressure, and pulse oximetry were attached and baseline were parameters noted. A 22G cannula was secured and intravenous normal saline infusion was started. Patient was also given inj. Dexamethasone 2 mg i.v. The preoperative heart rate (HR) was 115/ min., blood pressure (BP) was 90/56 mmHg, respiratory rate was 26/ min, SpO2 (on room air) was 88% and arterial blood gases showed pH-7.32, pO2-61, pCO2-39, HCO3-15, BE = -5, and SO2-89. A 10 F Ryle's tube was inserted to decompress the stomach. He was preoxygenated by the facemask with 100% oxygen. General anesthesia was induced by propofol 2.5 mg/kg and fentanyl 1.5 μg/kg. Intravenous succinylcholine 2 mg/kg was given for muscle relaxation. The patient was positioned supine with a rolled towel across the back between the scapulae to extend the neck and to push the upper trachea forward. After direct laryngoscopy rigid bronchoscope was introduced under direct vision by surgeon. Anesthesia and ventilation was maintained with halothane in 100% oxygen through the side port of the bronchoscope by attaching a Jackson Rees T-piece. Repeat doses of succinylcholine were given as necessary. The FB was visualized in the right upper lobe bronchus and then serrated extraction forceps were used to retrieve it. The surgeon grasped the FB and tried to remove it but it stuck at the level of subglottis. Even after multiple attempts, the FB could not be extracted due to its larger size. Meanwhile all the vital parameters were carefully observed. An attempt of Heimlich maneuver was tried on patient in the supine position with performer's hands positioned slightly above the naval and well below the xiphoid process and then pressed into the abdomen with quick a upward thrust. The maneuver led to the expulsion of the FB into the oropharynx that was immediately grasped and removed with the help of Magill's forceps. Oral cavity was examined and the bronchoscope was reinserted to check for any possible remnant of FB and suction of secretions. After clearance by the surgeon, anesthesia was stopped and child was mask ventilated until he recovered fully. Post procedure he had a good cry, HR 80/ min, BP 100/60 mmHg, SpO2 97% on room air and arterial blood gases showed pH-7.42, pO2-72, pCO2-29, HCO3-18, BE = -4 and SO2-97. Post-operatively the patient was given antibiotics and monitored carefully. His stay in hospital was uneventful and he was discharged on the next day.

DISCUSSION

FB aspiration is most often suffered by small children, who are unable to appreciate the hazards and have tendency of putting small objects in their mouth;[3] however, can occur in any age group. Groundnuts and peanuts are the most common cause of airway obstruction in children according to various studies.[45]

The FB aspiration in children usually presents with an initial episode of choking with subsequent respiratory symptoms. There may be cough, wheeze, or stridor with decreased or abnormal breath sounds on examination.[6] Children with a triad of cough, wheezing, and decreased air entry should be suspected of FB in the tracheobronchial tree.[7] Fever and respiratory distress may be present in longstanding cases. The longstanding FB may also lead to complications such as recurrent pneumonia, bronchiectasis, atelectasis, and even death.[8] Therefore, immediate bronchoscopy should be done as soon as there is a suspicion of the FB. The rigid bronchoscope is mainly used for FB extraction and hemostasis from and in the bronchial tree.[9]

As in our case, rigid bronchoscopy was performed under general anesthesia with jet ventilation to maintain oxygenation and anesthesia. However, difficulty during extraction at the level of subglottis was observed possibly due to an increase in the size of the vegetative FB as it might have swollen over time due to water absorption.[10] Also, subglottic part is supposed to be the narrowest part of the airway in children.

Even experienced endoscopists sometimes fail to retrieve the FB. Open surgical procedures such as tracheostomy, thoracotomy, bronchotomy, and sometimes pulmonary resection are options and needed in 0.3-4% cases.[1112] Singh et al.,[13] described the role of tracheostomy in the management of the FB airway obstruction in children. In their study, out of 342 patients who were studied for airway FB removal, four (1.2%) patients required tracheostomy. The indications for tracheostomy in the study by Singh et al. were subglottic FB of long duration, sharp subglottic FB, and FB that were larger than the glottis chink. Though the removal of the stucked vegetable FB can be done by fragmentation but this may cause further problems.[14]

In the present case, while the child was under general anesthesia and in the supine position, an attempt was made to remove the vegetative FB stucked at the subglottic level by Heimlich maneuver. The maneuver lifted the diaphragm and forced enough air from the lungs to create an artificial cough.[2] Cough was intended to move and expel the obstructing FB in upper airway. Though, such a maneuver when performed in supine position has shown to be effective in expelling water from the lung of drowning victims,[15] its use in managing a FB obstruction under general anesthesia has not been described. We speculate that the effectiveness of the Heimlich maneuver in removing the groundnut that impacted at the subglottic level was partly due to smooth and atraumatic margins of the FB.

Heimlich maneuver is not free from complications. Even if performed correctly, traumatic complications such as rib fractures, gastric, or esophagus perforations, pneumomediastinum, aortic valve cusp rupture, diaphragmatic herniation, jejunum perforation, hepatic rupture, splenic or mesenteric laceration, and acute pancreatitis have been described. However, the overall rate of complication is low. Further, the alternate technique such as tracheostomy is more invasive and not always free from complications,[16] but can be done if the Heimlich maneuver fails.

CONCLUSION

The case presents the successful use of the Heimlich maneuver in a pediatric patient for the retrieval of FB stucked at the subglottic level following failed attempts at rigid bronchoscopy under general anesthesia. Thus, we recommend that this lifesaving maneuver should always be attempted in such a situation before choosing surgical techniques like tracheostomy.