Successful emergency airway management in a case of removal of foreign body bronchus in a pediatric patient.

Foreign body (FB) aspiration into the respiratory tract is a common incident, especially in the pediatric age group and can, sometimes, pose a real challenge to the anesthesiologists as far as the airway management is concerned. Here, we report a case of FB bronchus in a 3 year 2 months old boy, presenting to the emergency in a cyanosed and comatosed condition with severe respiratory distress. In spite of the unavailability of a pediatric fiberoptic bronchoscope in our hand, the gradual declining condition of the baby made us to take the challenge. The FB was successfully removed through a tracheotome using a nasal endoscope.

INTRODUCTION

Asphyxiation by an aspirated foreign body (FB) is a leading cause of accidental death among children younger than 4 years.[1] The commonly aspirated objects include peanuts, seeds and other food particles.[2] Many anesthetic problems and hazards exist in children with inhaled foreign bodies, especially considering the fragile pediatric cardiopulmonary status and the small pediatric airway being shared for anesthesia and endoscopy.

CASE REPORT

A 3 year 2 months old male child, weighing 13 kg, presented to the emergency with history of sudden coughing and chocking while eating apple at home about 2 h back. As per his parents’ version, there was difficulty in breathing following cough and gradual bluish discoloration of lips and fingers. The child was rushed from the emergency department to the emergency operation theatre, monitors attached and resuscitated with 100% O2 through the mask with Jackson-Rees modification of Ayre's T-piece in semi-recumbent position to correct hypoxemia as much as possible. The child was comatosed, dehydrated, with gasping breath and central cyanosis. Pulse rate was 168/min, respiratory rate was 44/min with SpO2 of 44% and decreased respiratory movement of the right chest. On auscultation breath sound was decreased with wheeze and crepitations in the middle and lower part of the right chest. Owing to the rapidly declining physical condition of the child, no investigation was done and the diagnosis was made on the basis of history and clinical findings. Intravenous cannulation done with a 22G cannula and intravenous (IV) fluid started with Ringer lactate.

Injection glycopyrrolate 0.01 mg/kg and injection hydrocortisone 5 mg/kg were given IV We planned to maintain spontaneous ventilation throughout the operative procedure and not to increase the peak inspiratory pressure to avoid the dislodgement of the FB from its place. Anesthesia was commenced with sevoflurane 1 vol.% by mask when saturation improved to 90% and maintained with sevoflurane. Pediatric fiberoptic bronchoscope was not available in the department. Initial attempt was made by ear, nose, and throat surgeon with adult rigid bronchoscope with the idea to make a tight fit on the glottic opening maintaining anesthesia through the same and to assess the position of the FB in the respiratory tract. But there was difficulty found in fixing it tightly and negotiating the grasper. Patient was desaturating too. As the SpO2 was gradually declining, child was immediately intubated with a 4.5 mm cuffed endotracheal tube (ETT) and maintained on spontaneous ventilation with sevoflurane, O2, and N2O. He was maintaining SpO2 at around 94%. A tracheotome was made at the level of 3rd and 4th tracheal cartilage [Figure 1] and an adult rigid nasal endoscope (4 mm, 70°) was introduced through the tracheotome by the side of the ETT [Figure 2] with risk of airway being compromised as part of fresh gas flow was leaking and part of it going to the left lung. FB was found in the proximal part of right bronchus and removed with the help of a crocodile forceps. The FB was in the form of a piece of apple, with its skin, of size of about 2 cm × 1 cm [Figure 3]. Extubation was done with proper tracheobronchial suctioning at the end of the procedure and a metallic tracheostomy tube (26Fr) was placed in the tracheotome.

Figure 1

Tracheotome done

Figure 2

Nasal endoscope and crocodile forceps introduced through tracheotome

Figure 3

Piece of apple with its skin

Postoperative period was uneventful and the child recovered gradually. Moist O2 inhalation at 2 l/min was given for that night. Antibiotic, nebulization with salbutamol thrice daily and hydrocortisone 5 mg/kg IV were continued for 2 days. Paracetamol suppository 15 mg/kg was prescribed for analgesia. Tracheostomy tube was removed after 2 days and skin was closed by primary closure. A chest X-ray done after 2 days was found normal.

DISCUSSION

Inhaled FB is an important cause of death in children. Fragile pediatric cardiopulmonary status and limited functional residual capacity lead to reduced respiratory reserve, increased shunting and propensity for airway closure. This coupled with the relative increased oxygen consumption lead to rapid hypoxemia when ventilation is sub-optimal. The aspiration of a FB, by no means, is an uncommon occurrence, especially in the pediatric age group,[3] more commonly in younger children. Almost 20% of children who have inhaled foreign bodies are between 0 and 3 years of age.[4] Preventative measures, supervision are vital to reduce these deaths. The commonly aspirated objects include peanuts, seeds and other food particles.[2] They can get lodged at any site from supraglottis to the terminal bronchioles[3] resulting in a wide range of clinical problems. The majority of foreign bodies (88%, confidence interval (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%).[1]

The inhaled foreign bodies can be removed by rigid or flexible bronchoscope.[5] However, in absence of or with failure of the bronchoscopic procedure, innovative approaches are to be adopted so as to save a life. Here, we had such a case of FB aspiration which was life-threatening and had to be managed without a fiberoptic bronchoscope.

An already compromised airway compelled an induction that maintain spontaneous ventilation to minimize the risk of converting a partial proximal obstruction to a complete one,[1] as positive pressure ventilation may drive the FB further peripherally.[6] Hence, we preferred maintaining spontaneous ventilation with inhalational agent as the FB was in the bronchus. In a survey study, Kain et al. concluded that inhalation induction was favored most often for removal of foreign bodies in the airway, while intravenous induction was preferred for removal of foreign bodies in the gastroesophageal tract.[7]

Moreover, the tracheotome made to remove the FB complicated the situation, as there were chances that the inspired air would leak through it[8] and maintaining saturation was quite difficult.

However, the case was successfully managed and a precious life was, thereby, saved.

CONCLUSION

During handling a compromised airway, flexibility of the approach must be there. The technique applied may not be the best one, but anesthesiologist must be prepared to alter the approach according to the demand of the situation. Expertise of personnel, clear clinical plans, and familiarity with equipment is the key to success.