Management of Patients With Airway Foreign Bodies The Anesthesiologist’s Perspective

1. Management of Patients With Airway Foreign Bodies The Anesthesiologist’s Perspective Dr. Robert Hoskin MD Ph.D Department of Anesthesia Royal Columbian Hospital New Westminster, BC Canada January 2010 Airway Foreign Bodies 2010

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11. Overview Spectrum of presenting symptoms from chronic to emergent Preparation Communication Constant Re-evaluation Individualize approach to each patient Anesthetic Considerations: Shared Airway Possible Full Stomach Spontaneous vs controlled ventilation Airway Edema Unstable Airway Foreign Bodies 2010

12. Presentation of Aspirated Foreign Bodies • Spectrum of symptoms depending on size and location of FB • Peripheral Airway FB’s may take weeks to months to cause symptoms: • Chronic lobar pneumonia • Unilateral wheeze • Chronic Cough • Hemoptysis Airway Foreign Bodies 2010

13. Presentation of Aspirated Foreign Bodies Most Foreign Body aspirations occur in children less than 3 years old Right lung > Left lung 1/3 of parents were unaware of the aspiration incident, or recalled an event occurring >1 week prior to presentation Airway Foreign Bodies 2010

14. Presentation of Aspirated Foreign Bodies Spectrum of symptoms depending on size and location of FB FB’s in trachea or at the cords may cause Dyspnea Stridor Aphonia Coughing Cyanosis Total Obstruction Airway Foreign Bodies 2010

15. Presentation of Aspirated Foreign Bodies Supraglottic Foreign Body- Inspiratory Wheeze Infraglottic Foreign Body- Expiratory Wheeze Airway Foreign Bodies 2010

16. Presentation of Aspirated Foreign Bodies Spectrum of symptoms depending on size and location of FB Identity of FB may or may not be known: Coins Small toys Beads Peas, beans, nuts, candies, raisins, grapes, seeds, etc. Airway Foreign Bodies 2010

17. Presentation of Aspirated Foreign Bodies Spectrum of symptoms depending on size and location of FB Foreign Bodies may impede airflow in 4 ways: “Check valve”: air may be inhaled but not exhaled “Ball Valve”: air may be exhaled but not inhaled “Bypass valve”: partial obstruction of inhalation and exhalation “Stop Valve”: total blockage Airway Foreign Bodies 2010

18. Presentation of Aspirated Foreign Bodies Spectrum of symptoms depending on size and location of FB There may be more than one Foreign Body! Airway Foreign Bodies 2010

19. Presentation of Aspirated Foreign Bodies Spectrum of symptoms depending on size and location of FB FB’s can move: partial obstruction can become total obstruction suddenly and unexpectedly. Airway Foreign Bodies 2010

20. Pre-Operative Assessment Severity of Airway Obstruction Gas Exchange Level of Consciousness Fasting Status Nature and location of Foreign Body: History Radiographic Exam Physical Exam Unilateral wheeze Air Entry Aphonia, stridor Airway Foreign Bodies 2010

21. X-Ray Findings in Airway Foreign Bodies Many Airway FB’s are radiolucent Many CXR’s are normal, especially in first 24 hours Secondary Evidence on CXR: Atelectasis, Air Trapping with mediastinal shift Pneumonia Inspiratory/Expiratory Films Airway Foreign Bodies 2010

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26. Pre-Operative Preparation Fasting if patient stability permits Anticholinergic medication Sedation- relatively contraindicated IV access Preparation of OR Anesthesia equipment Endoscopy equipment and Endoscopist Airway Foreign Bodies 2010

27. Anesthetic Considerations Positive Pressure Ventilation may push FB further peripherally So: usual approach is to maintain spontaneous ventilation Airway Foreign Bodies 2010

28. Anesthetic Considerations Inhalation induction with Sevoflurane in 100% O2 Avoid N2O May induce sitting up if patient very agitated or in severe respiratory distress Induction may be slow if mainstem bronchus is obstructed Airway Foreign Bodies 2010

29. Anesthetic Considerations • Once appropriate depth of anesthesia is reached, endoscopist may proceed • Constant communication between endoscopist and anesthesiologist • Anesthesia circuit may be attached to sidearm of rigid bronchoscope to allow insufflation of Sevo/O2 Airway Foreign Bodies 2010

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33. Anesthetic Considerations Ventilation via sidearm of Rigid Scope: Caution to avoid hyperinflation if scope occludes airway Same channel in scope for ventilation and instrumentation: Gas flow may be impeded by forceps, etc. in channel Contamination of room air may be a concern especially during PPV Patient may become hypoxic if scope is pushed distally in bronchial tree during attempts to grasp a FB Airway Foreign Bodies 2010

34. Intraoperative Concerns Unable to measure ETCO2- hypercarbia may develop Loss of airway Laryngospasm Bronchospasm Regurgitation Arrhythmias Fragmentation of FB Pneumothorax Loss of spontaneous ventilation Airway edema Airway trauma, bleeding, perforation . . . Airway Foreign Bodies 2010

35. Intraoperative Concerns During attempted removal, FB may become hung up on vocal cords or in trachea Sudden new total airway obstruction Solution: endoscopist may need to use scope to push FB down a mainstem bronchus to allow ventilation of one lung Regroup, re-oxygenate, re-attempt removal Airway Foreign Bodies 2010

36. Postoperative Management Treatment of bronchospasm with bronchodilators Treatment of airway edema with racemic epinephrine CXR and physical exam looking for: Resolution of preoperative findings (unilateral wheeze, etc.) Development of new complications e.g. pneumothorax Edema and infection may take days to normalize Some Foreign Bodies require repeated procedures before normal air entry is restored Airway Foreign Bodies 2010

37. Words of Wisdom Normal CXR does not rule out Foreign Body All that wheezes is not asthma Practice with a duplicate Foreign Body Be ready and equipped Don’t turn a non-obstructing FB into an obstructing one Don’t miss the second FB- go back for another look Not all FB’s can be removed endoscopically Airway Foreign Bodies 2010

38. Overview Spectrum of presenting symptoms from chronic to emergent Preparation Communication Constant Re-evaluation Individualize approach to each patient Anesthetic Considerations: Shared Airway Possible Full Stomach Spontaneous vs controlled ventilation Airway Edema Unstable Airway Foreign Bodies 2010