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Table of Contents  
ORIGINAL ARTICLE
Year : 2017  |  Volume : 11  |  Issue : 4  |  Page : 871-874  

A retrospective analysis on anesthetic management during rigid bronchoscopy in children with foreign body aspiration: Propofol and sevoflurane with controlled ventilation


Senior Resident, Karnataka Institute of Medical Sciences, Hubballi, Karnataka, India

Date of Web Publication28-Nov-2017

Correspondence Address:
Rashmi Suresh Patil
W/o Dr. Chetan Hoskatti, G-4, Kalburgi Greens, Near Sub Jail, Vishweshwar Nagar, Hubballi - 580 032, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/aer.AER_154_17

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   Abstract 


Background: Bronchoscopic removal of foreign body in the airway is one of the important life-saving procedure and demands skill and expertise on the part of the surgeon and anesthesiologist. Aim: To study the outcome of controlled ventilation during rigid bronchoscopy in children with foreign body aspiration. Materials and Methods: A review of fifty cases of foreign body in the bronchi, from January 2014 to December 2015 was undertaken in Vittal Institute of Child Care Hospital, Dharwad, through patient case records. Patients between 6 months and 14 years were included in the study. Cases of foreign body in the larynx and trachea were excluded. Patients were induced with propofol and maintained on sevoflurane. The parameters observed were bronchoscopy attempts, succinylcholine requirement, episodes of laryngospasm, cough, bronchospasm and spontaneous recovery. Statistical analysis was done by Chi-square test using software OpenEpi version 7.3. Results: Of 45 patients with organic foreign body, 42 (94%) patients required one attempt of bronchoscopy and 3 (6%) patients required two attempts. Five (100%) patients with inorganic foreign body required single attempt (P = 0.66). Forty-three (96%) patients with organic foreign body required two repeat doses of succinylcholine and 2 (4%) patients required three repeat doses. All 5 (100%) patients with inorganic foreign body required two repeat doses (P = 0.7461). Two (4%) patients aspirated with organic foreign body had laryngospasm, and there was no cough or bronchospasm with either patient. Two (4%) patients with organic foreign body required tracheostomy. Inorganic foreign body group of patients had lesser complications. Conclusion: In our study, patients on controlled ventilation had few intraoperative complication and smooth early recovery. Controlled ventilation with relaxation should be preferred for any pediatric bronchoscopies. Eliciting history of type of foreign body helps in planning and management of procedure.

Keywords: Controlled ventilation, organic and inorganic foreign body, respiratory tract infection, rigid bronchoscopy


How to cite this article:
Annigeri RV, Patil RS. A retrospective analysis on anesthetic management during rigid bronchoscopy in children with foreign body aspiration: Propofol and sevoflurane with controlled ventilation. Anesth Essays Res 2017;11:871-4

How to cite this URL:
Annigeri RV, Patil RS. A retrospective analysis on anesthetic management during rigid bronchoscopy in children with foreign body aspiration: Propofol and sevoflurane with controlled ventilation. Anesth Essays Res [serial online] 2017 [cited 2019 Aug 19];11:871-4. Available from: http://www.aeronline.org/text.asp?2017/11/4/871/219352




   Introduction Top


Foreign body aspiration is important cause of mortality and morbidity if not treated immediately in pediatric patients. The degree of severity depends on the type of objects swallowed, starchy objects adsorbs water and turns partial to complete obstruction while lipophilic objects cause intense chemoinflammation.[1] Total or near total obstruction of larynx or trachea causes asphyxia leading to death, so prompt and immediate measures are to be taken for retrieval of foreign body.[2]

The three main issues in managing a pediatric patients are they are not cooperative, have smaller airway lumen, and the airway is shared by both surgeon and anesthesiologist.[3] These factors make it more challenging for both surgeon and anesthesiologist in the management. The results are highly appreciable due to recent advances in anesthesia and bronchoscopy.[4] In the present study, we have made an attempt to show the outcomes of the cases being managed in tertiary care center.


   Materials and Methods Top


A review of fifty cases of foreign body in the bronchi from January 2014 to December 2015 was undertaken in Vittal Institute of Child Care Hospital, Dharwad. Patients between 6 months and 14 years were included in the study through well maintained and documented case records in the form of case sheets. Preformed pro forma was maintained and all the findings were documented by single anesthesiologist involved in the study. The analysis of clinical material including age, sex, incidence, site, clinical presentation, radiological investigations, availability of history of foreign body aspiration, type and location of foreign body, and preanesthetic evaluation was done. Cases of foreign body in the larynx and trachea were excluded as also those in whom thorough investigations including bronchoscopy failed to reveal a foreign body. Cases in whom the data were inadequate were not included in the study. Ethical committee clearance was taken and informed written and risk consent was taken from all patients. Some of the patients were full stomach; a risk consent was taken. All patients were evaluated by pediatrician, and bronchoscopy was done. After securing an intravenous (IV) access, all the study patients were premedicated with injection glycopyrrolate 4 μg/kg IV and injection hydrocortisone 2 mg/kg IV and bronchodilators before bronchoscopy. After shifting to operation theater, standard monitors were attached (Pulse oximeter, ECG, NIBP, ETCO2). Patients were preoxygenated with 100% oxygen with Jackson Rees circuit for 3 min. Patients were induced with propofol 2 mg/kg IV; muscle relaxation with injection succinylcholine 1 mg/kg was given after confirming adequate ventilation. The circuit was connected to ventilating port of rigid bronchoscope with fiberoptic light source and ventilated with 100% oxygen. Anesthesia was maintained with fentanyl 1 μg/kg, intermittent doses of succinylcholine 0.5 mg/kg and sevoflurane depending on requirement (hemodynamics) of the patient was given. Nitrous oxide was not used to limit pulmonary inflation and rupture.

The parameters observed in the study were:

  1. Broncoscopy attempts
  2. Succinylcholine requirement
  3. Episodes of laryngospasm
  4. Other complications (intraoperative cough, bronchospasm)
  5. Spontaneous recovery.


After successful removal of foreign body, a check bronchoscopy was also done. Patients were monitored in the postoperative care unit till, maintaining saturation on room air, budecortisone nebulization was given to all patients, and later shifted to recovery room and observed.

Statistical analysis

Categorical data were analyzed with Chi-square test. Types of foreign body comparison were done by Chi-square test using Software OpenEpi version 7.3 developed by the OpenEpi Project.


   Results Top


A total of fifty cases were included in the study.

Age and sex

The age ranged from 6 months to 14 years, 35 cases (70%) being between 3 months and 3 years. There were 35 males and 15 females in our series [Table 1].
Table 1: Age and sex distribution of cases

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Types of foreign body

Organic foreign bodies were seen in 45 cases (90%) as compared to inorganic ones in only 5 cases (1%). Twenty-eight (56%) foreign bodies were found lodged in the right bronchus and 17 (34%) in the left. In 5 (10%) cases, there were foreign bodies in both the bronchi [Table 2].
Table 2: Site of foreign body

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Clinical presentation

Classical triad of chocking cough and noisy respiration with diminished air entry on examination is not always seen, but history is suggestive of foreign body aspiration in most of the cases. The duration of enlodgement of the foreign bodies before presentation ranged from 12 h to 6 months. A history of an episode of foreign body inhalation (35 cases) and cough (40 cases) were the most common symptoms followed by breathlessness (30 cases), fever (15), vomiting (5 cases), cyanotic spells (8 cases), and chest pain (2 case) [Table 3]. On clinical examination, a diminished breath sound on one side of the chest (40) was the most common finding. In the remaining 10 cases, breath sounds were equal in intensity on both sides. The respiratory system examination revealed no abnormality in 2 cases. A significant number of 22 cases had rales and 22 cases had rhonchi. Intercostal and suprasternal retraction was noted in 20 cases and stridor in 15 cases [Table 4]. Only 2 patients presented with severe respiratory distress and cyanosis, and oxygen saturation was 50%–60%. These patients were immediately transferred to operation theater, and removal of foreign bodies was done by bronchoscopy.
Table 3: Presenting symptoms of patients

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Table 4: Presenting signs in patients

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Radiology

Plain X-ray of the chest revealed obstructive emphysema in thirty cases. Pneumonitis was noted in 8 cases, collapse in 4 cases, and normal finding in 8 cases.

Management

In all cases, the foreign body was removed successfully by bronchoscopy using a rigid bronchoscope with fibreoptic lighting under general anesthesia (using muscle relaxants). All patients received pre- and post-operative antibiotic coverage and injectable steroid to prevent mucosal edema. All the patients were premedicated with injection glycopyrrolate 4 μg/kg and injection hydrocortisone 2 mg/kg. After shifting to operation theater, monitors were attached as per ASA guidelines (pulse oximeter, ECG, NIBP ETCO2). Patients were preoxygenated with 100% oxygen for 3 min with Jackson Rees circuit. Patients were induced with injection propofol 2 mg/kg and muscle relaxant injection succinylcholine 1 mg/kg. Anesthesia was maintained with injection fentanyl 1 μg/kg, sevoflurane, and intermittent doses of injection succinylcholine 0.5 mg/kg. Bronchoscopy was done on one occasion in 42 (94%) patients and two occasions in 3 (6%) patients in patients with organic foreign body and 5 (100%) patients with inorganic foreign body required single attempt (P = 0.66). Two patients (4%) with organic foreign body had laryngospasm which needed three repeated doses of succinylcholine and rest 43 (96%) patients required two repeated doses, and all five (100%) patients with inorganic foreign body required two doses of succinylcholine (P = 0.7461) and no patients had intraoperative cough and bronchospasm. The difference between organic and inorganic foreign body for bronchoscopy attempts and succinylcholine repeated doses was statistically not significant [Table 5]. Laryngospasm was treated appropriately with 100% oxygen and injection hydrocortisone 2 mg/kg and injection deriphyllin 1.5 mg/kg. Tracheostomy was needed in 2 (4%) patients with organic foreign body to help removal of foreign body which was very difficult to remove through glottis which required intubation and long-acting muscle relaxant injection atracurium 0.5 mg/kg [Table 5], no mortality in the series. Of all cases, the interesting was a 4-year-old male child suffering from repeated respiratory tract infection referred for bronchoscopy, it revealed whistle in right bronchus. Ten patients were discharged within 24 h, 30 patients between the 2nd and 5th day. The rest were hospitalized for a longer period between 6 and 20 days.
Table 5: Parameters observed

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   Discussion Top


Foreign body in the airway is a common emergency problem. In our institution, the number of cases are increasing probably as a result of nonavailability of bronchoscope in peripheral hospitals and in city hospitals. In the present study, it was found that detail clinical history and high degree of clinical suspicion are the main stays of diagnosis. Preoperative assessment is done thoroughly to see where the foreign body is located, type of foreign body, and time since ingestion.[5] As the duration of time since ingestion increases, it becomes difficult for the assessment as no one would have witnessed the event, and in most of the cases, chest X-ray will be nonspecific. The child had difficulty in swallowing hard foodstuffs such as nuts and seeds and has inadequately developed protective respiratory reflexes.[6] This makes it more vulnerable than adults to the inhalation of foreign bodies into the respiratory passage. The male predominance in this series is in agreement with the published reports.[7],[8],[9],[10] A possible explanation for this is offered by Gupta et al.[8] who state that “boys by nature are more curious and inquisitive than girls.” The high predominance of organic foreign body in this series is in keeping with published reports.[7],[8],[9] Organic foreign body absorbs water and also causes intense chemoinflammation. This, coupled with the high frequency in children under the age of 3 years, makes it advisable not to offer nuts and seeds to small children, who are liable to aspirate them into the respiratory passage.

About 40% of our patients presented within 24 h of aspiration of the foreign body and 40% came between the 6th and the 10th day; this might be due to the pact that it takes 7–14 days after the aspiration to develop serious complication, such as consolidation or collapse.

About 70% of the patients were admitted with history of inhalation of a foreign body, many after close questioning. Of the 30% patients who had fever, 90% had organic foreign body.

Contrary to expectation, 20% of patients had equal breath sounds on both sides of the chest, while only 22% of the patients showed crepitation probably due to lung infection. Thus, one must be willing to consider a foreign body as a differential diagnosis even when there are no abnormal physical signs in the chest.

The most common radiological finding was obstructive emphysema (60% cases). This is in conformity with other reports.[11] Further, X-rays of the chest were completely normal in 16% cases. This would indicate that even a normal X-ray of the chest does not negate the diagnosis of a foreign body in the respiratory passage. However, when there is suspicion of foreign body in X-ray, whatever may be the X-ray bronchoscopy is mandatory. Harlan et al.[12] opined that radiographic imaging should not alter the decision of surgical intervention (bronchoscopy). Rigid bronchoscopy under general anesthesia for foreign body removal is gold standard procedure.[13] In our study, we used propofol for induction and succinylcholine for controlled ventilation and sevoflurane for maintainance. We had lesser intra- and post-operative complication and early smooth recovery. Farrell showed that IV induction with sevoflurane has lower incidence of side effects, and decreased airway resistance facilitates removal of foreign body. In this study, two anesthesiologists were involved; who are trained in pediatric anesthesia.[14] In this study, patients were kept on spontaneous ventilation; they observed intraoperative adverse effects such as coughing, breath holding, body movement, bronchospasm, and laryngospasm which were not observed in our study except for two patients who had laryngospasm. Positive pressure ventilation is preferred as muscle relaxation techniques improve oxygenation, facilitate smooth removal of foreign body, reduce untoward anesthetic effects on cardiac output, and also known to reduce risk of atelectasis.[14] Chai et al. also showed that sevoflurane induction followed by combination of sevoflurane and continuous infusion of propofol has fewer adverse outcomes.[15] Controlled ventilation also decreases the risk of laryngospasm; this helps in smooth retrieval of foreign body and early postoperative recovery,[16] which is observed in our study. Intraoperative cough and bronchospasm were not observed in our study as patients were maintained on controlled ventilation. In some patients, we could not come to a conclusion of organic or inorganic foreign body by history which affected in planning anesthetic management, and also, some patients with full stomach were also taken depending on the need of procedure. Since it is a retrospective analysis, we had maintained and well documented all the data and findings required for our study; patients whose data were lacking were not included in our study.


   Conclusion Top


In our study, patients on controlled ventilation with succinylcholine and sevoflurane had no intraoperative cough or bronchospasm, and postoperatively, patients had early smooth recovery. According to this study, controlled ventilation with relaxation should be preferred for any pediatric bronchoscopies.

In general, the results of treatment of foreign bodies in the respiratory tract appear to be good with early diagnosis and intervention and also with appropriate anesthetic management. Patients with inorganic foreign body have lesser complications with easy removal and smooth recovery.

Eliciting history of type of foreign body helps in anticipating the complications and planning the procedure.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

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Salih AM, Alfaki M, Alam-Elhuda DM. Airway foreign bodies: A critical review for a common pediatric emergency. World J Emerg Med 2016;7:5-12.  Back to cited text no. 1
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Liu J, Xiao K, Lv X. Anesthesia and ventilation for removal of airway foreign bodies in 35 infants. Int J Clin Exp Med 2014;7:5852-6.  Back to cited text no. 3
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Fidkowski CW, Zheng H, Firth PG. The anesthetic considerations of tracheobronchial foreign bodies in children: A literature review of 12,979 cases. Anesth Analg 2010;111:1016-25.  Back to cited text no. 5
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David SS, Subbiah B. Foreign bodies in the air and food-passages in children (report of four cases). Indian Pediatr 1973;10:183-5.  Back to cited text no. 6
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Cohen SR, Herbert WI, Lewis GB Jr., Geller KA. Foreign bodies in the airway. Five-year retrospective study with special reference to management. Ann Otol Rhinol Laryngol 1980;89(5 Pt 1):437-42.  Back to cited text no. 7
    
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Gupta A, Chopra K, Saha M, Khanna SK, Gupta RK, Narayanan PS, et al. Foreign bodies in the tracheobronchial tree. Indian Pediatr 1977;14:133-4.  Back to cited text no. 8
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Ono J. Foreign bodies in air and food passages in the Japanese. Arch Otolaryngol 1965;81:416-20.  Back to cited text no. 9
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Rothmann BF, Boeckman CR. Foreign bodies in the larynx and tracheobronchial tree in children. A review of 225 cases. Ann Otol Rhinol Laryngol 1980;89(5 Pt 1):434-6.  Back to cited text no. 10
    
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Harlan RM, Andrew BS, Randal C. Utility of conventional radiography in the diagnosis and management of paediatrics airway foreign bodies. Ann Otol Rhinol Laryngol 1998;89:434-6.  Back to cited text no. 12
    
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Kendigelen P. The anaesthetic consideration of tracheobronchial foreign body aspiration in children. J Thorac Dis 2016;8:3803-7.  Back to cited text no. 13
    
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Farrell PT. Rigid bronchoscopy for foreign body removal: Anaesthesia and ventilation. Paediatr Anaesth 2004;14:84-9.  Back to cited text no. 14
    
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Chai J, Wu XY, Han N, Wang LY, Chen WM. A retrospective study of anesthesia during rigid bronchoscopy for airway foreign body removal in children: Propofol and sevoflurane with spontaneous ventilation. Paediatr Anaesth 2014;24:1031-6.  Back to cited text no. 15
    
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    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5]


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