Abstract
Aspiration of a foreign body is a significant cause of accidental death in young children, particularly those 1 to 4 years old. Most aspirated objects are pieces of food that lodge in the bronchial tree. The anesthesiologist should determine (1) where the aspirated object is lodged, (2) what was aspirated, and (3) when it was aspirated. Bronchoscopy and general anesthesia to remove an aspirated foreign body from a small child is hazardous if performed by inexperienced clinicians, with a worldwide mortality rate of about 0.4%. The anesthesiologist should ensure the airway is patent and that ventilation is adequate; maintain arterial oxygenation despite gas exchange potentially being impaired by airway obstruction, atelectasis, or pneumonia; and prevent coughing, bucking, and airway trauma during the stimulus of bronchoscopy. Both inhalational and intravenous anesthesia are feasible methods, and both controlled and spontaneous ventilation can be successfully used. Close cooperation and clear communication between the anesthesiologist, bronchoscopist, and assistants are essential to ensure safe extraction of the mislocated object.
Keywords
aspiration, bronchoscopy, foreign body, pediatric anesthesia
Case Synopsis
A 3-year-old boy is booked for an urgent rigid bronchoscopy for evaluation and removal of a suspected aspirated foreign body. He has previously been treated unsuccessfully with bronchodilators and antibiotics for a week-long history of coughing, wheezing, and mild tachypnea. The parents thought they recalled a prior episode of choking while he was eating peanuts. Chest x-ray showed localized right-sided air trapping and emphysema.
Problem Analysis
Definition
Aspiration of a foreign body is a significant cause of accidental death in young children, particularly those 1 to 4 years old. Most aspirated objects are pieces of food or other organic material. Nuts (particularly peanuts) and seeds (especially sunflower and watermelon seeds) are the most frequently aspirated types of objects. Death may occur acutely through complete mechanical airway obstruction or severe laryngospasm. Survivors may develop pneumonia or empyema if the object is not removed. Bronchoscopy with general anesthesia to remove an aspirated foreign body from a small child is hazardous if performed by inexperienced clinicians, with a worldwide mortality rate of about 0.4%. Loss of airway, hypoventilation and hypoxia are the main contributors to mortality under anesthesia.
Recognition
Diagnosis is typically made through a combination of history, examination, and radiologic investigation, although bronchoscopy is the most definitive investigation.
A history of a witnessed choking event is highly suggestive of an aspiration event. Although the positive predictive value is high, the negative predictive value is much lower, because many aspiration episodes are unnoticed by caregivers.
Frequent presenting signs and symptoms include persistent cough, wheeze (often localized), and tachypnea; cyanosis and stridor are less common.
A chest x-ray may be suggestive of a foreign object in the airway. As organic matter is the most common type of aspirated material, most inhaled bodies are radiolucent. A substantial minority of x-rays are reported as normal. Common abnormalities induced by luminal obstruction, however, include localized emphysema and air trapping, or atelectasis and infiltrate ( Fig. 57.1 ). Pneumothorax and pneumomediastinum are rare.
