Prof. A K Sethi’s EORCAPS 2008 Prof.

A K Sethi’s EORCAPS 2008

FOREIGN BODY BRONCHUS

Dr. Homay Vajifdar

Prof. A K Sethi’s EORCAPS 2008

Prof. A K Sethi’s EORCAPS 2008 Prof. A K Sethi’s EORCAPS 2008

FOREIGN BODY BRONCHUS TYPE OF FOREIGN BODY

Maximum incidence - age group – why ?
• 1 – 3 years • Commonly inhaled objects are:
Organic foods – seeds, nuts, chunks of carrots, bones
Related to
• Lack of molar teeth - edibles broken up, not

adequately chewed • Less commonly aspirated:

• Habit of putting all things in mouth Coins, toy parts, jewels, batteries, needles and pins

Preponderance in boys - aggressive nature

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 Prof. A K Sethi’s EORCAPS 2008 Prof. A K Sethi’s EORCAPS 2008

NATURE OF FOREIGN BODY

ORGANIC F/B METALLIC F/B
• The degree of tissue reaction depends on the nature
Irritation Less initial inflammation
of foreign body
↓ ↓
Inflammation Oxidizes
• Organic foreign bodies swell up and obstruct the ↓ ↓
bronchial passage. Oedema Rough edges
↓ ↓
• Swollen organic foreign bodies get easily fragmented Granulation Penetrates walls
when grasped, fragments may occlude both main ↓
stem bronchi – inability to ventilate . Pneumonia

Prof. A K Sethi’s EORCAPS 2008 Prof. A K Sethi’s EORCAPS 2008

DIAGNOSIS …contd
Clinical Presentation Physical findings

• H/o aspiration
- choking, coughing while eating • ↓ breath sounds
- audible wheeze
- respiratory distress (stridor, tachypnoea, • Wheeze,
in drawing of chest, cyanosis)
• Patient may present late
• Crepts, conducted sounds
- cough, sputum, fever not responding to t/t
- CXR – collapse and consolidation
• Mediastinal shift
syndrome of forgotten foreign body

Prof. A K Sethi’s EORCAPS 2008 Prof. A K Sethi’s EORCAPS 2008

DIAGNOSIS SUPPORTED BY TYPES OF BRONCHIAL OBST

• X-Ray chest – AP and Lat views
1. Check valve
• Fluoroscopy
2. Ball valve
• Ultrasonography

3. Stop valve
• CT scan

• MRI 4. Bypass valve

• V/Q scan

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 Prof. A K Sethi’s EORCAPS 2008 Prof. A K Sethi’s EORCAPS 2008

CHECK VALVE BALL VALVE

• Ingress of air in inspiration, but no egress during • Smooth rounded foreign body
expiration → Obstructive emphysema
• Dislodges in expiration, re-impacts in inspiration
• Mediastinal shift to opposite side → early atelectasis

• Depressed dome of diaphragm • Mediastinal shift to same side

• Elevated dome of diaphragm

Prof. A K Sethi’s EORCAPS 2008 Prof. A K Sethi’s EORCAPS 2008

STOP VALVE BYPASS VALVE

• Partial obstruction of lumen during both – inspiration

• Total occlusion due to large or swollen organic and expiration
foreign body, in both inspiration and expiration
• Reduction in ventilation
• Collapse and consolidation of affected broncho-
pulmonary segment • ↓ aeration and opacity in involved lung field

• Slight mediastinal shift

Prof. A K Sethi’s EORCAPS 2008 Prof. A K Sethi’s EORCAPS 2008

RADIOLOGICAL FINDINGS

• Radio- opaque - readily identified

• Radio-lucent - signs of partial or complete obstruction
• Complete obst – atelectasis
• Partial obst – obstructive emphysema with depressed
diaphragm and mediastinal shift to opposite side
• Pneumonia
• Pneumothorax –uncommon, due to obst emphysema
and penetration due to sharp foreign body
• Normal X-ray within first 24 hrs

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 Prof. A K Sethi’s EORCAPS 2008 Prof. A K Sethi’s EORCAPS 2008

GOALS OF ANAESTHESIA

• Control of airway
• Suppression of airway reflexes
• Amnesia
• Unobstructed, immobile surgical field
• No time restriction for surgeon
• ↓ secretions and prevent aspiration
• Smooth emergence
• Safe extubation

Prof. A K Sethi’s EORCAPS 2008 Prof. A K Sethi’s EORCAPS 2008

HOW TO ACHIEVE GOALS ? RUSH FOR SURGERY

• Rush for surgery / assess ? • Acute stridor with air hunger and cyanosis

• Inhalational or intravenous induction ? • Severe respiratory obstruction

• Spontaneous or controlled ventilation ? • 100 % O2, immediate bronchoscopy

• To use or avoid N2O ?

Prof. A K Sethi’s EORCAPS 2008 Prof. A K Sethi’s EORCAPS 2008

INDUCTION SPONTANEOUS RESPIRATION

Advantage
• No IPPV – no distal migration of f/b

Inhalational or intravenous induction depending on Disadvantages

patient’s condition and situation • No protection against aspiration

• Sudden movement → tracheal / laryngeal damage

• Deep anaesthesia needed → hypoventilation, delayed

recovery
• Instrumentation → turbulence, resistance and ↑ work

of breathing

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 Prof. A K Sethi’s EORCAPS 2008 Prof. A K Sethi’s EORCAPS 2008

CONTROLLED VENTILATION USE OF N2O

Advantages
• Relaxed glottis allows smooth passage of

bronchoscope • 100 % oxygen not possible

• Minimal laryngospasm, coughing, bucking, unwanted

vocal cord motion • Expansion of trapped air spaces →

• Rapid recovery with intact reflexes - Further mediastinal shift
- CVS compromise
Disadvantage - Pneumothorax
• Distal dislodgement of foreign body

Prof. A K Sethi’s EORCAPS 2008 Prof. A K Sethi’s EORCAPS 2008

ANAESTHESIA

Induction
• Pre oxygenation, atropine 0.02mg kg

• O2 + N2O + Halothane / Sevofluorane

• IV Thiopentone / ketamine / propofol

Maintenance
• O2 + N2O + inhalational agent + opioid

• Intermittent suxamethonium / NDMR

Prof. A K Sethi’s EORCAPS 2008 Prof. A K Sethi’s EORCAPS 2008

Contd….. MONITORING

Reversal
• SpO2
• Remove bronchoscope • ECG
• Ventilate with 100 % O2 (bag & mask) • NIBP
• Intubate and ventilate • Pre-cordial stethoscope
• Neostig 0.05 mg/kg + atr 0.02mg/kg • Temperature
• Neuromuscular monitoring

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 Prof. A K Sethi’s EORCAPS 2008 Prof. A K Sethi’s EORCAPS 2008

TECHNIQUES OF VENTILATION DISADVANTAGES

• Uncertain oxygen concentration

• Apnoeic oxygenation
• Hypoxia
• Jet ventilation
• CO2 retention
• HFJV
• Barotrauma

Prof. A K Sethi’s EORCAPS 2008 Prof. A K Sethi’s EORCAPS 2008

COMPLICATIONS Contd…….

Cardiac arrhythmias
Bronchospasm
• Light anaesthesia, ↑ vagal tone
Bronchial / carinal stimulation (light GA)
• Hypoventilation, hypoxemia
• Deepen level of anaesthesia

• Bronchodilators - terbutaline 5-10 µg / kg i/m or s/c

Managed with (maximum dose of 0.4 mg)
• ↑ FiO2

• Hyperventilate – normal EtCO2

Pneumothorax
• Deepen level of anaesthesia,
IPPV in necrotizing bronchopneumonia or ball
• Lidocaine 1 mg / kg
valve obst

Bleeding

Prof. A K Sethi’s EORCAPS 2008 Prof. A K Sethi’s EORCAPS 2008

POST OPERATIVE CARE Contd…

• Close observation for:

• Humidified oxygen
- stridor
• Bronchodilators
- respiratory distress
• Antibiotics
• Misc:
• Postural drainage and physiotherapy
- Dexamethasone (0.5 - 1.5 mg / kg)
- Racemic epinephrine (2.25 %)
• Check X-ray nebulize over 10 min in 1:6 – 1:10 dilution

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 Prof. A K Sethi’s EORCAPS 2008 Prof. A K Sethi’s EORCAPS 2008

FLEXIBLE BRONCHOSCOPY

• Only indicated if patient is stable to diagnose the

presence of foreign body – performed under sedation
and LA

• If foreign body is found, it is removed with rigid

bronchoscope

• No role in presence of respiratory distress

Prof. A K Sethi’s EORCAPS 2008 Prof. A K Sethi’s EORCAPS 2008

FOREIGN BODY OESOPHAGUS

Endo tracheal intubation is a must

• Accidental dropping of foreign body

into unprotected larynx

Prof. A K Sethi’s EORCAPS 2008

RETAINED F/B OESOPHAGUS

• Broncho-oesophageal fistula
• Aorto-oesophageal fistula
• Mediastinitis
• Oesophageal diverticulum
• Lobar atelectasis
• Large f/b - pressure on trachea - resp obst
• Requires thoracotomy for removal