1. Airway Foreign Bodies 2010 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

2. Airway Foreign Bodies 2010

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

12. Airway Foreign Bodies 2010 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

13. Airway Foreign Bodies 2010 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

14. Airway Foreign Bodies 2010 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

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

16. Airway Foreign Bodies 2010 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.

17. Airway Foreign Bodies 2010 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

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

19. Airway Foreign Bodies 2010 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.

20. Airway Foreign Bodies 2010 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

21. Airway Foreign Bodies 2010 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

22. Airway Foreign Bodies 2010

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

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

28. Airway Foreign Bodies 2010 Anesthetic Considerations Inhalation induction with Sevoflurane in 100% O 2 Avoid N 2 O May induce sitting up if patient very agitated or in severe respiratory distress Induction may be slow if mainstem bronchus is obstructed

29. Airway Foreign Bodies 2010 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/O 2

30. Airway Foreign Bodies 2010

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

34. Airway Foreign Bodies 2010 Intraoperative Concerns Unable to measure ETCO 2 - hypercarbia may develop Loss of airway Laryngospasm Bronchospasm Regurgitation Arrhythmias Fragmentation of FB Pneumothorax Loss of spontaneous ventilation Airway edema Airway trauma, bleeding, perforation...

35. Airway Foreign Bodies 2010 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

36. Airway Foreign Bodies 2010 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

37. Airway Foreign Bodies 2010 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

38. Airway Foreign Bodies 2010 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