Anesthetic management for removal of aerodigestive tract F.

Guide : DR.VIKRAM SIR

Presented by : DR. SEEMA YADAV

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Aspirated (Airway) Foreign Body

Majority < 3 yrs age Male > Female Location of foreign body in the right or left main bronchus depends on patients age and physical position at the time of inhalation Angle made by the main stem bronchi with the trachea is similar until the age of 5 years

Aspiration in young children

Lack of molar teeth Poorer mastication Tendency to put things in mouth Playing with things in mouth Immature protective laryngeal reflexes

Objects Commonly Ingested or Aspirated by Children

seeds, nuts peanuts coins bones balloons jacks buttons toys pins hair clips marbles beverage tops screws nails
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Clinical Staging
1. Initial phase: choking, coughing, wheezing,
gagging
2. Asymptomatic phase: due to mucosal adaptation

3. Late phase: Laryngeal / Tracheal / Bronchial

4. Complication phase: pneumonia, emphysema,

lung abscess, atelectasis

Late Clinical Features

a. Laryngeal: partial or total airway obstruction,
hoarseness, aphonia, hemoptysis
b. Tracheal: airway obstruction, hemoptysis,

wheezing
c. Bronchial: cough, ipsilateral wheezing,

ipsilateral decreased breath sounds

Bypass valve & Stop valve effect

Partial Obstruction Total Obstruction

Wheezing

Late Atelectasis

Check valve & Ball valve effect

No Expiration No Inspiration

Emphysema

Early Atelectasis

Diagnosis

History

Physical Exam Radiography

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History of choking
Highly sensitive (> 90%) for aspiration

Specificity: 45 76%

Classic history:
Choking episode followed by coughing spells

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Physical Exam
Sensitivity: 24-86 %

Specificity: 12-64 % Decreased unilateral breath sound Unilateral Wheezing

Stridor
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Chest x-ray
Normal in 20- 40 % of cases

Inspiratory/ expiratory film

Air-trapping on expiration

Atelectasis
Infiltration

Consolidation

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Clinical Diagnosis
Conscious pt:

1. Hoarseness / aphonia
2. Respiratory distress
Unconscious pt: 1. No chest movement 2. No air exchange at nose /

mouth. 3. Cyanosis.

Radio-opaque F.B. Bronchus

Radio-opaque F.B. larynx

Radio-lucent F.B.

Right Lung collapse & Left emphysema

Management of choking in an unconscious patient

1. Patient placed in supine position

2. Open airway + mouth to mouth

ventilation 3. Correct airway obstruction

Correcting airway obstruction in an unconscious pt

5 Back blows

failure
5 Abdominal thrusts Or 5 Chest thrusts
(pregnancy, age < 8 yrs)

failure
Open pts mouth + blind finger sweeps.

Continue this sequence till FB is removed or pt is ready to be shifted to operation theatre.

Management of choking in a conscious pt

If patient can speak, cough, or breathe:
Do not interfere. Patient to be examined by an ENT specialist as soon as possible. If the patient cannot speak, cough, or breathe: Begin treatment for obstructed airway.

Correcting airway obstruction in a conscious pt > 1 yr old

5 Back blows failure 5 Abdominal thrusts (Heimlich maneuver)

Or 5 Chest thrusts (for pregnancy, age < 8 yrs)

Continue this sequence till FB is removed

Heimlich Maneuver
Stand behind sitting / standing pt & pass
your arms around pts waist. Hold your fist against pts abdomen b/w umbilicus & ribcage. Lock hands & apply 5 rapid, inward + upward thrusts to dislodge FB.

Heimlich Maneuver

Chest thrusts
Stand behind standing pt & pass your arms around pts chest. Hold your fist against pts sternum in its centre. Lock hands & apply 5 rapid, backward thrusts to dislodge FB.

Correcting airway obstruction in an infant

5 Back blows
failure 5 Chest thrusts

Continue this sequence till FB is removed or pt is ready to be shifted to operation theatre.

Chest thrusts in an infant

Supporting pts head, keep infant supine b/w your hands, with head lower

than trunk.
Using 2 fingers, deliver 5

rapid backward thrusts on

sternum.

Surgical Management
For life threatening stridor

Cricothyrotomy
Emergency Tracheostomy

For foreign body removal

Direct Laryngoscopy

Rigid Bronchoscopy
Thoracotomy & Bronchotomy

Prevention of choking
Adults:
Cut food into small pieces
Chew food slowly & thoroughly Avoid laughing / talking during eating Avoid excess alcohol with / before meals

Infants & Children:

Keep small objects away from children Avoid playing with food or toys in mouth

Swallowed Foreign Body

 Majority of foreign body ingestions occur in the pediatric population

Peak incidence between 6mos and 6yrs

In adults, foreign object ingestion more common with: o o o o Psychiatric disorders Mental retardation Those seeking some secondary gain Edentulous adults

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Diagnosis

Plain X-ray (PA & Lateral): soft tissue neck, chest,

abdomen for radio-opaque FB

Fluoroscopy with Barium soaked cotton pledget

for radiolucent FB

Barium Swallow

Flexible Oesophagoscopy

Coin in cricopharynx

Meat bolus in Cricopharynx

Toe ring in cricopharynx

Open safety pin

Pharyngeal FB

Common sites: tonsil, pyriform fossa, vallecula, base tongue Diagnosis confirmed by indirect laryngoscopy Usually removed in OPD but may require removal by Hypo-pharyngoscopy GA

Oesophageal & Gastric FB

Common sites: cricopharynx, aortic indentation &

cardiac end

Usually removed by rigid oesophagoscopy GA

Advancement into stomach is safe in difficult FB

Oesophagotomy rarely required for impacted FB

FB reaching stomach, usually passes out in stool

Emetic & Cathartic agents are contraindicated

Indications for Immediate Intervention

Associated respiratory obstruction Total oesophageal obstruction Disc battery (perforation occurs in 8-12 hrs) Sharp, impacted foreign body

Gastro-intestinal FB > 5 cm in a child < 2 yr

Gastro-intestinal FB with acute abdominal

pain
No progress of FB in serial X-ray after 24 hr Gastric FB with pyloric stenosis

Complications of neglected FB
1. Oesophageal ulceration & stricture

2. Oesophageal perforation mediastinitis

3. Peri-oesophageal cellulitis

4. Retro-pharyngeal abscess
5. Respiratory obstruction due to tracheal compression laryngeal oedema

Anesthetic management for removal of aspirated F.B

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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
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Pre-Operative Preparation
Fasting if patient stability permits IV access Anticholinergic medication Sedation- relatively contraindicated Preparation of OR - Anesthesia and resuscitation equipment - Endoscopy equipment and Endoscopist

MONITORING
1.Pulse oximeter 2. ECG 3. NIBP

4. Precordial stethoscope
5. Temp. and end tidal co
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Anesthetic Considerations

Both controlled and spontaneous ventilation techniques used during anesthesia for bronchoscopic FB removal

Positive Pressure Ventilation may push FB further peripherally

So: usual approach is to maintain spontaneous ventilation
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Anesthetic Considerations
Inhalation induction with Sevoflurane in 100% O2
Avoid N2O May induce in sitting up if patient very agitated or in severe respiratory distress

Induction may be slow if mainstem bronchus is obstructed

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Anesthetic Considerations

Once appropriate depth of anesthesia is reached, endoscopist may proceed Constant communication between endoscopist & anesthesiologist
Anesthesia circuit may be attached to side-arm of rigid bronchoscope to allow insufflation of Sevo/O2
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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 Contamination of room air may be a concern esp. during PPV Patient may become hypoxic if scope is pushed distally in bronchial tree during attempts to grasp a FB

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Anesthetic Considerations
Controlled ventilation with msl relaxant & intermittent apnea technique or jet ventilation
Induction inj thiopentone sod.(4-6 mg/kg) or propofol (2-2.5 mg/kg)+ sch. (1-1.5mg/kg) i.v Maintanance - msl relaxant ( sch 0.25 - 0.5 mg/kg ) and propofol (0.5 -1 mg/kg )

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Anesthetic Considerations
O intermittently from venturi high pressure injector device through narrow needle placed at proximal end of bronchoscope or bag & mask ventilation Not suitable for pts with compromised airway, obese and poor lung compliance

Period of apnea or hypoventilation should not

exceed 2-3 min
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Intraoperative Concerns
Unable to measure ETCO2- hypercarbia may develop Loss of airway

Laryngospasm / Bronchospasm
Regurgitation

Arrhythmias

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Intraoperative Concerns
Fragmentation of FB Pneumothorax Loss of spontaneous ventilation Airway edema Airway trauma, bleeding, perforation . . .
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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

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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 F.B require repeated procedures before normal air entry is restored

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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

Dont turn a non-obstructing FB into an obstructing one Dont miss the second FB- go back for another look Not all FBs can be removed endoscopically
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 Once foreign body ingestion is diagnosed, decision must me made : - whether or not intervention is necessary - degree of urgency

- what means of intervention

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Management is influenced by: Patients age and clinical condition Size, shape, and classification of the ingested material The anatomic location of lodged object Technical abilities of the endoscopist
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Without high-grade obstruction or acute distress can be managed less urgently b/c spontaneous passage may occur.

Under no circumstances should a foreign object or food bolus impaction be allowed to remain in the esophagus >24hrs.

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In children, the duration may be unknown.

When duration is unknown, most recommend endoscopy under general anesthesia and surgical consultation Pharyngeal FB - under local anesthesia

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Pre-Operative Preparation
Fasting IV access Anticholinergic & antiemetic medication Sedation Preprocedure radiograph to verify location

Anesthetic considerations
Standard monitoring

Rapid sequence induction with thiopental & succinylcholine,& an appropriate-sized orotracheal tube introduced Once an adequate depth of anesthesia and a stable airway are obtained, the endoscopy can proceed

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Observe until sedatives wear off (at least 4 hours) Reinsertion of endoscope after object removal (to rule out perforation) Do followup barium swallow in adults
Not necessary in children unless esophagitis present and risk of stricture
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Management of FB aero-digestive tract

Take proper history i.v access should always be taken Equipments for intubation should always be ready Emergency tray should be ready to deal with any incidence of laryngospasm or bronchospasm Keep the patient under observation till full consciousness is regained

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