Tracheobronchial Foreign Bodies in Children

Asphyxiation by an inhaled foreign body is a leading cause of accidental death among children younger than 4 years. A review article examining 12,979 paediatric bronchoscopies made the following observations:

Epidemiology

  • Most aspirated foreign bodies are organic materials (81%, confidence interval [CI] = 77%-86%), nuts and seeds being the most common.
  • The majority of foreign bodies (88%, CI = 85%-91%) lodge in the bronchial tree, with the remainder catching in the larynx or trachea.
  • The incidence of right-sided foreign bodies (52%, CI = 48%-55%) is higher than that of left-sided foreign bodies (33%, CI = 30%-37%). A small number of objects fragment and lodge in different parts of the airways.
  • A history of a witnessed choking event is highly suggestive of an acute aspiration.
  • A history of cough is highly sensitive for foreign body aspiration but is not very specific. On the other hand, a history of cyanosis or stridor is very specific for foreign body aspiration but is not very sensitive.
  • Signs and symptoms typical in delayed presentations include unilateral decreased breath sounds and rhonchi, persistent cough or wheezing, recurrent or nonresolving pneumonia, or rarely, pneumothorax.
  • Only 11% (CI = 8%-16%) of the foreign bodies were radio-opaque on radiograph, with chest radiographs being normal in 17% of children (CI = 13%-22%).
  • The common radiographic abnormalities included localized emphysema and air trapping,¬†atelectasis, infiltrate, and mediastinal shift.
  • Although rigid bronchoscopy is the traditional diagnostic “gold standard,” the use of computerized tomography, virtual bronchoscopy, and flexible bronchoscopy is increasing.
  • Reported mortality during bronchoscopy is 0.42%.
  • Although asphyxia at presentation or initial emergency bronchoscopy causes some deaths, hypoxic cardiac arrest during retrieval of the object, bronchial rupture, and unspecified intraoperative complications in previously stable patients constitute the majority of in-hospital fatalities.
  • Major complications include severe laryngeal edema or bronchospasm requiring tracheotomy or reintubation, pneumothorax, pneumomediastinum, cardiac arrest, tracheal or bronchial laceration, and hypoxic brain damage (0.96%).
  • Aspiration of gastric contents is not reported.

End expiratory film: delayed emptying of the left lung suggests local air trapping

Anaesthetic considerations

  • Preoperative assessment should determine where the aspirated foreign body has lodged, what was aspirated, and when the aspiration occurred (“what, where, when”).
  • The choices of inhaled or IV induction, spontaneous or controlled ventilation, and inhaled or IV maintenance may be individualized to the circumstances. Although several anesthetic techniques are effective for managing children with foreign body aspiration, there is no consensus from the literature as to which technique is optimal.
  • An induction that maintains spontaneous ventilation is commonly practiced to minimize the risk of converting a partial proximal obstruction to a complete obstruction.
  • Controlled ventilation combined with IV drugs and paralysis allows for suitable rigid bronchoscopy conditions and a consistent level of anesthesia.
  • Close communication between the anesthesiologist, bronchoscopist, and assistants is essential.

The Anesthetic Considerations of Tracheobronchial Foreign Bodies in Children: A Literature Review of 12,979 Cases
Anesth Analg. 2010 Oct;111(4):1016-25