Management of foreign body aspiration
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Management of Foreign body aspiration. PowerPoint PPT Presentation

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Management of Foreign body aspiration. Speaker : Dr. Pragati Nanda. Moderator : Dr. Subhash Chawla. FOREIGN BODY ASPIRATION. Common ,but a life threatening problem. Cause of morbidity and mortality.

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Management of Foreign body aspiration.

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Management of Foreign body aspiration.

Speaker : Dr. Pragati Nanda. Moderator : Dr. Subhash Chawla.


  • Common ,but a life threatening problem.

  • Cause of morbidity and mortality.

  • Can cause chronic lung injury.

  • Challanging for anaesthetist.

  • High degree of suspicion is required for diagnosis.

Foreign Bodies

  • Foreign body aspiration

  • Toddlers

    • Oral exploration

    • Lack posterior dentition

    • Easy distractibility

    • Cognitive development (edible?)

Involuntary safety muscular mechanics in adults.

  • 1. soft palate is pulled up and posteriorly,prevent reflux of food into nasal cavities. 2. palatopharangeal folds move medially to form a slit, allow only chewed food to pass. 3. epiglottis moves down and close to glottis.

Foreign Body Aspiration

  • Vegetable matter in 70-80%

    • Peanuts & other nuts (35%)

    • Carrot pieces, beans, sunflower & watermelon seeds

  • Metallic objects

  • Plastic objects

  • Organic f.b are more liable to evoke larangospasm, tracheobronchitis and lung infection. Hence, when patient presents, often has fever.

  • vegitable FB are slippery,hard to grip and friable. They usually get swollen, struk at subglottis, may lead to complete obstruction.


  • Bronchi – 80-90%

    • Right mainstem most common

      • Carina

      • Less divergent angle

      • Greater diameter

  • Trachea

  • Larynx

    • Larger objects, irregular edges

    • Conforming objects

  • Relevant Anatomy

  • Airway foreign bodies can become lodged in the larynx, trachea, and bronchus. The size and shape of the object determine the site of obstruction.

  • large, round, or expandable objects produce complete obstruction, and irregularly shaped objects allow air passage around the object, resulting in partial obstruction.


  • 1. check valve: air can be inhaled but not exhaled.[emphysema]. 2. ball valve: air can be exhaled but not inhaled.[broncho pul segment collapse]. 3. bypass valve: FB partially obstructs both in insp. and exp. 4. stop valve: total obstruction, airway collapse and consolidation.

  • Presentation

  • In general, aspiration of foreign bodies produces the following 3 phases:

  • Initial phase - Choking and gasping, coughing, or airway obstruction at the time of aspiration

  • Asymptomatic phase - Subsequent lodging of the object with relaxation of reflexes that often results in a reduction or cessation of symptoms, lasting hours to weeks

  • Complications phase - Foreign body producing erosion or obstruction leading to pneumonia, atelectasis, or abscess

Foreign Body Aspiration

  • History

    • Choking

    • Gagging

    • Wheezing

    • Hoarseness

    • Dysphonia

  • Can mimic asthma, croup, pneumonia

  • “A positive history must never be ignored, while a negative history may be misleading”

  • Foreign Body Aspiration

    • Tachepnia, rib and sternal retraction, cyanosis,n/v.

    • Hypoxic seizures, arrest,hypoxic brain damage.

    • Asymptomatic interval

      • 20-50% not detected for one week

    • Inflammation and Complications

      • Cough

      • Emphysema

      • Obstructive atelectasis

      • Hemoptysis

      • Pneumonia

      • Lung abscess

      • Fever

    Foreign Body Aspiration

    • Physical exam

      • Larynx/cervical trachea

        • Inspiratory or biphasic stridor,aphonia, complete obstruction.

      • Intrathoracic trachea

        • Prolonged expiratory wheeze,comp obs.

      • Bronchi

        • Unequal breath sounds

        • Diagnostic triad - <50%

          • Unilateral wheeze

          • Cough

          • Ipsilaterally diminished breath sounds

    • Fiberoptic laryngoscopy

    Foreign Body Aspiration

    • Radiography

      • PA & lateral views of chest & neck

      • Inspiration & expiration [atelectesis on insp, hyperinflation on exp. In affected bronchus.]

      • Lateral decubitus views [lower lung doesn’t collapse if FB present.]

      • Airway fluoroscopy [for intraop evaluation, to locate FB in lung periphery.]

    • 25% have normal radiography


    • Obstructive emphysema

    • Normal x-ray

    • Pneumonitis

    • Collapse with mediastinal shift

    • Foreign body. If still a diagnostic delima,CT scan is advised.

    Foreign Body Aspiration

    Foreign Body Aspiration

    Foreign Body Aspiration

    Foreign Body Aspiration

    • Indications

    • Perform surgical intervention with rigid bronchoscopy on patients:

    • who have a witnessed foreign body aspiration.

    • those with radiographic evidence of an airway foreign body.

    • those with the previously described classic signs and symptoms of foreign body aspiration. A strong history of suspected foreign body aspiration prompts an endoscopic evaluation, even if the clinical findings are not as conclusive or are not present

    • Contraindications

    • No contraindications exist to the removal of an airway foreign body from a child.

    • If necessary, health problems can be optimized before surgical intervention. However, even children who are at high risk due to health reasons still need surgical intervention to remove the foreign body.

    • History of the Procedure

    • Until the late 1800s, airway foreign body removal was performed by bronchotomy.

    • The first endoscopic removal of a foreign body occurred in 1897.

    • Chevalier Jackson revolutionized endoscopic foreign body removal in the early 1900s with principles and techniques still followed today.

    • The development of the rod-lens telescope in the 1970s and improvements in anesthetic techniques have made foreign body removal a much safer procedure.

    Foreign Body Aspiration

    • Goal of treatment

    • Prompt endoscopic removal under conditions of maximal safety and minimal trauma.

    • GA is always technique of choice.

    • Communication and cooperation between anaesthetist and endoscopist is must.


    • Challanging;

    • Fighting irritable child.

    • Full stomach.

    • Sharing of airway.

    • Difficult to maintain oxygenation and ventilation,as pulmonary gas exchange is already reduced.

    • Difficulty pertaining to pediateric airway.


      • Trained personnel

      • Instruments assembled and checked

      • Await for emptying of stomach

      • Find duplicate FB to test instruments and techniques

    Preoperative considerations.

    • Severity of airway obstruction, gas exchange and level of conciousness.

    • Nature and location of FB,degree and duration of obstruction.

    • fasting status. Delaying intervention must be balanced against potential functional impairment and oxygenation.

    • metoclopramide 0.15mg/kg iv.

    • Atropine 0.02mg/kg iv.

    Foreign Body Aspiration

    • General anesthesia

    • Spontaneous ventilation

    • Laryngoscopes

    • Bronchoscopes

    • Suction

    • Forceps

    • Rod-lens telescopes


    • 1. Adequate oxygenation.

    • 2. Controlled cardiorespiratory reflexes during bronchoscopy.

    • 3. Rapid return of airway reflexes.

    • 4. Prevention of pulmonary aspiration.

    • 5. Meticulous monitoring : spo2,ECG,NIBP,EtCO2.


    • Oxygen sevoflurane induction.

    • Monitor, IV line.

    • Ketamine 2mg/kg- safe in peadtric pts,full stomach,leaves cough reflex intact,provides CVS stability and prevents bronchospasm.

    • Atropine 0.02mg/kg- dec secreations and obtund autonomic reflexes during airway instrumentation.

    • Nitrous oxide is avoided,as it inc gas volume,air traping and possible rupture of affected lung.

    • Suxa 1.5 mg/kg if controlled ventilation planned.

    Foreign Body Aspiration

    • Ready to assume airway during induction

    • Laryngoscopy

      • Topical anesthesia- ligocaine spray 3-4mg/kg.[prevents larangospasm]

      • Examination of upper airway

      • Atraumatic insertion of bronchoscope

    • Bronchoscopy

      • Attached to ventilating circuit

    Foreign Body Aspiration

    • Bronchoscopy

      • Suction opposite bronchus

      • IPPV through side arm mapelson F circuit.

      • Advance to foreign body

      • Atraumatically grasp foreign body

      • Repeat bronchoscopy

        • Suction bronchus

        • Multiple foreign bodies in 5-19%

      • Remove granulation tissue

      • Topical vasoconstrictors for bleeding

    Foreign Body Aspiration

    • Slipped foreign body

      • Push back into bronchus,stablise and remove.

    • Sharp foreign body

      • Advance bronchoscope over FB, to prevent trauma.

    Anaesthetic maintainence

    • oxygen, halo/iso.[ give more time for airway manipulation] Or rpt ketamine.[no OT pollution]

    • Suxa 0.25-0.5mg/kg with atropine 0.02mg/kg.

    • High flows are needed to compensate leak around bronchoscope.

    • Ventilation has to be intrupted while suctioning and removal of foreign body.

    • If foreign body is big/swollen tracheostomy may be needed.

    • Big FB can be taken out in piecies.

    • Apnea/ oxygen insufflation, is prefered at some crucial time, ideally should not last beyond 1min. After 5 min hypercarbia may lead to dysarrythmias.

    • If ventilation is inadequate with rigid broncoscope,high frequency jet ventilation via bronchoscope or ECMO can be used.

    • For FB embeded in mucosa,wait for 48-72hrs. Let odema subside. Rpt bronchoscopy , if unsuccessful- thoracotomy.

    Spontaneous v/s controlled ventilation

    • SPONTANEOUS VENTILATION. ADV; 1. no dislodgement of FB. 2. unhurried bronchoscopy. 3. relatively safe. DISADV; 1. inc coughing, bucking. 2. inc chances of bronco/ larangospasms and arrythmias.[inadequate depth]. 3. inc resistance bcoz of bronchoscope and suctioning. 4. large FB doesn’t come out because of VC movements and closure.

    • After removal of foreign body, check bronchoscopy is done to ensure full clearence and check impaction site for trauma/ bleeding/granulation.

    • Inj Dexamethasone 0.4-1mg/kg, humidified oxygen and bronchodialators given postop.

    Foreign Body Aspiration

    • Complications

    • Larago/bronchospasm; ms. Relaxation,adequate ventilation.

    • Arrhythmias: hyperventilation , lignocaine.

    • Pneumothorax

    • Pneumomediastinum

      • Pneumonia

        • Antibiotics, physiotherapy

      • Atelectasis

        • Expectant management, physiotherapy

    • If postop stridor or distress: nebulise with racemic Epinephrine.

    • Observe the child in recovery room for signs of subglotic odema, haemorhage, bronchospasm and airway perforation.

    • Postop SPO2 and ECG monitoring.

    • 6-8hrs later chest x-ray to assess-lung expantion, exclude pneumothorax, residual FB,mediastinal emphysema from barotrauma.


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