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Table of Contents
LETTER TO EDITOR
Year : 2013  |  Volume : 29  |  Issue : 1  |  Page : 127-128

Anesthetic management in removal of neglected tracheobronchial foreign body


Department of Anesthesiology and Critical Care,Rajarajeshwari Medical College and Research Hospital,Bangalore, India

Date of Web Publication10-Jan-2013

Correspondence Address:
S Rangalakshmi
007, Skyline Tower Block, Chandra Layout, Nagarbhavi, Bangalore - 560 072
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0970-9185.105825

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How to cite this article:
Rangalakshmi S, Dixit N. Anesthetic management in removal of neglected tracheobronchial foreign body. J Anaesthesiol Clin Pharmacol 2013;29:127-8

How to cite this URL:
Rangalakshmi S, Dixit N. Anesthetic management in removal of neglected tracheobronchial foreign body. J Anaesthesiol Clin Pharmacol [serial online] 2013 [cited 2019 Oct 14];29:127-8. Available from: http://www.joacp.org/text.asp?2013/29/1/127/105825

Sir,

Asphyxiation by an inhaled foreign body is a leading cause of accidental death among children younger than 3 years. [1 ] A clinical triad of coughing, wheezing, and unilateral breath sounds has been shown to have high specificity for the presence of foreign body. Outcomes have improved over the years because of advances in anesthesia and bronchoscopy. Although several anesthetic techniques are effective for managing children with foreign body aspiration, there is no consensus as to which technique is optimal. [2 ]

A 10-year-old boy was admitted with aspiration of a 1 in. nail, which was impacted in the left main bronchus for 6 months. He was posted for a repeat bronchoscopic removal of the same after a failed attempt at removal 10 days before coming to us. The boy presented with recurrent lower respiratory tract infection which was not responding to conservative management. Respiratory system examination revealed a decreased air entry over the left interscapular and axillary regions. Auscultation revealed extensive rhonchi and crepitations over the left side of the chest. There were occasional rhonchi over the right interscapular region. His investigations were within normal limits except for an eosinophilia with leucocytosis (total count-17000/cu.mm and absolute eosinophil count was 1880/cu.mm). Chest radiograph PA and lateral view revealed a radio opaque obliquely placed foreign body (nail) in the left main bronchus [Figure 1]. Computerized tomography scan thorax showed a linear nail in the region of carina extending predominantly in the left main bronchus and partly into the right main bronchus [Figure 2]. It was decided to do a rigid bronchoscopy under general anesthesia keeping a flexible fiberoptic bronchoscope (FFB) [3 ] and back up for thoracotomy ready. On the day of surgery, patient was nebulized with 2% lignocaine and monitors were attached. In the operating room, patient was preoxygenated and 0.2 mg glycopyrrolate was given intravenously (IV). Induction of anesthesia was accomplished with propofol 25 mg, fentanyl 50 mcg, and suxamethonium 15 mg IV and patient's airway handed over to the surgeons for rigid bronchoscopy after recording oxygen saturation (SpO 2 ) of 100%. A 6 mm rigid bronchoscope was introduced. Anesthesia was maintained with spontaneous ventilation using an inhalational mixture of oxygen with sevoflurane and intermittent IV boluses of propofol and fentanyl. The foreign body was visualized, grasped with a grasper, and gradually retrieved through the rigid bronchoscope. Immediately after removal of the nail [Figure 3], there was decreased air entry on the left side with SpO 2 falling to 84%. The trachea of the patient was immediately intubated and positive pressure ventilation delivered to the lungs, but the SpO 2 and air entry did not improve. A fiberoptic bronchoscope was introduced through the endotracheal tube, which revealed a mucus plug in the left main bronchus. It was removed and a bronchial lavage given with normal saline following which air entry improved and saturation increased to 92%. The neuromuscular blockade was reversed and the trachea extubated. The procedure lasted around 45 min. Postoperative chest radiograph showed absence of the foreign body. Antibiotics were continued for 5 days along with nebulization and bronchodilators. Patient was discharged 6 days later.
Figure 1: Chest radiograph showing nail in the left main bronchus

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Figure 2: CT scan showing nail in the carina extending into the left main bronchus

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Figure 3: Nail measuring 1 inch

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The ventilating rigid bronchoscope has been traditionally considered the technique of choice for the preoperative diagnostic assessment of an airway obstruction involving the trachea and for the safe removal of tracheobronchial foreign bodies. [4],[5 ] We had the fiberoptic bronchoscope ready for any eventuality and it was used to remove the mucus plug when the patient desaturated after removal of the nail.[5]

 
  References Top

1.Fidkowski CW, Zheng H, Firth PG. The anesthetic considerations of tracheobronchial foreign bodies in children: A literature review of 12,979 cases. Anesth Analg 2010;111:1016-25.  Back to cited text no. 1
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2.Bist SS, Varshney S, Kumar R, Saxena RK. Neglected foreign body in an adult. JK Sci 2006;8:222-4.  Back to cited text no. 2
    
3.Righini CA, Morel N, Karkas A, Reyt E, Ferretti K, Pin I, et al. What is the diagnostic value of flexible bronchoscopy in the initial investigation of children with suspected foreign body aspiration? Int J Pediatr Otorhinolaryngol 2007;71:1383-90.  Back to cited text no. 3
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4.Soodan A, Pawar D, Subramanium R. Anesthesia for removal of inhaled foreign bodies in children. Paediatr Anaesth 2004;14:947-52.  Back to cited text no. 4
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5.Litman RS, Ponnuri J, Trogan I. Anesthesia for tracheal or bronchial foreign body removal in children: An analysis of ninety-four cases. Anesth Analg 2000;91:1389-91.  Back to cited text no. 5
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    Figures

  [Figure 1], [Figure 2], [Figure 3]



 

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