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Table of Contents
LETTER TO EDITOR
Year : 2014  |  Volume : 30  |  Issue : 1  |  Page : 119-121

Spontaneous ventilation and not controlled ventilation for removal of foreign body when present in both bronchi in a child


Department of Anesthesiology and Critical Care, All India Institute of Medical Sciences, New Delhi, India

Date of Web Publication24-Jan-2014

Correspondence Address:
Jyotsna Punj
Department of Anesthesiology and Critical Care, All India Institute of Medical Sciences, New Delhi - 110 029
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0970-9185.125734

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How to cite this article:
Punj J, Nagaraj G, Sethi D. Spontaneous ventilation and not controlled ventilation for removal of foreign body when present in both bronchi in a child. J Anaesthesiol Clin Pharmacol 2014;30:119-21

How to cite this URL:
Punj J, Nagaraj G, Sethi D. Spontaneous ventilation and not controlled ventilation for removal of foreign body when present in both bronchi in a child. J Anaesthesiol Clin Pharmacol [serial online] 2014 [cited 2019 Sep 17];30:119-21. Available from: http://www.joacp.org/text.asp?2014/30/1/119/125734

Sir,

A 14-month-old, 8 kg male child reported to the emergency room with breathlessness and choking sensation for the last 8 h, after eating peanuts. On examination, the child was tachypneic with room air oxygen saturation of 88%. Chest auscultation revealed conducted sounds on the left side and decreased breath sounds on the right side. Immediate chest X-ray showed hyperinflation of left lung field and crowding of ribs on the right side along with hyperinflation of right lower zone [Figure 1]. A provisional diagnosis of right endobronchial foreign body was made. Being an emergency, a CT Scan could not be performed and the child was immediately shifted to the operating room for bronchoscopy. Routine monitors were attached and intravenous dexamethasone 4 mg, glycopyrolate 3 mg, and lignocaine 9 mg were administered. Anesthesia was induced with oxygen in sevoflurane. Intravenous mgsuccinylcholine 8 mg was injected to facilitate bronchoscope insertion, but there was loss of chest expansion with decreasing SpO 2 levels and thus the bronchoscope was removed. Fortunately, spontaneous respiration were restored, thereby increasing the SpO 2 to 94%. Reintroduction of bronchoscope was facilitated with increasing concentration of sevoflurane (8%); however, this caused decreased ventilatory efforts of the child and resulted in a similar scenario. Return of spontaneous ventilation increased the oxygen saturation to 94%. Bronchoscopy was now performed in a spontaneous breathing child by titration of sevoflurane (4%), maintaining SpO 2 between 91-94%. Peanut cotyledons were removed from the right as well as the left main bronchus. Rest of the course was uneventful. Post 24 h, chest X-ray showed bilateral lung expansion [Figure 2] and child was discharged after 48 h.
Figure 1: Crowding of ribs on right side with hyperinflated left lung field

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Figure 2: Post bronchoscopy X-ray showing bilateral expanded lung fields

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Ventilation during brochoscopy is accompanied with concomitant risks; with controlled ventilation forcing the foreign body deeper into the smaller airways, while maintenance of spontaneous ventilation resulting in unexpected movement or coughing. [1],[2],[3]

During anesthesia, lung volume is reduced and bronchial smooth muscle relaxes, thereby increasing the compressibility of large airways. [4] Moreover, muscle relaxation causes loss of chest wall tone and disrupts the forces of active airway inspiration, thereby further reducing external support of the narrowed airway. [5] However spontaneous ventilation preserves a larger airway diameter than would occur during controlled ventilation.

We postulate that as the peanut cotyledons were present in both the bronchi, anesthesia and controlled ventilation resulted in loss of chest wall tone and narrowing of airway diameter, thereby leading to failure of adequate ventilation. On resuming spontaneous ventilation, the bronchi were comparatively of larger diameter making ventilation possible as was evident from appearance of end tidal CO 2 tracing and improvement in O 2 saturation.

In children younger than 3 years of age as the angles created by the right and left main stem bronchi are approximately equal at 55°, aspirated foreign bodies may be equally distributed between the left and right main bronchus. [6] Thus, there is a possibility of the presence of foreign body in both bronchi. Preserving spontaneous respiration for bronchoscopy may be a better choice in this age group.

 
  References Top

1.Landsman IS, Werkhaven JA, Motoyama EK. Anesthesia for Pediatric Otorhinolaryngologic Surgery. In: Motoyama EK, Davis PJ, editors. Smiths anesthesia for infants and children. Maryland Heights: Mosby Elsevier; 2006. p. 789-822.  Back to cited text no. 1
    
2.Eren S, Balci AE, Dikici B, Doblan M, Eren MN. Foreign body aspiration in children: Experience of 1160 cases. Ann Trop Paediatr 2003;23:31-7.  Back to cited text no. 2
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3.Donlon JV: Anesthetic and airway management of laryngoscopy and bronchoscopy. In Airway Management: Principles and Practice. Benumof JL, ed. Mosby, St. Louis: 1996, 666-85.   Back to cited text no. 3
    
4.Neuman GG, Weingarten AE, Abramowitz RM, Kushins LG, Abramson AL, Ladner W. The anesthetic management of a patient with anterior mediastinal mass. Anesthesiology 1984;60:144-7.  Back to cited text no. 4
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5.Gothard JW. Anesthetic considerations for patients with for anterior mediastinal masses. Anesthesiol Clin 2008;305-14.  Back to cited text no. 5
    
6.Van Looij MA, Rood PP, Hoeve LJ, Borgstein JA. Aspirated foreign bodies in children: Why are they more commonly found on the left? Clin Otolaryngol Allied Sci 2003;28:364-7.  Back to cited text no. 6
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