Retained Foreign Body Airway in Child: An Anesthetic Management

Abstract

An 11-year-old boy came to the outpatient department (OPD) with a history of dry cough and wheeze for the past 1 month. A chest X-ray revealed no significant findings. The patient subsequently revealed a history of ingestion of a whistle 6 months previously. The patient was posted for diagnostic bronchoscopy using a flexible bronchoscope. The same revealed a small cylindrical object impacted at the division of the right bronchus, which was removed by performing rigid bronchoscopy. A flexible bronchoscope was used to diagnose the cause of long-standing cough and wheeze. After confirmation of the foreign body (FB), the patient was administered general anesthesia. Rigid bronchoscope was introduced through the trachea, with which the FB was removed. The patient was induced, and a muscle relaxant was given, followed by the removal of the FB in a short time.

Introduction

A major cause of infant and child mortality, particularly in underdeveloped nations, is pediatric foreign body (FB) aspiration, a potentially fatal illness. Children from birth to early childhood have reported about 7% mortality. ¹ In the trachea, larynx, and lobar bronchi, FB impaction is less common, and it is most commonly found in the bronchus, with the right more than the left main bronchus. ² Long-retained airway foreign bodies may lead to impaction at the lodged sites, which makes it difficult for most otorhinologists to retrieve them under FB guidance. For the removal of an aspirated FB, rigid bronchoscopy is the standard technique adopted if there is a high suspicion of a FB in the airway. ³

Case Report

An 11-year-old boy presented to the outpatient department (OPD) with a history of cough and wheeze since 1 week. The patient had no significant medical history. On examination, the heart rate was 96/min, the respiratory rate was 22/min, and SpO₂ was 98% on room air. General physical examination was appropriate for age and gender. On examination of the respiratory system, bilateral basal wheeze on auscultation was heard, which was persistent even after treatment with ipratropium and levosalbutamol nebulization. The other systemic examinations, including cardiovascular, gastrointestinal, and the central nervous system, were normal. Chest radiography showed normal bronchovascular markings and no specific findings of atelectasis or hyperinflated lungs (Figure 1).

Figure 1.

Chest Radiography Showed Normal Bronchovascular Markings.

The patient was posted for diagnostic bronchoscopy. Written informed consent for the procedure was obtained. Local anesthesia was administered using lignocaine nebulization. Sedation was planned, and drugs were administered according to the per kg body weight. Under aseptic precautions, a superior laryngeal block was given with 3 mL of plain lignocaine 1%. Transtracheal injection, after confirmation of the needle in the trachea, 2 mL of plain lignocaine 1% was instilled. After the block, diagnostic bronchoscopy was done, which revealed a cylindrical-shaped FB that was found to be impacted in the right bronchus (Figure 2). After confirmation of the FB by fiberoptic bronchoscopy, the patient was administered general anesthesia. Injection Propofol 50 mg IV was given. Steroids, such as injection Hydrocort 50 mg, injection Dexamethasone 4 mg, and injection bronchodilator Deriphyllin 0.5 mL IV, were also given. Muscle relaxation was achieved with atracurium. Ventilation was done with the side port of the rigid bronchoscope. The FB was removed with alligator forceps, which were found in the right bronchus.

Figure 2.

Foreign Body Retrieved from Right Bronchus.

The FB that was removed was a 40 mm length cylindrical structure that led to the formation of granulation tissue at the point of circumferential contact on the bronchial wall (Figure 3). The intraoperative period was uneventful, and there was no bleeding at the impacted FB site. The patient was reversed with injection Neostigmine with injection Glycopyrrolate according to per kg weight. Post bronchoscopy, the patient had a cough, for which nebulization with 0.5 mL Duolin with 1 mL dilution was given. Once the patient was fully awake and conscious, the patient was shifted to the recovery room, wherein he was maintained with 3 L oxygen. After the FB was removed, the wheeze was reduced on auscultation. In the postoperative period, intravenous steroids and nebulizations with ipratropium and levosalbutamol were administered. The patient was followed up a week later, and the patient had no significant breathing difficulty, and his chest was clear.

Figure 3.

Foreign Body in Right Bronchus.

Discussion

In children, FB aspiration is a frequent issue that can jeopardize airway integrity. It is more common in male than in female children in early childhood. Children are more prone to explore objects that they come across, and ambulatory preschoolers are often left unmonitored. ⁴ Also, due to the high incidence of upper respiratory tract infections, there is a lack of protective reflex coordination between swallowing and inhalation; hence, patients are more susceptible to FB aspiration. ⁵ Many studies have shown that foreign bodies that are inhaled are most frequently found to be lodged in the right bronchus. In one study, the percentage for the site of lodgment of the FB was found to be between 40% and 48%. ⁶ A patient may have an array of symptoms from an FB embedded in the airway. Usually, they present with cough, wheeze, breathlessness, reduced air entry unilaterally, and choking. ⁷ Both diagnostic and therapeutic procedures carry high mortality in FB aspiration cases. In cases where the FB had gone undiagnosed for a long duration, such patients may have complications; they may present as pneumonia, atelectasis, bronchiectasis, or lung abscess. ⁵ The sensitivity of a chest radiograph varies from 68.73%, and the specificity varies from 45% to 67%. ⁸ Hence, a normal chest radiograph does not always confirm the presence or absence of an FB, leading to delayed diagnosis and treatment. Some children only present with persistent crying when there is a small FB in the bronchus. A proper case history, physical examination, and radiological investigations do not always rule out FB aspiration. Bronchoscopy plays a pivotal role in such cases. Early diagnosis leads to fewer complications. ⁹ We need to differentiate between pneumothorax, atelectasis, and pneumonia. Pneumothorax can be excluded as patients may be in respiratory distress, whereas pneumonia will be associated with fever, cough, and mild breathlessness. Atelectasis can be diagnosed by chest X-ray. One basic strategy to confirm the FB lodgment in the airways is to employ flexible bronchoscopy under local topical anesthesia and intravenous sedatives. The standard method for identifying and retrieving foreign bodies from the airways is rigid bronchoscopy under general anesthesia. ¹⁰

Conclusion

A high degree of suspicion is required for the diagnosis of an undiagnosed FB in the bronchus. Chronic FB in the bronchus can be asymptomatic. Early diagnosis can prevent life-threatening complications. A flexible fiberoptic bronchoscope must be used for the diagnosis of an undiagnosed FB in children.