Anesthetic Management During Bronchoscopic Removal of a Unique, Friable Foreign Body

Abstract

To the Editor: Inadvertent aspiration of foreign bodies in the tracheobronchial region occurs most often in children between 1 and 3 yr of age (1,2), although no age group is immune to it. It is important to insure adequate ventilation and prevent hypoxia during removal of tracheobronchial foreign bodies. The rigid ventilating bronchoscope (VBS) has improved the safety of the procedure (2), but other methods should be considered in the event of insufficient ventilation through the VBS. Other methods include high-frequency jet ventilation through the VBS (3), the bronchofiberscope (4), or extracorporeal membrane oxygenation (ECMO) when there is complete tracheal occlusion and the other methods are ineffective (5,6). Removal of vegetable foreign bodies poses additional challenges, as these bodies can be slippery, hard to grip, and friable, making them hard to remove as one piece. In our case, a 10-yr-old boy presented to our hospital’s pediatrics department with a history of having swallowed a tamarind seed 1.5 mo earlier. Since then, he had experienced breathing difficulty, cough with sputum production, and right-sided chest pain. He had received antibiotics and decongestants. A plain radiograph showed uniform opacification of the right lung and rightward deviation of his trachea; the left lung field was normal. We diagnosed bronchial obstruction from a foreign body, and administered oxygen pending surgical removal the following morning. After placement of monitors and anesthetic induction with propofol, the ear–nose–throat surgeon introduced a rigid VBS with a telescopic port into the trachea, under direct camera guidance. We connected the breathing circuit to the ventilation port of the VBS and commenced positive-pressure ventilation. We maintained anesthesia with 0.5%–1% halothane in oxygen and ventilated the lungs manually with 100% oxygen. Spo2 was 94%–96% and EtCO2 was 30–35 mm Hg. The telescopic camera revealed a swollen tamarind seed completely occluding the opening of the right mainstem bronchus. The seed was friable and slippery, making it difficult to grasp. After many attempts, the surgeon grabbed the seed and pulled it into the trachea. However, as he pulled the seed through the vocal cords, it slipped from the forceps and lodged in the subglottic region. Manual ventilation became impossible, and EtCO2 was no longer detectable. We turned off the halothane and attempted ventilation with 100% oxygen, to no avail. Within a minute, his Spo2 decreased to <20%, and his heart rate decreased from 120 to 30 bpm. We then administered 0.6 mg IV atropine. The surgeon tried desperately to free the stuck seed. As a last resort, he pushed the seed back into the trachea, while we injected the second dose of 0.6 mg of IV atropine. We could then ventilate the lungs with difficulty. The patient’s Spo2 increased to 70%, and the heart rate increased to 80 bpm. Auscultation identified no chest sounds on the right, and minimal air entry on the left. The telescopic camera confirmed that the tamarind seed was now obstructing the opening of the left mainstem bronchus, and we were ventilating the lungs through the mostly collapsed right lung. We attempted jet ventilation (Manujet III, VBM Germany) through the instrument port of the VBS. After approximately 10 min, the Spo2 increased to 90%, and his heart rate increased to 140 bpm. The surgeon successfully removed the seed in pieces. We subsequently suctioned copious secretions from the right main bronchus, which markimproved ventilation. With much better air entry on the right side, we awakened the patient and extubated the trachea. Spo2 in room air after extubation was 93%. The patient was treated postoperatively with steroids, aminophylline infusion, salbutamol, steam, and supplemental oxygen. The patient’s condition improved quickly, and he was discharged from the hospital 4 days after the procedure. In our case, the patient almost died from the prolonged hypoxia because we attempted to remove the seed as a whole, resulting in complete airway obstruction. We propose that large friable foreign bodies be removed in pieces to preclude complete obstruction. Careful preoperative planning of airway management alternatives, including ECMO if available, may prevent complications such as those we faced. Sanjeev Kumar, MD Ashok Kr. Saxena, MD, DA, FAMS Mahendra Kumar, DA, MD Rajesh Singh Rautela, MD Department of Anesthesiology and Intensive Care Neelima Gupta, MS Arun Goyal, MS Department of E.N.T. University College of Medical Sciences and G.T.B. Hospital Delhi, India [email protected]