Delayed Retrieval of a Hollow Foreign Body from the Trachea of an 850-g Newborn

Abstract

To the Editor: A tracheal foreign body in a premature newborn is extremely rare and may occur during tracheal intubation. To our knowledge, only two cases have been reported, wherein the foreign bodies were placed during tracheal intubation and immediately removed.1,2 We report a case in which the distal portion of a suction catheter was left in the trachea after tracheal suctioning and was detected on a follow-up chest radiograph twelve days later. A 7-day-old 850-g boy born prematurely at 26 wk of gestation was transferred with a history of difficulty in passing a suction catheter through the esophagus and for further work-up for esophageal atresia with tracheoesophageal fistula. Initial chest radiograph showed lung markings with opacification at the right base. On hospital day 9, the trachea was intubated for increasing respiratory distress and extubated 3 days later. Chest radiograph suggested a tubular structure in the trachea extending into the right main bronchus. Computerized tomography showed a 4-cm long foreign body below the vocal cords. While receiving oxygen via continuous positive airway pressure, he was brought to the operating room for removal of foreign body under anesthesia. Two milligrams of propofol were given IV over a 4-min period, and after an atraumatic laryngoscopy, 1 mg of lidocaine was sprayed on the vocal cords (0.1 mL of a 1% solution). After allowing the infant to breathe 1% sevoflurane while awaiting the topical anesthetic to be effective, laryngoscopy with a Parson laryngoscope enabled visualization of a tubular fragment of a suction catheter through a 4.0-mm 0° endoscope. Despite movement of this foreign body with breathing, it did not protrude above the glottic opening and a microlaryngeal cup forceps were advanced through the glottis to withdraw it. Subsequent bronchoscopy showed no airway injury or presence of any tracheoesophageal fistula. Removal of foreign bodies from the airway is especially challenging in a very premature newborn <1000 g. Performing laryngoscopy or instrumenting the airway with the patient awake is risky because of potential increase in intracranial pressure and intraventricular hemorrhage in premature babies.3 Mask fit is often difficult and controlled ventilation especially in the presence of tracheoesophageal fistula carries the risk of distending the stomach and decreasing functional residual capacity. Continuous use of potent IV agents carries the risk of prolonged apnea and sedation. We opted to give 1 mg of propofol IV followed by another 1 mg of propofol for induction of anesthesia, and then followed by topical anesthesia. The propofol allowed the operator to apply the 1 mg of lidocaine directly on to the vocal cords to produce topical anesthesia. The dose of lidocaine was arrived at by using a dose slightly less than the standard dose, which is 1.5–3 mg/kg. Two minutes after the lidocaine placement, it was possible to remove the foreign body from the airway with the patient breathing spontaneously but still sedated. Tracheal and esophageal foreign bodies, although extremely rare in neonates, can still occur during intubation and suctioning and may be overlooked if not identified immediately after removal of a fragmented suction catheter. The compressibility and patency of the catheter lumen likely contributed to the delay in diagnosis in this patient. Susan Verghese, MD Department of Anesthesia Raafat Hannallah, MD Department of Anesthesia David Powell, MD Department of General Surgery Maria Pena, MD Department of Otolaryngology Children's National Medical Center Washington [email protected]