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YOUR PATIENT

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A 2-year-old child is brought to the ER. The mother states that an older sibling was eating peanuts and the child grabbed some and put them in his mouth, and since then the child has been irritable and coughing continuously.

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Upon exam, the child is coughing with no evidence of acute respiratory distress. There are decreased breath sounds on the right side.

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Chest x-ray shows hyperinflation of the right lung.

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PREOPERATIVE CONSIDERATIONS

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Pediatric airway foreign body aspiration has a high rate of airway distress, morbidity, and mortality in children less than 3 years of age. The peak age for aspiration events is 1-2 years; this is due to incomplete dentition, immature swallowing coordination, and a tendency to be easily distracted while eating. The most common foreign body retrieved is peanuts. Other aspirated items include pieces of food, such as carrots, nuts, candies, grapes, seeds, popcorn, and hot dogs. Nonfood objects include coins, pills, safety pins, marbles, ball bearings, and beads. Food items like nuts can expand and become friable, and, as a result, they get fragmented during their removal and cause further obstruction. Peanuts can release oils and cause chemical irritation. Presenting symptoms vary from no apparent distress to impending respiratory failure, depending on the size and location of the foreign body. Children may also present with coughing, wheezing, shortness of breath, fever, or recurrent pneumonia.

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ANESTHETIC MANAGEMENT

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  • Use mask induction with sevoflurane or IV induction with propofol with spontaneous ventilation.

  • IV atropine or glycopyrrolate is given to dry secretions and prevent vagal-induced bradycardia from the insertion of the bronchoscope.

  • Maintain anesthesia with total intravenous anesthesia with propofol and/or remifentanil infusion.

  • Spray the larynx with 1-2% lidocaine prior to passage of the bronchoscope.

  • Use a precordial stethoscope to detect changes in breath sounds or regional ventilation.

  • Remain in constant communication with the surgeon.

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POSTOPERATIVE CONSIDERATIONS

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Patients are placed in a head-up position and monitored for possibility of airway obstruction secondary to edema. If the patient has stridor, humidified oxygen, IV dexamethasone (maximum 10 mg/kg), and nebulized racemic epinephrine (2.25%) (0.05 mL/kg, max 0.5 mL) may be administered. Patients are admitted to the floor or the intensive care unit depending on the degree of lung irritation. They may be discharged home the next day if stable.

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DOs and DON’Ts

  • ✓ Do maintain spontaneous ventilation.

  • ⊗ Do not use nitrous oxide, as it can cause air trapping distal to the obstruction.

  • ✓ Do have instruments for emergency cricothyrotomy or tracheotomy available if complete airway obstruction occurs after induction.

  • ⊗ Do not use jet ventilation due to the risk of barotrauma and pneumothorax.

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SURGICAL MANAGEMENT

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A rigid ventilating bronchoscope with an optical telescope forceps is most commonly used for foreign body removal. The anesthesia circuit is connected ...

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