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 Table of Contents  
CASE REPORT
Year : 2019  |  Volume : 2  |  Issue : 1  |  Page : 45-47

Airway management of an infant with an impacted subglottic foreign body


Department of Anaesthesia, JSS Hospital, Mysore, Karnataka, India

Date of Web Publication25-Apr-2019

Correspondence Address:
Dr. Sarika M Shetty
Department of Anaesthesia, JSS Hospital, Mysore - 570 004, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ARWY.ARWY_11_18

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  Abstract 


Foreign body (FB) aspiration is common in children and constitutes a life-threatening clinical situation. A high index of suspicion is necessary in the investigation of a child with stridor. Rigid bronchoscopy is frequently used for both diagnosis and treatment of FB aspiration. Occasionally, tracheostomy is required for securing airway during retrieval of a subglottic FB.

Keywords: Infant, rigid bronchoscopy, subglottic foreign body, tracheostomy


How to cite this article:
Shetty SM, Rakshitha H R, Anil Kumar M R, Gurudatt C L. Airway management of an infant with an impacted subglottic foreign body. Airway 2019;2:45-7

How to cite this URL:
Shetty SM, Rakshitha H R, Anil Kumar M R, Gurudatt C L. Airway management of an infant with an impacted subglottic foreign body. Airway [serial online] 2019 [cited 2019 Aug 18];2:45-7. Available from: http://www.arwy.org/text.asp?2019/2/1/45/257043




  Introduction Top


Removal of a subglottic foreign body (FB) is one of the challenging tasks for anaesthesiologists as it may lead to partial or complete life-threatening airway obstruction. We describe our management of an infant posted for diagnostic rigid bronchoscopy which progressed to the performance of a tracheostomy to secure the airway and retrieve the impacted FB.


  Case Report Top


A 7-month-old girl weighing 6 kg, apparently normal the previous 2 days, presented with grunting respiration, hoarseness of voice and fever. A day following admission, the child had sudden bouts of cough with streaks of blood in the oral cavity. The child was posted for elective diagnostic rigid bronchoscopy to rule out any airway pathology. There was nothing significant in the birth, growth, developmental and immunisation history. On examination, the child was febrile and restless with a heart rate (HR) of 168/min, respiratory rate (RR) of 50/min and oxygen saturation (SpO2) of 93% on room air. Stridor and subcostal retraction were present. The abdomen was soft, and there was no cardiovascular or neurological abnormality. Investigations revealed haemoglobin of 11.2 g/dL, total count of 20,100 cells/mm3 and blood group – O positive. Neck and chest X-ray did not suggest any evidence of radiopaque FB. Echocardiography revealed a small patent foramen ovale with left-to-right shunt, patent ductus arteriosus with left-to-right shunt, trivial tricuspid regurgitation and good biventricular function. The child was kept nil orally for 6 h for solids and 2 h for clear liquids.

In the operating room, preoperative vitals recorded were HR of 162/min, RR of 50/min and SpO2 of 93% on room air. Ringer lactate solution was on flow. Injection glycopyrrolate 0.1 mg, midazolam 0.1 mg and fentanyl 6 μg were administered. After preoxygenation with 100% oxygen for 3 min, the child was induced with sevoflurane 5%, and after confirming the adequacy of ventilation with bilateral chest rise on bag-mask ventilation, succinylcholine 10 mg was administered. Gentle bag-mask ventilation was continued. After 60 s, direct laryngoscopy was performed with a Macintosh #1 laryngoscopic blade and vocal cords sprayed with 2 mL of 4% lignocaine. Rigid bronchoscopy was attempted with a 3-mm scope by the paediatric surgeon. Although the cords were readily visible and relaxed, it was not possible to pass the scope beyond the cords due to some unidentified subglottic obstruction. To maintain haemodynamic stability and saturation, an attempt was made to pass the rigid scope once again but without any success. The child was ventilated with 100% oxygen using bag-mask, and rigid bronchoscopy was attempted with a 2.5-mm scope which also could not be negotiated between the cords. In the meanwhile, the child was gradually desaturating (SpO280%) with HR dropping to 80 to 90/min. Mask ventilation was resumed with 100% oxygen, and injection atropine 0.1 mg was given; SpO2 improved to 100% and HR to 130/min. A decision to intubate and secure the airway was taken. Endotracheal intubation was unsuccessful using 3.0 mm and 2.5 mm ID uncuffed endotracheal tubes by two anaesthesiologists. Bag-mask ventilation with oxygen and sevoflurane 4% was continued and emergency tracheostomy was planned after obtaining consent from parents. Tracheostomy was done using a 4.0 mm ID uncuffed tracheostomy tube, and the child was ventilated with a mixture of sevoflurane in oxygen and nitrous oxide. Injection atracurium 3 mg was given for complete relaxation. Rigid bronchoscopy attempted again with a 3-mm scope revealed a thin strip of metallic foil in the subglottic region just below the vocal cords. A small part of the foil was impacted in the mucosa, and by gentle manipulation, the entire piece of metallic foil was retrieved using forceps. [Figure 1] shows the thin strip of FB that was removed. Injection hydrocortisone 10 mg was given. A 3-mm rigid bronchoscope could be easily passed below the vocal cords, and bleeding or mucosal tear was ruled out. There was mild oedema of the vocal cords. The child was shifted to the paediatric intensive care unit with tracheostomy tube in situ, electively ventilated and gradually weaned off the ventilator within 24 h. The tracheostomy tube was removed, and stoma was closed by 4th postoperative day, followed by discharge on the 6th day.
Figure 1: Piece of metal foil removed from subglottic region

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  Discussion Top


FB aspiration is an important cause of respiratory distress, morbidity and mortality in children, especially under the age of 3 years.[1] Children tend to put objects impulsively into their mouth, running the risk of aspiration. Most aspirated FBs cross the larynx and get lodged in the trachea or bronchus with an occasional FB remaining in the larynx. Anaesthesia for rigid bronchoscopy in infants is a challenging procedure since the airway pathology itself may worsen the obstruction under anaesthesia causing early desaturation or the bronchoscopy may be difficult as it happened in our child. Diagnostic rigid bronchoscopy can be dangerous as a specific cause is not known, and lethal haemorrhage from a lesion or mucosal erosion following chronic inflammation may result. An occasional FB can get displaced and cause distal obstruction. Laryngospasm and bronchospasm pose an additional risk during the procedure. There may be occasions when an endoscopic approach to airway FBs should be abandoned in favour of a surgical procedure. Open surgical interventions for FB airway can be in the form of tracheostomy, thoracotomy, bronchotomy and/or pulmonary resection. The need for open surgical interventions range from 0.3% to 4%.[2]

The goals of anaesthesia include adequate oxygenation, controlled cardiorespiratory reflexes during bronchoscopy, rapid return of upper airway reflexes, prevention of pulmonary aspiration and meticulous monitoring of SpO2, blood pressure, electrocardiogram and end-tidal carbon dioxide.[3] A careful history and clinical examination with relevant investigations could lead to a diagnosis of aspirated FB.[4] In our case, no history of FB aspiration could be elicited from the parents. The child presented with stridor, hoarseness of voice and fever. In addition, neck and chest X-rays were inconclusive. Difficulty encountered in passing the small size scope and endotracheal tube beyond the vocal cords raised a suspicion of upper airway obstruction. To secure a definitive airway for ventilation and to facilitate the surgical visualisation of the upper airway, tracheostomy was considered. Careful and gentle inspection of the airway can be performed with assured ventilation when the airway is secured. Adequate space is also necessary for the surgeons to visualise the upper airway in the already-existing minimal space in infants. Successful bag-mask ventilation was essential in this case to prevent hypoxia till tracheostomy was done and the cause for obstruction was relieved. Tracheostomy made the diagnostic bronchoscopy procedure very safe wherein there were no episodes of desaturation, and the surgeon could manipulate the scope till the obstruction was identified and relieved. Muscle relaxation necessitates controlled ventilation but also allows delivery of less anaesthesia, prevents coughing and trauma and facilitates removal of FB through vocal cords.[3] Laryngeal and vocal cord oedema would be a definite complication in the postoperative period which was circumvented by the tracheostomy.

The possibility of a FB has to be borne in mind in any child coming with respiratory symptoms. Although rare, FB in the subglottic region should kept in mind while investigating a child in stridor.[5] During controlled ventilation and manipulation, the FB may get dislodged and cause distal airway obstruction that could be more dangerous. This can be prevented by tracheostomy. Expertise in both airway management and bronchoscopy is essential to prevent further deterioration.

Acknowledgment

We would like to thank Dr Anil Kumar, Paediatric Surgeon, for his cooperation and support during the management of this case.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Daines CL, Wood RE, Boesch RP. Foreign body aspiration: An important etiology of respiratory symptoms in children. J Allergy Clin Immunol 2008;121:1297-8.  Back to cited text no. 1
    
2.
Singh JK, Vasudevan V, Bharadwaj N, Narasimhan KL. Role of tracheostomy in the management of foreign body airway obstruction in children. Singapore Med J 2009;50:871-4.  Back to cited text no. 2
    
3.
Kalyanappagol VT, Kulkarni NH, Bidri LH. Management of tracheobronchial foreign body aspirations in paediatric age group: A 10-year retrospective analysis. Indian J Anaesth 2007;51:20-3.  Back to cited text no. 3
  [Full text]  
4.
Swain SK, Panigrahi R, Mishra S, Sundaray C, Sahu MC. An unusual long standing tracheal foreign body – A rare incidence. Egypt J Ear Nose Throat Allied Sci 2015;16:91-3.  Back to cited text no. 4
    
5.
Kamath MP, Murthy PS, Hazarika P. A case of foreign body in the subglottic region. Indian J Otolaryngol Head Neck Surg 1999;51:6-8.  Back to cited text no. 5
    


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