Inhaled foreign body in a child with asthma9-year-old girl, 28 kg, with asthma, for rigid bronchoscopy
Inhaled foreign body: shared airway, spontaneous versus controlled ventilation
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Know this first
- A choking history strongly suggests an inhaled foreign body; most are radiolucent.
- Timing follows her breathing: an emergency outranks fasting; a stable child can wait.
- Keep her breathing: ventilator breaths may drive the cap further down.
- Topical lidocaine to a ceiling of 3 mg/kg; dexamethasone 0.4–1 mg/kg for subglottic oedema.
- Sudden deterioration means pneumothorax until proven otherwise.
The patient
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Consider
What are your considerations?
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- A 9-year-old with asthma and a 5-day-old inhaled pen cap, now febrile with lobar collapse. Patient
- At 9 she understands us, but her asthma makes her airway reactive under light anaesthesia.
- Late presentation brings infection and swelling around the cap, making removal harder. Disease
- Shared airway: the cap can move or break and block the other bronchus. Surgery
Prepare
How do you prepare?
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- Stable on air: I'd wait out fasting unless she worsens; if she can't wait, I accept the aspiration risk. Stem trigger
- Salbutamol before induction for her asthma; IV access first. Disease
- Plan with ENT: ventilation, losing the cap in the trachea, thoracotomy as last resort. Surgery
- Atropine 10–20 mcg/kg drawn up for vagal responses. Crisis
- No nitrous oxide with possible air trapping. Disease
Plan
How do you conduct the anaesthetic?
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- Induction keeping her breathing; no forceful positive pressure. Airway
- TIVA once deep, so anaesthesia continues while the scope is in.
- Her larynx and trachea sprayed with lidocaine, no more than 3 mg/kg.
- Circuit on the bronchoscope side port; I assist her breathing as needed.
- Relaxant only once positive pressure ventilation is established.
- Dexamethasone 0.4–1 mg/kg, maximum 20 mg, against subglottic oedema. After surgery
Crisis
During retrieval she becomes hard to ventilate, with prolonged expiration and wheeze; SpO2 85%. What do you do?
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- Bronchospasm in an asthmatic; I also exclude a moved object and pneumothorax. (Crisis)
- Surgeon pauses; 100% oxygen; propofol to deepen her.
- Salbutamol into the bronchoscope circuit.
- Magnesium 40–50 mg/kg IV, maximum 2 g, over 20–60 minutes.
- Still severe: IV adrenaline 1 mcg/kg boluses, from a 10 mcg/mL dilution.
- Silent side with falling BP: decompress a pneumothorax.
Crisis
Thirty minutes after removal and extubation she has inspiratory stridor and recession; SpO2 92%. What do you do?
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- Subglottic oedema after rigid bronchoscopy: oxygen, upright, kept calm. Crisis
- Nebulised racemic adrenaline, 0.5 mL of 2.25% in 3–5 mL saline.
- Dexamethasone if not yet given; it takes 4–6 hours to peak.
- Watched 4 hours past the final nebuliser in case it rebounds. After surgery
- Chest X-ray: lung re-expanded, no pneumothorax.
Fatal mistakes
- Forceful positive pressure pushing the cap deeper.
- Missing a pneumothorax in sudden collapse.
- No plan if the object drops into the trachea.
Checked against: Stoelting 8e · Miller 10e · Global Strategy for Asthma Management and Prevention (2024 update) · Barash 9e · Mayo review
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