DP02: LEFT SECONDARY BRONCHUS FOREIGN BODY DIAGNOSED BY ANESTHESIA TEAM AFTER NEGATIVE UPPER ENDOSCOPY FOR REMOVAL OF ESOPHAGEAL FOREIGN BODY
Amy E Burns, MD; Amanda M Taylor
Nemours Children's Specialty Care Jacksonville
Introduction: Pediatric airway foreign bodies are life-threatening events. Although the majority of foreign bodies are located on the right mainstem bronchus due to the anatomy, a significant number do occur on the left. A high index of suspicion and vigilance are essential in the management of foreign bodies of both the airway and esophagus.
Case Report: An 11-month-old presents emergently to the operating room for removal of esophageal foreign body. He had a witnessed choking event earlier that day and chest x-ray is indicative of a foreign body in the proximal esophagus. Parents report he has been coughing and it is unclear if due to foreign body or a respiratory infection. He is active, but coughing, wheezing, and drooling in the pre-operative area. Following intravenous induction and uneventful intubation, an upper endoscopy is performed by the proceduralist without identification of a foreign body in the esophagus, stomach, or duodenum. Due to the history and pre-operative airway reactivity, the anesthesia team decides to perform a flexible fiberoptic exam to evaluate for a airway FB prior to emergence from anesthesia. This demonstrates a clear trachea and right side but mucus and a possible object on the left. An ENT surgeon is consulted intra-operatively and a rigid bronchoscopy performed identifying an object in a left secondary bronchus with airway inflammation and secretions. The object is removed and the patient emerges from anesthesia and is extubated without complications.
Discussion: Pediatric airway foreign bodies are life-threatening events that occur in 1 in 3-4,000 children. They occur predominantly on the right side, but a significant number occur on the left side and can be missed if not considered. Pediatric airway foreign bodies occur primarily in patients less than 3 years of age and have significant mortality. In these children the airway FB is most often organic in nature. In older children, FBs are often inorganic objects such as pen caps and paperclips. Removal of airway foreign bodies is accomplished with rigid bronchoscopy. Anesthesia is maintained with a native airway and spontaneous ventilation; positive pressure is avoided to prevent advancing the object further into the airway.
Esophageal foreign bodies, in contrast, are often objects such as coins, buttons, or batteries although organic material can become lodged in the esophagus especially when there is an underlying esophageal abnormality, ineffective chewing, or mental health issues. Esophageal FBs also occur predominantly in the 6 months to 3 year age group. Anesthetic management involves endotracheal intubation to prevent the object from entering the airway during FB removal.
Intra-operative management of both esophageal and airway foreign bodies requires constant communication between the anesthesia care team and the surgeon.
Conclusion: The proactive approach by the anesthesia team identifying this airway foreign body facilitated timely care, a second anesthetic and potentially minimized morbidity for this patient. As peri-operative physicians, the anesthesiologists role is far more than intubation and extubation. We are integral members of the team and often have the most comprehensive understanding of their medical history. We are our patient's protectors.