Foreign body aspiration

Surgical approach

• Usually rigid bronchoscopy (ENT/thoracic surgeon) ± optical forceps/basket retrieval
  • Inspect trachea → main bronchi; suction secretions/blood; remove FB under direct vision
  • May require repeated passes; intermittent removal of bronchoscope to clear lens/forceps
• If distal/small FB: flexible bronchoscopy (often as adjunct) via rigid scope or ETT
• If cannot retrieve / complications: thoracotomy/VATS (rare) for bronchotomy/lung resection
• Post-removal: re-inspect for second FB, mucosal trauma, bleeding; consider CXR/CT depending on course

Anaesthetic management (typical case: rigid bronchoscopy for FB removal)

• Type of anaesthesia: GA (shared airway, high aspiration/obstruction risk)
• Airway: rigid bronchoscope (ventilation via side port) OR ETT with flexible bronchoscopy; SGA generally not suitable for retrieval
  • Ventilation options: spontaneous, controlled ventilation, jet ventilation (HFJV) depending on team preference and pathology
• Duration: commonly 20–60 min, but unpredictable (multiple attempts/bleeding/bronchospasm)
• Pain: usually mild–moderate (airway instrumentation); main issues are coughing/bronchospasm rather than incisional pain
• Key anaesthetic aims: maintain oxygenation/ventilation, avoid dislodging FB to complete obstruction, minimise airway reactivity, plan for rapid deterioration

Definition and epidemiology

• Inhalation of a solid/liquid material into larynx/tracheobronchial tree causing partial/complete obstruction and/or inflammatory sequelae
• Common in children (1–3 years); also adults with impaired airway reflexes (intoxication, neuro disease, dental work, trauma, elderly)
• Objects: nuts/seeds, grapes, popcorn; toys; teeth/dentures; bones; iatrogenic (dental crowns, suction tips)

Pathophysiology and anatomical considerations

• Location: laryngeal/tracheal FB → stridor/complete obstruction; bronchial FB → unilateral wheeze, air-trapping, atelectasis
• Right main bronchus more common in adults (wider, more vertical); in children distribution more even
• Ball-valve effect: inspiratory entry with expiratory obstruction → hyperinflation, mediastinal shift, V/Q mismatch
• Organic FBs (nuts) swell and cause intense inflammation; delayed presentation → pneumonia, bronchiectasis, granulation tissue, haemoptysis

Clinical presentation

• History: choking episode, sudden cough, wheeze, voice change; may be unwitnessed in children
• Acute severe: stridor, cyanosis, inability to speak/cry, reduced air entry, agitation → collapse
• Subacute/chronic: persistent cough, recurrent pneumonia, unilateral wheeze, fever; may mimic asthma
• Exam: unilateral reduced breath sounds/wheeze; localized crackles; signs of hyperinflation; consider concomitant aspiration pneumonitis

Investigations

• CXR: may be normal; look for unilateral hyperinflation/air-trapping, atelectasis, consolidation, mediastinal shift; radiopaque FB sometimes visible
  • Expiratory films/decubitus views in children can demonstrate air-trapping
• CT chest: high sensitivity for radiolucent FB and complications; consider if stable and diagnosis uncertain (avoid delaying definitive management in severe cases)
• Bronchoscopy is diagnostic and therapeutic (rigid preferred in children and for retrieval)
• ABG if severe respiratory compromise; baseline labs if infection/bleeding risk or prolonged case

Immediate management (pre-hospital / ED principles)

• If complete obstruction: follow basic life support choking algorithm (back blows/chest thrusts in infants; abdominal thrusts in older children/adults) then CPR if unresponsive
• Avoid blind finger sweeps; remove only visible FB
• If partial obstruction and effective cough: encourage coughing, oxygen, minimal agitation; urgent ENT/thoracic + anaesthesia involvement
• Nebulised adrenaline/steroids may temporise laryngeal oedema but do not treat FB; do not delay bronchoscopy in significant obstruction

Preoperative assessment and planning

• Assess severity: work of breathing, SpO2 on oxygen, ability to lie flat, stridor vs wheeze, unilateral air entry, exhaustion, altered consciousness
• Fasting: treat as full stomach; however, do not delay life-saving bronchoscopy for fasting time
• IV access: ideally before induction; in distressed child may be after inhalational induction—balance against agitation and deterioration
• Discuss with surgeon: FB type/location, plan for ventilation technique, need for topicalisation, anticipated bleeding, backup plan (ETT, tracheostomy, thoracotomy)
• Equipment: rigid bronchoscopes (sizes), optical forceps, suction, HFJV set-up if used, difficult airway trolley, tracheostomy set, emergency front-of-neck access kit, bronchodilators

Induction strategy (key FRCA themes)

• Main hazard: converting partial obstruction to complete obstruction (FB moves proximally) and loss of spontaneous ventilation
• If significant obstruction/uncertain location: consider maintaining spontaneous ventilation during induction until airway secured/FB visualised
  • Common approach: inhalational induction with sevoflurane in 100% O2, gentle assistance only if needed
  • Avoid vigorous positive pressure before bronchoscope in place if risk of distal displacement/ball-valve worsening
• If stable distal bronchial FB and good reserve: IV induction with controlled ventilation may be acceptable (local practice); ensure ability to ventilate before paralysis
• RSI: may be considered in adults with low obstruction risk and high aspiration risk, but can be dangerous if obstruction risk is high; decision is case-specific
• Antisialagogue (e.g., glycopyrrolate) may improve view and reduce secretions, especially with ketamine or in children

Maintenance and ventilation options during rigid bronchoscopy

• Shared airway: continuous communication; agree signals for apnoea/ventilation pauses and when surgeon needs stillness
• Ventilation techniques (choose based on patient, FB, surgeon, equipment):
  • Spontaneous ventilation: preserves airway tone; may reduce risk of complete obstruction; can be challenging due to CO2 retention, movement, laryngospasm
  • Controlled ventilation via side port: better control of gas exchange; requires good seal and may worsen air-trapping if ball-valve; consider low pressures/long expiratory time
  • HFJV (supraglottic/subglottic via bronchoscope): excellent surgical access; risks include barotrauma, air-trapping, hypercapnia, inadequate exhalation with distal obstruction
• Anaesthetic technique: TIVA (propofol/remifentanil) or volatile via bronchoscope circuit; ensure depth to prevent coughing/laryngospasm
• Muscle relaxants: may be avoided initially if maintaining spontaneous ventilation; if used, ensure ability to ventilate and have clear plan for rapid desaturation
• Topical local anaesthetic to larynx/trachea may reduce reflexes (dose carefully in children; consider total lidocaine limit)

Monitoring and access

• Standard AAGBI monitoring; capnography may be unreliable/leaky but still useful for trends; consider transcutaneous CO2 if prolonged and available
• Preoxygenate; anticipate rapid desaturation (children). Use high FiO2 unless laser use (rare here)
• IV access secured; consider arterial line in unstable adult/major comorbidity or anticipated prolonged case

Complications (and how to respond)

• Complete airway obstruction (FB dislodges proximally): call for help, 100% O2, attempt ventilation via bronchoscope, remove bronchoscope if obstructing, rigid laryngoscopy/forceps, emergency front-of-neck access if cannot oxygenate
• Laryngospasm/bronchospasm: deepen anaesthesia, CPAP/100% O2, consider propofol bolus, suxamethonium for laryngospasm; bronchodilators (salbutamol), adrenaline in severe bronchospasm; consider steroids
• Hypoxia/hypercapnia: pause surgery, ventilate effectively, check circuit leaks/obstruction, consider changing technique (e.g., controlled ventilation), treat air-trapping (reduce rate, longer expiratory time)
• Bleeding: suction, topical vasoconstrictor (surgeon), secure airway (ETT) if needed, consider tranexamic acid case-by-case; be prepared for aspiration and worsening gas exchange
• Pneumothorax/barotrauma (esp. HFJV/air-trapping): sudden desaturation, hypotension, high inflation pressures; treat with needle decompression/chest drain
• Post-obstructive pulmonary oedema (rare): supportive ventilation/PEEP, diuretics not primary; ICU if severe

Emergence and postoperative care

• Decide extubation vs intubation/ICU based on: airway oedema/trauma, bleeding, bronchospasm, hypoxia, prolonged procedure, comorbidity, aspiration pneumonitis
• Extubation: fully awake with protective reflexes; consider deep extubation only in selected cases with minimal risk and experienced team
• Analgesia: paracetamol ± NSAID if appropriate; small opioid doses if needed; treat sore throat/cough
• Observe for: stridor, wheeze, haemoptysis, pneumothorax, fever; consider post-op CXR if difficult retrieval, barotrauma risk, persistent symptoms
• Antibiotics: not routine for uncomplicated removal; consider if established pneumonia/organic FB with infection