|Year : 2015 | Volume
| Issue : 1 | Page : 148-150
Bronchial lavage and chest percussions relieved complete airway obstruction due to crushed foreign body: A case report
Roshdi R Al-Metwalli MD
Department of Anesthesiology, University of Dammam, Al-Khobar, Saudi Arabia
|Date of Submission||08-Dec-2014|
|Date of Acceptance||06-Jan-2015|
|Date of Web Publication||25-Mar-2015|
Roshdi R Al-Metwalli
Department of Anesthesiology, King Fahad Hospital, University of Dammam, PO Box 40081, Al-Khobar 31952
Source of Support: None, Conflict of Interest: None
Tracheobronchial foreign body (FB) is always a clinical challenge. Dropping the FB during retrieval is a potentially life-threatening complication, which, if not promptly diagnosed and treated, can prove fatal. We present a case of complete airway obstruction due to crushed and slipped FB during its retrieval from the upper airway. Its tiny fragments dropped down and obstructed the lower bronchial trees. This is a very rare potentially lethal event, which was successfully managed with concomitant bronchial lavage and chest percussion.
Keywords: airway, foreign body, bronchial lavage
|How to cite this article:|
Al-Metwalli RR. Bronchial lavage and chest percussions relieved complete airway obstruction due to crushed foreign body: A case report. Ain-Shams J Anaesthesiol 2015;8:148-50
|How to cite this URL:|
Al-Metwalli RR. Bronchial lavage and chest percussions relieved complete airway obstruction due to crushed foreign body: A case report. Ain-Shams J Anaesthesiol [serial online] 2015 [cited 2021 May 6];8:148-50. Available from: http://www.asja.eg.net/text.asp?2015/8/1/148/153960
| Introduction|| |
Foreign body (FB) aspiration is a common cause of mortality and morbidity in children, with a peak incidence occurring during the second year of life , .
Most (81%) of the aspirated FBs are organic materials, especially nuts and seeds ,,, . Typically, children present with a history of choking, acute coughing, and wheezing witnessed by guardian , . Clinical presentation and physical examination findings in FB aspiration may not be typical or may suggest a different diagnosis with consequent serious complications  . The majority of aspirated FBs in children was located in the bronchi and was successfully removed in 99% of children using rigid bronchoscope under general anesthesia [6, 10, 11]. Sometimes, a nut may break into amorphous and hard pieces and bronchoscopic removal becomes very difficult and frequently more than one attempt is needed  . In addition, friable objects that swell easily, such as beans, create a risk for complete respiratory obstruction by leaving the forceps and crumbling into both main bronchi  . We present a very rare case of complete respiratory obstruction, due to crushing and fragmentation of a FB during its retrieval through the vocal cord and fall down obstructing the lower bronchial trees of both lungs.
| Case report|| |
A 2-year-old female child, weighing 14 kg, was admitted to Emergency Room (ER) Department with a 1-day history of choking and severe bouts of cough. An expected history of FB inhalation was given by the parents. Preoperative examination showed a healthy female child with persistent cough, symmetrical chest expansion, diminished air entry on the right side, and SpO 2 of 100%. She was not dyspneic or febrile and without any other medical problem. Preoperative chest radiography did not show any FB but a mild hyperinflated, hypertranslucent left lung field was detected ([Figure 1]). On the basis of clinical presentation, positive history of FB inhalation and radiographic findings, urgent rigid bronchoscopy under general anesthesia was planned.
|Figure 1: Preoperative chest radiography shows a mild hyperinflated, hypertranslucent left lung fi eld with no foreign body detected.|
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After placement of standard monitors, anesthesia was induced intravenously with fentanyl 1 μg/kg and propofol 2.5 mg/kg. Muscle relaxant (rocuronium 0.5 mg/kg intravenously) was given to facilitate bronchoscopy and to prevent potential coughing and bucking during the procedure. Rigid bronchoscope with a ventilatory side port (VBS) was introduced by ENT surgeon using conventional laryngoscope. We connected the breathing circuit to the ventilation port of the VBS. Anesthesia was maintained with 1-2% sevoflurane in oxygen and the lungs were manually ventilated with 100% oxygen. SpO 2 was 100% and EtCO 2 was 37 mmHg. The surgeon could see a FB in the right main bronchus (looked as a swollen peanut). After many attempts, the surgeon grabbed the FB and pulled it up. While the surgeon was retrieving the FB, he noticed a resistance at the level of the vocal cord; at the same time, he lost the direct vision through the bronchoscope and passed the vocal cord blindly. The forceps came out without the FB and he did not find it in the mouth. While he was preparing himself for a second look, we started mask ventilation, and surprisingly we discovered a very high resistance and manual ventilation became impossible. EtCO 2 was no longer detectable (complete respiratory obstruction) and SpO 2 decreased to 80%. Surgeon quickly reinserted the VBS; he found that the FB has crushed into multiple very tiny fragments, some of them found at the inlet of both main bronchi. He tried to catch and remove, but the patient SpO 2 decreased to 40% and her heart rate decreased from 140 to 70 bpm. The surgeon immediately came out and we then administered 0.2 mg intravenous atropine, and patient was intubated with endotracheal tube size 4.0 mm, but manual ventilation was still impossible, and SpO 2 decreased to less than 20%. Patient was tilted laterally with the right side up and we started chest percussion hoping to clear the right bronchus by dislodging the fragments, but a discouraging improvement in ventilation and SpO 2 was noticed. We decided to start bronchial lavage using normal saline and strong suction with manual ventilation and alternating (right and left) chest percussion in-between. A marked improvement in SpO 2 occurred, and we continued lavage until 100% SpO 2 was obtained with full chest expansion. A final VBS was performed to exclude another FB or residual fragments. As EtCO 2 was 87 mmHg, patient was reintubated and mechanically hyperventilated for about 20 min to decrease the EtCO 2 to 40 mmHg. Hydrocortisone 4 mg/kg intravenous was given and residual muscle relaxation was reversed. Patient was extubated fully awake and sent to the recovery room without any respiratory compromise. Child showed uneventful recovery and was discharged on the second postoperative day after confirmation of normal chest radiography ([Figure 2]).
|Figure 2: Second postoperative day chest radiography shows normal lung fi elds.|
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| Discussion|| |
We presented a case of complete airway obstruction due to crushed fragile FB during its retrieval from the upper airway. It is a very rare life-threatening complication, which was successfully treated with concomitant bronchial lavage and chest percussion.
Dislodgement of all or part of the FB or a fragment of the FB into the mainstem bronchus of the contralateral lung is a potentially lethal complication, if the originally involved bronchus remains obstructed by inflammation or residual FB , . Inadequate relaxation of the vocal cord, attempts to remove a large FB as a whole  , inexperienced operator  , as well as unsuccessful attempts to push the FB into a distal position  could be principle causes of complete airway obstruction during FB retrieval. In our present case, we believed that the cause of this complication is multifactorial, including large swollen FB, loss of direct vision, and blind upward retrieval against resistance as well as inexperienced operator who was not able to use the telescopic camera that allows FB retrieval under clear vision of all observers.
Chest physiotherapy has been used years ago to facilitate airways clearance that included chest percussion, postural drainage, chest vibration, and shaking the chest wall. It is an effective technique to increase mucous clearance in many lung pathologies  . We used chest percussion with the patient in the right lateral position as a trial to dislodge the fragments and clear the right mainstem bronchus. Although Sayuti et al.  have succeeded to dislodge a FB using chest percussion, we failed most probably because of trapping of very small fragments in the small bronchioles as well as the left mainstem bronchus was also blocked with small fragments.
In our present case, we used the bronchoalveolar lavage on the basis of the suggestion that the FB has crushed into small fragments and dropped to obstruct the lower bronchial trees causing severe respiratory obstruction. We believed that the only way to relieve obstruction was to wash out these tiny fragments with saline lavage. Kapur et al.  and Appelboam et al.  have successfully used repeated therapeutic bronchoscopic lavage to clear the airway of two different cases of severe sand aspiration in association with near-drowning.
| Conclusion|| |
Saline bronchoalveolar lavage with concurrent chest percussion was helpful in washing out the tiny fragments of severely crushed FB in the tracheobronchial tree and relieving a completely obstructed airway.
| Acknowledgements|| |
The author thank all members of the Department of Anesthesia in King Fahad Hospital, Al-Khobar, Saudi Arabia, with special thanks to Dr N. Emad, Dr K. Alaa, and A. Taha, who attended the case in this stressful situation.
Conflicts of interest
There are no conflicts of interest.
| References|| |
Centers for Disease Control and Prevention (CDC). Nonfatal choking-related episodes among children - United States, 2001. Morb Mortal Wkly Rep 2002; 51:945-948.
Kramer TA, Riding KH, Salkeld LJ. Tracheobronchial and esophageal foreign bodies in the pediatric population. J Otolaryngol 1986; 15:355-358.
Inglis AF Jr, Wagner DV. Lower complication rates associated with bronchial foreign bodies over the last 20 years. Ann Otol Rhinol Laryngol 1992; 101:61-66.
François M, Thach-Toan , Maisani D, Prévost C, Roulleau P. Endoscopy for exploration for foreign bodies of the lower respiratory tract of the child. Apropos of 668 cases. Ann Otolaryngol Chir Cervicofac 1985; 102:433-441.
Schmidt H, Manegold BC. Foreign body aspiration in children. Surg Endosc 2000; 14:644-648.
Tan HK, Brown K, McGill T, Kenna MA, Lund DP, Healy GB Airway foreign bodies (FB): a 10-year review. Int J Pediatr Otorhinolaryngol 2000; 56:91-99.
Cohen S, Avital A, Godfrey S, Gross M, Kerem E, Springer C. Suspected foreign body inhalation in children: what are the indications for bronchoscopy? J Pediatr 2009; 155:276-280.
Heyer CM, Bollmeier ME, Rossler L, Nuesslein TG, Stephan V, Bauer TT, Rieger CH. Evaluation of clinical, radiologic, and laboratory prebronchoscopy findings in children with suspected foreign body aspiration. J Pediatr Surg 2006; 41:882-1888.
Mu L, He P, Sun D. The causes and complications of late diagnosis of foreign body aspiration in children. Report of 210 cases. Arch Otolaryngol Head Neck Surg 1991; 117:876-879.
Eren S, Balci AE, Dikici B, Doblan M, Eren MN Foreign body aspiration in children: experience of 1160 cases. Ann Trop Paediatr 2003; 23:31-37.
Black RE, Johnson DG, Matlak ME. Bronchoscopic removal of aspirated foreign bodies in children. J Pediatr Surg 1994; 29:682-684.
Keith FM, Charrette EJ, Lynn RB, Salerno TA. Inhalation of foreign bodies by children: a continuing challenge in management. Can Med Assoc J 1980; 122:55-57.
Kumar S, Saxena AK, Kumar M, Rautela RS, Gupta N, Goyal A. Anesthetic management during bronchoscopic removal of a unique, friable foreign body. Anesth Analg 2006; 103:1596-1597.
Pawar DK. Dislodgement of bronchial foreign body during retrieval in children. Paediatr Anaesth 2000; 10:333-335.
Hughes CA, Baroody FM, Marsh BR. Pediatric tracheobronchial foreign bodies: historical review from the Johns Hopkins Hospital. Ann Otol Rhinol Laryngol 1996; 105:555-561.
McCool FD, Rosen MJ. Nonpharmacological airway clearance therapies: ACCP evidence-based clinical practice guidelines. Chest 2006; 129:250-259.
Sayuti R, Fadzil A, Ahmad R. Impacted foreign body in secondary bronchus: chest percussions during therapeutic bronchoscopy. Int J Pediatr Otorhinolaryngol Extra 2009; 4:75-76.
Kapur N, Slater A, McEniery J, Greer ML, Masters IB, Chang AB. Therapeutic bronchoscopy in a child with sand aspiration and respiratory failure from near drowning - case report and literature review. Pediatr Pulmonol 2009;44:1043-1047.
Appelboam R, Williams MP, Duffy MR. Sand aspiration: a case report and review of the radiological features and management. Anaesthesia 2010; 65:848-854.
[Figure 1], [Figure 2]