Complete airway obstruction by foreign body

Adresa pentru corespondenţă: Prof. Tiberiu Ezri MDDepartment of AnesthesiaWolfson Medical CenterHalochamim 62, Holon 58100, IsraelE-mail: tezri@bezeqint.net

Jurnalul Român de Anestezie Terapie Intensivă 2013 Vol.20 Nr.2, 125-129

Complete airway obstruction by foreign body: anotheranesthetic challenge. A brief review

A. Izakson1, M. Papiashvili2, Elena Potylchansky3, T. Ezri4*

1 Sieff Medical Center, Zafed, Israel, Medical Faculty, Bar Ilan University2 Assaf Harofeh Medical Center, Affiliated to Tel Aviv University, Israel3 Anderson Cancer Center, Houston Texas USA4 Wolfson Medical Center, Holon, Tel Aviv University, Israel* Outcomes research Consortium, Cleveland OH, USA

AbstractIn this brief review we present the challenging management of complete airway obstruction by foreign

body, from the anesthesiologist’s point of view. A case report is followed by a description of the clinicalpicture of airway obstruction and its management including the use of some nonconventional managementalternatives. The review is concluded by proposing an airway obstruction management algorithm.

Note: this brief review will not include any discussion on the complete airway obstruction resultingfrom a failed intubation – ventilation scenario caused by difficult airway.

Keywords: airway obstruction, foreign body, management algorithm

J Rom Anest Terap Int 2013; 20: 125-129

IntroductionForeign body aspiration (FBA) is a life-threatening

emergency that requires prompt removal of the foreignbody (FB), which occasionally may remain undetecteddue to atypical history or misleading clinical and radio-logical findings. Up to 2000 deaths from foreign bodyaspiration (4% of the total amount of FB aspiration)are reported annually in the USA [1-3]. Most cases ofFB aspirations in adults occur due to failure of airwayprotection caused by neurological disorders, or de-creased level of consciousness such as it occurs withdeep sedation or general anesthesia without airwayprotection by an endotracheal or a tracheostomy tube[2, 4]. About 20% of the aspirated FB will lodge in thelarynx or trachea, 30% in the left bronchus and 50%in the right bronchus [1-3].

A study by Baharloo et al. [4] showed that in con-trast to the adult group, the majority of the FBs inchildren were lodged in the proximal airways, possiblybecause of the smaller bronchial tree diameter in thisage group. Twenty six percent of the FBs in childrenwere localized in the more distal and lobar bronchi.Unlike the common belief that in children FBs arelodged preferentially in the right bronchial tree becauseof its more vertical disposition [5], it was shown thatthis was the case only in the adults, while in childrenFBs may be found in either side [4].

The incidence of foreign body aspiration during deepsedation or anesthesia is unknown.

Report of an imaginary caseA 40-y.old healthy male was admitted to an in-

hospital dental clinic for extraction of a molar toothand reposition of a dislodged, two unit porcelain fusedto metal bridge. Besides local anesthesia, the patientalso requested sedation which was provided with 3mg of midazolam and 100 µg of fentanyl administeredintravenously. The patient’s vital signs were monitoredwith ECG, pulse oximetry and non-invasive bloodpressure measurement. One minute after the extraction

Izakson et al.126

Reasons for airway obstruction duringanesthesiaThe following conditions may lead to the develop-

ment of partial or complete airway obstruction duringanesthesia:

– Airway collapse during induction of anesthesiaculminating in failed intubation & ventilation aswell as airway collapse during anesthesia withoutendotracheal intubation or after extubation at theend of anesthesia.

– Anesthesia of a patient with an anterior media-stinal mass leading to central airway obstructionand inability to ventilate the patient despite suc-cessful intubation.

– Foreign body aspiration.

of the molar tooth, during the reposition of the bridge,it suddenly fell into the patient’s mouth. A few secondslater, the patient became agitated and cyanotic. Hewas unable to speak and was holding his neck withboth hands. The pulse oximeter showed an oxy-hemoglobin saturation of 70%, the heart rate was 150bpm and the blood pressure 180/95 mmHg. About aminute later the patient lost consciousness. With thesuspicion of tooth inhalation the managing team startedperforming abdominal thrusts to help dislodging the FB.This proved to be unsuccessful. The patient’s tracheawas easily intubated but ventilation was impossible andthe patient went into an asystolic cardiac arrest. Duringthe intubation, no FB could be seen in the larynx orelsewhere. Cardiopulmonary resuscitation (CPR) wasstarted and simultaneously rigid bronchoscopy wasperformed revealing that the bridge was impacted atthe level of carina making ventilation of both lungsimpossible. The otolaryngologist (ENT surgeon) wasunable to dislodge the FB by either trying to extract itor pushing it into a main bronchus. Trials to push apediatric ventilating tube exchanger or a 4 mm longmicrolaryngeal tube or a standard 3 mm cuffedendotracheal tube (ETT) beyond the FB were alsounsuccessful.

As a life-saving measure, within minutes, the car-diac surgical team who was present at the sceneconnected the patient to an Extracorporeal Oxygenator(ECMO) machine. The venous and the arterialcannulae were inserted into the femoral vein andfemoral artery, respectively.

Subsequently, the FB was extracted with a largerrigid bronchoscope. The patient was discharged fromthe hospital seven days later with residual neurologicimpairment.

Several questions could be asked regarding the ma-nagement of this case:

1. Was an anesthesiologist present in the OR duringthe administration of sedation? If not, was theteam certified to provide sedation and cardio-pulmonary resuscitation?

2. Was there a dedicated person for monitoringbesides the dentist who performed the dentalextraction?

3. Were the sedative drugs administered in a titra-tion fashion rather than a single bolus?

Clinical presentation of airway obstructionThe clinical picture of the acute FB aspiration

depends on the degree of obstruction and the locationof obstruction (Table 1). Complete obstruction at thelarynx is more frequent than complete airway obstruc-tion below the glottis.

It should be remarked that a partial obstruction canconvert to a complete obstruction by dislodgement ofthe FB caused by body position change.

4. What was the depth of sedation? Is deepsedation, even in the presence of an anesthe-siologist acceptable, without securing the airwaywith an endotracheal tube, in upper airwayprocedures including dental surgery?

However, in this review we will discuss only theissue of complete airway obstruction.

Table 1. Symptoms and signs of FB airway obstruction*

* depending on the degree of obstruction and location of the FB

Management guidelines1. Apply European Resuscitation Council (ERC)

or American Heart Association/Advanced CardiacLife Support AHA/ACLS foreign body removalguidelines including Heimlich maneuver [6, 7].

2. If this fails, follow the steps as described byStewart et al. [8] or other maneuvers/procedures as

Incomplete obstruction Complete obstruction Laryngeal FB Tracheal FB Bronchial FB

Able to speak, breathe and cough - Chocking - Unable to speak, breathe and cough

- Drooling - Loss of voice - Stridor

- Stridor - Croupy cough - Wheezing

- Wheezing - Hyperinflation or hypoinflation

Complete airway obstruction by foreign body 127

described below. With complete airway obstruction andfailed Heimlich maneuver:

• try to avoid mask ventilation before performinglaryngoscopy, if possible;

• with laryngeal FB, try to extract it with Magillforceps and if this fails proceed with surgicalairway;

• with tracheal or carinal FB, push the FB into abronchus and then perform bronchoscopy;

• if ventilation through an ETT is impossibleperform down/up maneuver with the ETT topass through a soft FB or push a solid FB into abronchus and if successful, perform broncho-scopy;

• if ventilation is still impossible, try to pass a long,4 mm microlaryngeal tube or a standard 3 mmcuffed ETT or a pediatric ventilating tube ex-changer or a gum-elastic bougie beyond the FBinto one of the bronchi and ventilate the lung;

• if ventilation is still impossible, with bilateral hyper-inflation, suspect a bilateral pneumothorax andperform bilateral needle thoracostomy (ball-valve effect) [9].

Some important issues should be remembered inregard to the management of FB airway obstruction[7]. First, management approaches are based on anec-

dotal reports and are not evidence based. Secondly,sticky materials are removed with difficulty by Heimlichmaneuver and even by bronchoscopy. Thirdly, abdo-minal thrusts to dislodge the FB are contraindicated inpregnancy and children less than 1 year of age.Furthermore, blind finger sweeps should be avoided.

Fig. 1. a. Chest radiography of a 51 year old female patient, admitted to the emergency department due to severe dyspnea and stridor.The picture demonstrates a large posterior mediastinal mass; b. Computed tomography of this patient after intubation successfully

performed only with a 5 mm ID endotracheal tube. The picture demonstrates a large posterior-middle mediastinal mass withmediastinal deviation, compressed trachea intubated by a small endotracheal tube and deviated esophagus with nasogastric tube; c.

Computed tomography of the patient with the mediastinal mass, nearly occluded trachea beneath the endotracheal tube; d. Computedtomography of the patient with the mediastinal mass with right upper lobe passive atelectasis.

Failure to relieve a complete airwayobstructionIn this rare situation, tracheostomy may save the

patient’s life if the FB is located at the glottis or supra-glottic and if all the other management maneuvers havefailed. If the FB is situated in the trachea or at thecarina and cannot be removed or moved in either direc-tion, resulting in complete lower airway obstruction,live-saving ECMO should be quickly instituted.

Extracorporeal Oxygenator (ECMO) has beenextensively used in pediatric cardiac surgery and otherlife threatening conditions as a last resort, life-savingtreatment [10-12].

ECMO or full cardiopulmonary bypass has beenalso used for preventive or emergency managementof complete “central airway” obstruction with acuteairway collapse, in pediatric and adult patients withanterior mediastinal masses of various origins [13-16](Fig. 1).

Izakson et al.128

ECMO has also been rarely used for managementof airway collapse due to FB aspiration [17-21].

As shown in these articles, if instituted early enough,ECMO may save the patients’ lives and moreover maydiminish the risk of residual brain damage.

Algorithm for management of FB airwayobstruction (Fig. 2)

Considering the complexity of some of the casesand the need for rapid intervention, we believe that anairway management algorithm must guide the clinicianunder such critical circumstances. Airway manage-ment algorithms may help clinicians in solving specificclinical scenarios and enable an organized approachwith multiple back-ups. However they should be simpleand should use a stepwise decision making.

Fig. 2. FB airway obstruction management algorithm. ACLS – Advanced Cardiac Life Support; ETT – endotracheal tube; FB –foreign body; ECMO – Extracorporeal Membrane Oxygenator

ConclusionsComplete airway obstruction due to foreign body

aspiration is a challenging, life-threatening conditionnecessitating prompt intervention. If conventionaltherapeutic means fail, nonconventional interventionsshould be considered such as placing the patient onextracorporeal membrane oxygenator.

Conflict of interestNothing to declare

References

1. .Swanson KL, Edell ES. Tracheobronchial foreign bodies. ChestSurg Clin N Am 2001; 11: 861-872

2. Boyd M, Chatterjee A, Chiles C, Chin R Jr. Tracheobronchialforeign body aspiration in adults. South Med J 2009; 102: 171-174

3. Limper AH, Prakash UB. Tracheobronchial foreign bodies inadults. Ann Intern Med 1990; 112: 604-609

4. Baharloo F, Veyckemans F, Francis C, Biettlot MP, RodensteinDO. Tracheobronchial foreign bodies: presentation and manage-ment in children and adults. Chest 1999; 115: 1357-1362

5. Mu L, He P, Sun D. Inhalation of foreign bodies in Chinesechildren: a review of 400 cases. Laryngoscope 1991; 101: 657-660

6. European Resuscitation Council Guidelines for Resuscitation2010: Section 1. Executive summary. Resuscitation 2010; 81:1219-1276

7. 2010 American Heart Association Guidelines for Cardiopulmo-nary Resuscitation and Emergency Cardiovascular Care: Section1. Executive summary. Circulation 2010; 122: S640-S656

8. Stewart CE. Airway foreign bodies. In: Stewart CE. Advancedairway management. Pearson Education Inc., Upper SaddleRiver, 2002: 230-235

9. Walls RM. Foreign body in the adult airway. In: Walls RM,Murphy MF (eds). Manual of emergency airway management(4th edition), Wolters Kluwer/Lippincott Williams & Wilkins,Philadelphia, 2012: 418-423

10. Ezri T, Golan A, Sasson L, Rozenman Y. Pheochromocytomainduced fulminant cardiogenic shock following laparoscopicsalpingectomy, successfully managed with extracorporealmembrane oxygenation. J Rom Anest Terap Int 2009; 16: 154-158

Complete airway obstruction by foreign body 129

Obstrucţia completă a căii aeriene princorp străin: o provocare anestezică.Scurt referat

RezumatÎn acest scurt referat sunt prezentate din punctul

de vedere al anestezistului dificultăţile tratamentului înobstrucţia căii aeriene prin corp străin. Prezentareaunui caz este urmată de descrierea tabloului clinic alobstrucţiei căii aeriene şi a tratamentului acesteia,incluzând utilizarea unor alternative terapeuticeneconvenţionale. Referatul se încheie cu un algoritmal tratamentului obstrucţiei căii aeriene. Notă: acestscurt referat nu include discutarea obstrucţiei completea căii aeriene în cadrul scenariului intubaţie – ventilaţieimposibilă produsă de o cale aeriană dificilă.

Cuvinte cheie: obstrucţia căii aeriene, corp străin,algoritm de tratament

11. Combes A, Leprince P, Luyt CE, et al. Outcomes and long-termquality-of-life of patients supported by extracorporeal membraneoxygenation for refractory cardiogenic shock. Crit Care Med2008; 36: 1404-1411

12. Combes A, Bacchetta M, Brodie D, Müller T, Pellegrino V.Extracorporeal membrane oxygenation for respiratory failurein adults. Curr Opin Crit Care 2012; 18: 99-104

13. Frey TK, Chopra A, Lin RJ, et al. A child with anterior mediastinalmass supported with veno-arterial extracorporeal membraneoxygenation. Pediatr Crit Care Med 2006; 7: 479-481

14. Felten M, Michel-Cherqui M, Puyo P, Fischler M. Extracorporealmembrane oxygenation use for mediastinal tumor resection.Ann Thorac Surg 2010; 89: 1012

15. Anderson DM, Dimitrova GT, Awad H. Patient with posteriormediastinal mass requiring urgent cardiopulmonary bypass.Anesthesiology 2011; 114: 1488-1493

16. Gardner JC, Royster RL. Airway collapse with an anteriormediastinal mass despite spontaneous ventilation in an adult.Anesth Analg 2011; 113: 239-242

17. Isherwood J, Firmin R. Late presentation of foreign bodyaspiration requiring extracorporeal membrane oxygenationsupport for surgical management. Interact Cardiovasc ThoracSurg 2011; 12: 631-632

18. Holliday T, Jackson A. Emergency use of extracorporeal mem-brane oxygenation for a foreign body obstructing the airway.Crit Care Resusc 2010; 12: 273-275

19. Willms DC, Mendez R, Norman V, Chammas JH. Emergencybedside extracorporeal membrane oxygenation for rescue ofacute tracheal obstruction. Respir Care 2012; 57: 646-649

20. Mellema JD, Bratton SL, Inglis A Jr, Morray JP. Use of cardio-pulmonary bypass during bronchoscopy following sandaspiration. A case report. Chest 1995; 108: 1176-1177

21. Freemyer R, McLean S, Tyroch A, Santoscoy R. Cardiopulmo-nary bypass and bronchoscopy for removal of large gravel inthe bronchial tree. J Trauma 2008; 65: 719-721