Management of Anesthesia in Pediatric Patients with Bronchoscopy Late Onset Foreign Body Aspiration

Introduction: Aspiration of foreign bodies in the airways is a severe and fatal condition if it occurs in children, because the risk of life-threatening obstruction is higher. Bronchoscopy is the main choice of procedure for treating foreign body aspiration, either with rigid bronchoscopy or flexible bronchoscopy. Anesthesia techniques are used with comprehensive anesthesia considerations, such as premedication, induction of anesthesia, maintenance of anesthesia, and monitoring.

Objective: To evaluate the management of anesthesia in a pediatric patient with foreign body aspiration in late-onset settings.

Case report: We report a case of anesthesia management in a child who aspirated a foreign body (peanuts) three days before being delivered to the hospital and undergoing a rigid bronchoscopy procedure. The patient experienced respiratory failure, and atelectasis was found in the right lower lobe of the lung upon arrival at the Emergency Unit (ER) due to the late onset of the case, so a secure airway must be performed before rigid bronchoscopy. Post-treatment care is carried out by observation and monitoring in the Intensive Care Unit (ICU) with complications of pneumonia. After three days of ICU treatment, the patient was transferred to the High Care Unit (HCU) in improved condition. The patient was discharged after three days of treatment in the low care Unit.

Conclusion: Rigid bronchoscopy is the best modality for extracting foreign bodies in the pediatric airway. Delayed onset effects from foreign body aspiration in the respiratory tract cause greater complications after bronchoscopy. Pneumonia is the most common complication. Comprehensive anesthesia evaluation and preparation are the keys to the success of this procedure.

INTRODUCTION

Foreign body aspiration is a serious and potentially lethal condition resulting from the entry of a foreign object into the airway. The symptoms that arise depend on the grade of airway obstruction. Death is a complication of foreign body aspiration that obstructs the airway. Foreign body (FB) aspiration is a common and serious problem in childhood, as it requires early recognition and treatment to avoid potentially fatal consequences. Foreign body aspiration could occur at any age, but it is more common in children. In adults, the incidence of foreign airway aspiration is related to conditions of decreased consciousness. Suspecting a foreign body and getting a satisfactory medical history are the most important steps in foreign body aspiration. Bronchoscopy is the main choice in treating foreign body aspiration. This procedure can be performed using flexible bronchoscopy or rigid bronchoscopy. Rigid bronchoscopy is the main choice for aspiration extraction of foreign bodies in children (¹–³).

Rigid bronchoscopy is used to evaluate the upper and lower airways. This assessment is useful for diagnosis and for therapeutic purposes. Complications caused by foreign objects in the airways can also arise from bronchoscopy, which is considered iatrogenic. Apart from that, aspiration of foreign objects in the airways is influenced by 3 things, there are geographical conditions, food variations, and environmental conditions. The most common aspiration of foreign bodies in the airways in children is peanut aspiration. In previous research, it was noted that at the age of 0-3 years, 50% of foreign body aspirations occurred, while at the age of 4-15 years, the incidence of foreign body aspiration occurred in the range of 75-85%. This is different from adults, the incidence of foreign body aspiration often occurs at old age (geriatric populations), and the number of males is greater than that of females (ratio 2:1). The cause of the high rate of foreign body aspiration in children is because of the tendency to put everything into their mouths, because children often cry, scream, and run around with food in their mouths, and also because the molar teeth in children have not yet formed, so the chewing process is not yet complete, and poor swallowing and easy aspiration into the airway in children (⁴–⁶).

Airway Anatomy

Anatomically, the respiratory system consists of the upper respiratory tract, consisting of the nose, pharynx, and larynx, and the lower respiratory tract, consisting of the trachea, bronchi, bronchioles, alveolar ducts, and alveoli. The pharynx is a tube-like channel 12.5 cm long that connects the posterior nasal cavity and oral cavity to the esophagus and larynx. The larynx is where the vocal cords are located below the epiglottis. During the swallowing process, the posterior part of the tongue together with the upper part of the larynx is pushed upwards, making the epiglottis close to prevent food or foreign objects from entering the larynx, however, if a foreign object enters the larynx and hits the vocal cords, a cough reflex will arise to expel the foreign object (⁷).

The trachea is a tube 11-14 cm long that connects the cricoid cartilage in the larynx with the primary bronchus. In the anterior part the trachea is formed from C-shaped cartilage and in the posterior part by muscle and connective tissue with a flat surface. The diameter of the trachea in adult males is 1.3-2.5 cm, while in adult females it is around 1.0-2.1 cm and consists of 16-20 tracheal rings. The tracheal ring functions to prevent the trachea from collapsing and plays a role in the flexibility of movement in the neck. The trachea then continues into the right main bronchus, which is wider, shorter (2.2 cm), and more vertical than the left main bronchus (5 cm), thereby increasing the opportunity for foreign objects to enter the main bronchial airway, especially the right main bronchus. The anatomy of the right main bronchus is divided into several subdivisions, namely 3 branching lobes, and then the left main bronchus is divided into several subdivisions, branching into two lobes (⁸).

Figure 1.Larynx and Trachea (⁸)

Diagnosis of Foreign Body Aspiration

The diagnosis of foreign body aspiration in children is not easy, patients often do not remember a history of choking due to a foreign body. In Rodriguez et al.'s (⁹) research, it was found that 6 out of 14 patients who experienced aspiration of metallic foreign bodies experienced a delay in diagnosis of more than 30 days. Posteroanterior (PA) and lateral chest x-rays are performed to evaluate the soft tissue of the neck area as an initial modality for suspected aspiration of foreign bodies in the upper airway. According to research by Pinto et al. (¹⁰), chest X-ray examination can identify foreign body aspiration in only 22.6% of cases, because the identification of the location of a foreign body depends on the material of the foreign body. And the chest X-ray image can be normal within the first 24 hours after the history of aspiration because that newest study by Wang et al. (¹¹) stated a chest CT scan is the highest rate sensitivity to confirm the diagnosis of foreign body airway obstruction.

Computed tomography (CT) is the gold standard and more sensitive for identifying foreign bodies. According to Wang et al. (¹¹), CT-guided bronchoscopy has a sensitivity of 100% and a specificity

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