AsthnaVeena1, S. S. Bist2, B. Bharti3, Shreesh Mehrotra4
1Professor; 3Resident, Department of Anesthesiology
2Professor &HoD; 4Assistant Professor, Department of Otorhinolaryngology
Himalayan Institute of Medical Sciences (HIMS), Swami Ram Nagar, Dehradun, Uttarakhand 248140, (India)
Correspondence: Dr.AsthnaVeena, Professor of Anesthesiology, Himalayan Institute of Medical Sciences (HIMS), Swami Ram Nagar, Jolly Grant, Dehradun, Uttarakhand 248140, (India)
ABSTRACT
Swallowing of foreign bodies is a fairly common pediatric emergency. Children usually swallow foreign objects into their bodies accidentally during playing. Foreign body in the trachea is a common condition which may be life threatening. Foreign body in bronchus is usually managed by bronchoscopy, though open surgical procedure may be rarely needed and sometimes it is life threatening. We report a case of a 5 year old male child who accidentally inhaled an open safety pin. Bronchoscopy was done to localize the site of the foreign body, but it was not possible to be removed by bronchoscopy as the pin was open. Then, tracheotomy was done and foreign body was removed successfully. Tracheotomy stoma was closed after the removal. Patient developed surgical emphysema within minutes of closure and presented with difficulty in breathing with bradycardia, immediately surgeon explored the surgical site and reopen tracheostomy site and the patient was managed successfully.
Keywords: Foreign body;Foreign Bodies/diagnosis; Tracheostomy; Bronchoscopy; Bronchoscopy/methods; Trachea
Citation:Veena A, Bist SS, Bharti B, Mehrotra S. Removal of an aspirated open safety pin from trachea. Anaesth Pain & Intensive Care 2015;19(3):416-418
INTRODUCTION
Aspiration of foreign body (FB) into the respiratory tract is a commonly encountered and serious problem in childhood and can be a significant cause of morbidity and mortality.
Tracheobronchial FB aspiration can lead to fatal acuterespiratory failure when it causes near-complete occlusion at the tracheal level. However, the FB’s that have lodged in the lower tracheobronchial tree can cause respiratory tract problems at the distal region, because occlusion can lead to ventilation failure which creates a favourable environment for infection. Laryngotracheal FBs, although less common than the bronchial ones, are particularly more dangerous as they could lead to choking and complete blockage of the airway.1,2
Rigid bronchoscopy is the mainstay of the treatment in these patients. However, on rare occasions, when the FB is sharp, pointed and risks perforating the airways, the removal may be performed by opening the trachea.
We report a case of 5yr old male child who aspirated a sharp FB into the airway (open safety pin) which was removed with endoscopic instruments and concomitant performance of tracheostomy. It is important to note that tracheostomy indication for removal of tracheobronchial FBs is reported in only 11 cases in literature suggesting that this is an extremely rare event.1-3
CASE REPORT
A 5 year old boy presented in ENT OPD with complaints of cough and difficulty in speaking for 7 days and difficulty in breathing for 3 days. History given by the parents suggested accidental ingestion of an open safety pin about 1 month back.
Preoperatively, the patient was conscious, oriented, afebrile, pulse rate was 102/min. Blood pressure 104 / 70 mm of Hg, respiratory rate of 22 / min and oxygen saturation was 95 % on room air. He had mild inspiratory stridor and on auscultation, there was bilaterally equal air entry, but slightly decreased. Other systems were examined and were within normal limits. Routine blood investigations were normal.
X-ray soft tissue neck revealed an open safety pin in the subglottic and cervical tracheal region which was open upwards. A diagnosis of laryngotracheal foreign body (open safety pin) was made and the patient was electively posted for foreign body removal by rigid bronchoscopy under general anesthesia.
Figure 1: X-ray soft tissue neck (lateral and AP) showing open safety pin in the subglottic region
After thorough pre-anesthetic check-up and parent’s consent, the procedure was planned. The patient was fasted for 6 hrs before surgery. Next morning, the patient was taken in the operation theatre. Basic monitoring,(blood pressure, pulse oximeter, ECG) was attached and the baseline readings were recorded. The patient was preoxygenated with 100% oxygen for 3-4 min. Inhalational induction of anesthesia was done with sevoflurane ≤ 8% in oxygen and the adequacy of mask ventilation was checked. The patient was then given Inj. hydrocortisone 50 mg, inj. fentanyl 40 µg and inj. atracurium10 mg. Rigid bronchoscope was introduced and ventilation was maintained with the ventilatory port. Anesthesia was maintained with intermittent boluses of inj. atracurium and sevoflurane. An open safety pin was visualized in the subglottic region with the sharp end of the safety pin impinged in the mucosa of the under surface of the vocal cords. Two attempts to close the open end of the safety pinfailed.
Removal of an open safety pin or sharp structure is likely to injure the endolaryngeal structures and can result in permanent voice morbidity.Weintubated the child with a non-cuffed endotracheal tube and secured the airway. Then the surgeon performed tracheostomy. Endoscopic forceps were used to pull the FB through the tracheostomy stoma. The safety pin was successfully and safely removed. After the procedure, the surgeon closed the tracheotomy site and the anesthesia was reversed with inj. neostigmine and glycopyrrolate. For postoperative pain relief, inj. paracetamol 300 mg infusion was given and the patient was shifted to PACU. The patient was hemodynamically stable and maintained a saturation of 98% on room air. While shifting the patient to PACU, the patient had few bouts of cough. After about 10 min, the childhad had swelling over face, neck and chest and had difficulty in breathing, bradycardia and decreased oxygen saturation. The patient was immediately shifted to operating room and ventilated with 100% oxygen. Inj. atropine 0.8 mg was given. Simultaneously, tracheostomy site was re-explored and a tracheostomy tube #4.5 was inserted by the surgeon. When the patient improved, he was shifted to PACU and close monitoring was done. Postoperatively, the patient was nebulized and steroid cover was continued to decrease laryngeal edema. Subsequent postoperative period was uneventful. Decannulation and strapping was done on 3rd postoperative day and the patient was discharged on 5th day in a satisfactory condition.
DISCUSSION
FB removal in children is a challenging procedure for anesthesiologists as the airway in paediatrics patients is narrow and desaturation is faster. Also, the surgeon and the anesthesiologist have to share the airway, while rarely necessary it is important that concomitant tracheostomy is indicated for patients who have aspirated particularly sharply pointed FBs lodged in the subglottis or in vocal cords. It is advisable that after removal of FB, tracheostomy stoma can be closed and endotracheal tube should be kept in situ, till the airway edema subsides. Alternatively, a tracheostomy tube is maintained till the subglottic edema subsides.2,4,5
In our case, due to open sharp points of safety pin impinged in mucosa of subglottic region and fear of injury to endolaryngeal structures, although no multiple attempts were taken by the surgeon, so they opted to close tracheostomy before shifting to PACU, but after immediate tracheostomy closure, patient developed airway irritation and cough leading to surgical emphysema, precipitating hypoxia, bradycardia, hemodynamic instability and cardiac arrest.
In a sharp foreign body, it is advised to remove the foreign body after closing it, although rarely necessitating tracheostomy and it is advisable not to immediately close a tracheostomy site in children. Intense cardiorespiratory monitoring is must in postoperative period.
Authors’ Contribution:
VA: Concept,manuscriptpreprationand writing
SSB: Concept and manuscript prepretion
SM: Manuscript prepration
BB: Concept
REFERENCES
1Professor; 3Resident, Department of Anesthesiology
2Professor &HoD; 4Assistant Professor, Department of Otorhinolaryngology
Himalayan Institute of Medical Sciences (HIMS), Swami Ram Nagar, Dehradun, Uttarakhand 248140, (India)
Correspondence: Dr.AsthnaVeena, Professor of Anesthesiology, Himalayan Institute of Medical Sciences (HIMS), Swami Ram Nagar, Jolly Grant, Dehradun, Uttarakhand 248140, (India)
ABSTRACT
Swallowing of foreign bodies is a fairly common pediatric emergency. Children usually swallow foreign objects into their bodies accidentally during playing. Foreign body in the trachea is a common condition which may be life threatening. Foreign body in bronchus is usually managed by bronchoscopy, though open surgical procedure may be rarely needed and sometimes it is life threatening. We report a case of a 5 year old male child who accidentally inhaled an open safety pin. Bronchoscopy was done to localize the site of the foreign body, but it was not possible to be removed by bronchoscopy as the pin was open. Then, tracheotomy was done and foreign body was removed successfully. Tracheotomy stoma was closed after the removal. Patient developed surgical emphysema within minutes of closure and presented with difficulty in breathing with bradycardia, immediately surgeon explored the surgical site and reopen tracheostomy site and the patient was managed successfully.
Keywords: Foreign body;Foreign Bodies/diagnosis; Tracheostomy; Bronchoscopy; Bronchoscopy/methods; Trachea
Citation:Veena A, Bist SS, Bharti B, Mehrotra S. Removal of an aspirated open safety pin from trachea. Anaesth Pain & Intensive Care 2015;19(3):416-418
INTRODUCTION
Aspiration of foreign body (FB) into the respiratory tract is a commonly encountered and serious problem in childhood and can be a significant cause of morbidity and mortality.
Tracheobronchial FB aspiration can lead to fatal acuterespiratory failure when it causes near-complete occlusion at the tracheal level. However, the FB’s that have lodged in the lower tracheobronchial tree can cause respiratory tract problems at the distal region, because occlusion can lead to ventilation failure which creates a favourable environment for infection. Laryngotracheal FBs, although less common than the bronchial ones, are particularly more dangerous as they could lead to choking and complete blockage of the airway.1,2
Rigid bronchoscopy is the mainstay of the treatment in these patients. However, on rare occasions, when the FB is sharp, pointed and risks perforating the airways, the removal may be performed by opening the trachea.
We report a case of 5yr old male child who aspirated a sharp FB into the airway (open safety pin) which was removed with endoscopic instruments and concomitant performance of tracheostomy. It is important to note that tracheostomy indication for removal of tracheobronchial FBs is reported in only 11 cases in literature suggesting that this is an extremely rare event.1-3
CASE REPORT
A 5 year old boy presented in ENT OPD with complaints of cough and difficulty in speaking for 7 days and difficulty in breathing for 3 days. History given by the parents suggested accidental ingestion of an open safety pin about 1 month back.
Preoperatively, the patient was conscious, oriented, afebrile, pulse rate was 102/min. Blood pressure 104 / 70 mm of Hg, respiratory rate of 22 / min and oxygen saturation was 95 % on room air. He had mild inspiratory stridor and on auscultation, there was bilaterally equal air entry, but slightly decreased. Other systems were examined and were within normal limits. Routine blood investigations were normal.
X-ray soft tissue neck revealed an open safety pin in the subglottic and cervical tracheal region which was open upwards. A diagnosis of laryngotracheal foreign body (open safety pin) was made and the patient was electively posted for foreign body removal by rigid bronchoscopy under general anesthesia.
Figure 1: X-ray soft tissue neck (lateral and AP) showing open safety pin in the subglottic region
After thorough pre-anesthetic check-up and parent’s consent, the procedure was planned. The patient was fasted for 6 hrs before surgery. Next morning, the patient was taken in the operation theatre. Basic monitoring,(blood pressure, pulse oximeter, ECG) was attached and the baseline readings were recorded. The patient was preoxygenated with 100% oxygen for 3-4 min. Inhalational induction of anesthesia was done with sevoflurane ≤ 8% in oxygen and the adequacy of mask ventilation was checked. The patient was then given Inj. hydrocortisone 50 mg, inj. fentanyl 40 µg and inj. atracurium10 mg. Rigid bronchoscope was introduced and ventilation was maintained with the ventilatory port. Anesthesia was maintained with intermittent boluses of inj. atracurium and sevoflurane. An open safety pin was visualized in the subglottic region with the sharp end of the safety pin impinged in the mucosa of the under surface of the vocal cords. Two attempts to close the open end of the safety pinfailed.
Removal of an open safety pin or sharp structure is likely to injure the endolaryngeal structures and can result in permanent voice morbidity.Weintubated the child with a non-cuffed endotracheal tube and secured the airway. Then the surgeon performed tracheostomy. Endoscopic forceps were used to pull the FB through the tracheostomy stoma. The safety pin was successfully and safely removed. After the procedure, the surgeon closed the tracheotomy site and the anesthesia was reversed with inj. neostigmine and glycopyrrolate. For postoperative pain relief, inj. paracetamol 300 mg infusion was given and the patient was shifted to PACU. The patient was hemodynamically stable and maintained a saturation of 98% on room air. While shifting the patient to PACU, the patient had few bouts of cough. After about 10 min, the childhad had swelling over face, neck and chest and had difficulty in breathing, bradycardia and decreased oxygen saturation. The patient was immediately shifted to operating room and ventilated with 100% oxygen. Inj. atropine 0.8 mg was given. Simultaneously, tracheostomy site was re-explored and a tracheostomy tube #4.5 was inserted by the surgeon. When the patient improved, he was shifted to PACU and close monitoring was done. Postoperatively, the patient was nebulized and steroid cover was continued to decrease laryngeal edema. Subsequent postoperative period was uneventful. Decannulation and strapping was done on 3rd postoperative day and the patient was discharged on 5th day in a satisfactory condition.
DISCUSSION
FB removal in children is a challenging procedure for anesthesiologists as the airway in paediatrics patients is narrow and desaturation is faster. Also, the surgeon and the anesthesiologist have to share the airway, while rarely necessary it is important that concomitant tracheostomy is indicated for patients who have aspirated particularly sharply pointed FBs lodged in the subglottis or in vocal cords. It is advisable that after removal of FB, tracheostomy stoma can be closed and endotracheal tube should be kept in situ, till the airway edema subsides. Alternatively, a tracheostomy tube is maintained till the subglottic edema subsides.2,4,5
In our case, due to open sharp points of safety pin impinged in mucosa of subglottic region and fear of injury to endolaryngeal structures, although no multiple attempts were taken by the surgeon, so they opted to close tracheostomy before shifting to PACU, but after immediate tracheostomy closure, patient developed airway irritation and cough leading to surgical emphysema, precipitating hypoxia, bradycardia, hemodynamic instability and cardiac arrest.
In a sharp foreign body, it is advised to remove the foreign body after closing it, although rarely necessitating tracheostomy and it is advisable not to immediately close a tracheostomy site in children. Intense cardiorespiratory monitoring is must in postoperative period.
Authors’ Contribution:
VA: Concept,manuscriptpreprationand writing
SSB: Concept and manuscript prepretion
SM: Manuscript prepration
BB: Concept
REFERENCES
- Kulkarni SJ, Kelkar VP. Removal of Large Foreign Body in the Bronchus by an Unusual Method. International Journal of Recent Trends in Science And Technology, 2014;10(3):470-471 [Free full text]
- Fidcowski CW, Zheng H, Firth PG. The anaestheticconsiderations of tracheobronchial foreign bodies in children:A literature review of 12,979 cases. AnesthAnalg. 2010 Oct;111(4):1016-25. [PubMed] doi: 10.1213/ANE.0b013e3181ef3e9c
- Yetim TD, Bayarogulları H, Arıca V, Akcora B, Arıca SG, et al. Foreign Body Aspiration in Children; Analysis of 42 Cases. J PulmonResp Med 2012;2:3 [Free full text]doi: 10.4172/2161-105X.1000121
- Esener Z, Sahinoglu H, Yuksel M, Guney E. Foreign body aspiration - bronchoscopy and anesthesia applied problems. OndokuzMayıs University J. Med.1986;3:93-103.
- Pan H, Lu Y, Shi L, Pan X, Li L, Wu Z. Similarities and differences in aspirated tracheobronchial foreign bodies in patients under the age of 3 years. Int J PediatrOtorhinolaryngol. 2012 Jun;76(6):911-4. [PubMed]doi: 10.1016/j.ijporl.2012.03.002.