Question

A 3-year-old child presents with respiratory distress and the child is planned for emergency bronchoscopic removal of foreign body in the right main bronchus. Discuss the anaesthetic concerns, technique of anaesthetizing this patient and possible complications.

Hint:

Always ensure that the child is adequately premedicated to reduce anxiety, and secure the airway before proceeding with bronchoscopic foreign body removal.

Answer 1

Step 1: Anaesthetic Concerns.
In a 3-year-old child undergoing emergency bronchoscopic removal of a foreign body, the primary concerns include:
- Airway management: The child may have partial or complete airway obstruction due to the foreign body. Intubation with a suitable-sized endotracheal tube should be planned. In some cases, a rigid bronchoscope may be used to directly visualize and remove the foreign body.
- Maintaining ventilation: Due to the compromised airway, maintaining adequate ventilation is crucial. The child may need to be managed with positive pressure ventilation or assisted ventilation if they cannot maintain spontaneous breathing.
- Aspiration and hypoxia: Aspiration of secretions or the foreign body itself may occur during the procedure. Additionally, hypoxia may develop if ventilation is not adequately maintained or if there is obstruction. The use of supplemental oxygen is essential throughout the procedure.

Step 2: Technique of Anaesthetizing the Patient.
The technique for anaesthetizing a child for bronchoscopy involves:
- Premedication: Sedation should be provided pre-operatively using agents like midazolam or oral sedatives to calm the child. This will help alleviate anxiety and ease the process of securing the airway.
- Induction of anaesthesia: Anaesthesia can be induced using inhalational agents such as sevoflurane or isoflurane via face mask, which is often preferable in children for ease of administration. Alternatively, intravenous induction with propofol may be used if the intravenous access is established.
- Airway management: Following induction, a size-appropriate endotracheal tube should be inserted to secure the airway. A rigid bronchoscope can be introduced if needed to remove the foreign body. Monitoring should include continuous pulse oximetry and capnography to ensure adequate oxygenation and ventilation.
- Muscle relaxation: Muscle relaxants such as succinylcholine may be required to facilitate intubation and the bronchoscopy procedure.

Step 3: Complications.
The potential complications include:
- Hypoxia: Prolonged ventilation difficulties, or an obstructed airway, may lead to hypoxia. This is a major concern in paediatric patients. Adequate monitoring and rapid intervention are critical.
- Aspiration: The child may aspirate secretions or food particles during the procedure, potentially leading to aspiration pneumonia. Prevention can be done through suctioning and ensuring airway protection during the bronchoscopy.
- Trauma to the airway: Inserting the bronchoscope or endotracheal tube can cause trauma to the airway, including laryngospasm or bronchospasm. Close monitoring and proper technique are crucial to minimize this risk.
- Airway obstruction: During removal of the foreign body, accidental displacement or movement of the foreign object can cause sudden complete obstruction, requiring immediate action.

Step 4: Conclusion.
Anesthesia for foreign body removal in a 3-year-old requires careful planning, especially in managing the airway and ventilation. Adequate preoperative sedation, secure intubation, and constant monitoring for complications like hypoxia and aspiration are essential for a safe procedure.