Case: pediatric airway foreign body

[ethilo]

Hey folks,
I thought I'd bring up an interesting case for people to talk about! Check this out:

On a weekend call shift, a 9 month old girl comes to the OR for airway foreign body removal. Baby has had a month now of initially tugging at ears and URI sxs, progressed to coughing, treated as bronchiolitis and eventually concern for development of pneumonia which has been treated with abx for the last 2 weeks. Now presented from PCP's office to the ED with increased tachypnea / respiratory distress, concerned pediatrician.

PMH also includes...
- Diagnosed with +salmonella enteritis within this last month after small blood found in stool.
- Has a 2 year old brother who plays with small toys. Aunt doesn't recall any swallowing events with patient.
- Aunt has recently been made as emergency foster parent in the last month as well, parents are not present / available.
- No issues with birth or other PMH.

Vitals: Sats low 90s%, normal HR/BP, tachypneic and experiencing mild respiratory distress. Afebrile.
Exam: Absent RUL/RML breath sounds. Some air movement in the RLL. L lung moves good air. Kid has wet tears, some appearance of apprehension and discomfort, audible cry with good energy and glomming onto her Aunt, tachypneic, no coughing.

CXR demonstrates hyperinflation of RML and RUL with some slight/mild leftward deviation.
Labs normal

24g IV in R hand from ED

Surgeon plans a direct laryngoscopy and likely FB removal

...aaaaaand GO!

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[MirrorTodd]

Immediately flush that IV to ensure it's working properly.

 

[Arch Guillotti]

Case should not be done anywhere but an academic medical center or some other big place.

 

[ethilo]

Case should not be done anywhere but an academic medical center or some other big place.

Hah! Yes, we're a Children's hospital, surgeon is a Pediatric ENT. A very good one, too.

 

[ethilo]

Immediately flush that IV to ensure it's working properly.

IV works great, lol

 

[DocVapor]

Prop, roc, here ya go.


What do I win?

 

[Arch Guillotti]

Hah! Yes, we're a Children's hospital, surgeon is a Pediatric ENT. A very good one, too.

That is the majority of this battle.

 

[Wolverines83]

prop drip, precedex load and drip, spontaneous ventilation.

Obviously have an ETT as backup in case you make the kid apneic.

Nice and deep before DL.

 

[Arch Guillotti]

prop drip, precedex load and drip, spontaneous ventilation.

Obviously have an ETT as backup in case you make the kid apneic.

Nice and deep before DL.

Yep, skip the roc.

ETT is a problem though if the foreign body is still in there. Not sure about jet ventilating a kid this young. At any rate you don’t want to be blamed for pushing the object further down.

 

[Hoya11]

Prop, roc, here ya go.


What do I win?

agree. having an iv is a luxury here and makes it an easy choice.

 

[Justice4all]

Prop and tube. Keep deep with boluses if necessary .Intermittent ventilation with coordination with ENT.

 

[Wolverines83]

Yep, skip the roc.

ETT is a problem though if the foreign body is still in there. Not sure about jet ventilating a kid this young. At any rate you don’t want to be blamed for pushing the object further down.

Agree about ETT / pushing things distal. It's an "oh **** he's apneic" solution. Don't want to be there but also don't want to not have it on hand should you end up in that situation.

Way I see it: Kid's alive with current respiratory mechanics....don't change them

 

[Precedex]

A lot of sevo and a little fentanyl is all you need. No ETT. If you need to ventilate do it through the rigid bronch.

 

[Arch Guillotti]

A lot of sevo and a little fentanyl is all you need. No ETT. If you need to ventilate do it through the rigid bronch.

I don't disagree with this sentiment but I would be prepared to run a propofol infusion at a very high rate. Kid needs to be deep. Not the time for bucking or coughing.

 

[Wolverines83]

Prop at 250-300mcg/kg/min, precedex load of 1mcg/kg

 

[Arch Guillotti]

Prop and tube. Keep deep with boluses if necessary .Intermittent ventilation with coordination with ENT.

How do you do the rigid bronch then? Take the tube in and out?

 

[ethilo]

In order to do rigid bronch and perform some kind of object extraction, surgeon needs a native airway because airway is just too small. Also, the surgeon and I decided that with the RML/RUL hyperinflation from air trapping behind the object this patient was at high risk of pneumothorax with any positive pressure ventilation and therefore would avoid intubation+PPV unless absolutely necessary, as such I aimed for spontaneous ventilation and deep deep deep.

Started with small propofol boluses while maintaining spontaneous respirations until child would accept a mask, then 300 mcg/kg/m propofol gtt followed by small titrated boluses of fentanyl, ketamine, glyco, and precedex.

Surgeon performed suspension laryngoscopy with good view of cords, ETT hooked to side port of rigid bronch to provide blow-by FiO2 since no electrocautery was necessary for this procedure.

Surgeon sprayed cords with lidocaine. Any twitching of cords resulted in more boluses of ketamine and fentanyl.

Eventually achieved the right plane of anesthesia, surgeon went down and found significant granuloma tissue completely obstructing bronchus intermedius. Dug around for a while and was unable to find a foreign body. It appeared more like a tumor or significantly inflamed tissue. Biopsies of the mass were taken and with the tissue taken it opened up a pathway for air exchange. Surgeon eventually decided to abort the procedure when something "hard" was encountered underneath that seemed like cartilaginous ring.

Since the obstruction was cleared enough to aerate the lung, the plan was to investigate the lesion urgently with imaging. Child therefore would need intubation for the scanner.

 

[WholeLottaGame7]

Hey folks,
I thought I'd bring up an interesting case for people to talk about! Check this out:

On a weekend call shift, a 9 month old girl comes to the OR for airway foreign body removal. Baby has had a month now of initially tugging at ears and URI sxs, progressed to coughing, treated as bronchiolitis and eventually concern for development of pneumonia which has been treated with abx for the last 2 weeks. Now presented from PCP's office to the ED with increased tachypnea / respiratory distress, concerned pediatrician.

PMH also includes...
- Diagnosed with +salmonella enteritis within this last month after small blood found in stool.
- Has a 2 year old brother who plays with small toys. Aunt doesn't recall any swallowing events with patient.
- Aunt has recently been made as emergency foster parent in the last month as well, parents are not present / available.
- No issues with birth or other PMH.

Vitals: Sats low 90s%, normal HR/BP, tachypneic and experiencing mild respiratory distress. Afebrile.
Exam: Absent RUL/RML breath sounds. Some air movement in the RLL. L lung moves good air. Kid has wet tears, some appearance of apprehension and discomfort, audible cry with good energy and glomming onto her Aunt, tachypneic, no coughing.

CXR demonstrates hyperinflation of RML and RUL with some slight/mild leftward deviation.
Labs normal

24g IV in R hand from ED

Surgeon plans a direct laryngoscopy and likely FB removal

...aaaaaand GO!

I mean, interesting for residents? Or attendings who don't do a lot of peds? This is standard **** at any halfway decent size children's hospital.

Prop at 300mcg/kg/min, topicalize airway, turn to ENT, have a few cuffed/uncuffed ETTs available, blow-by through rigid scope. Only a few ways to **** it up. Don't be too light. Don't be too deep and go apneic. If it's something organic (popcorn, peanuts are the worst) that falls apart and pus/blood spills into the contralateral bronchus, then you have a real problem. If you have to, mainstem the contralateral bronchus and OLV.

 

[ethilo]

I mean, interesting for residents? Or attendings who don't do a lot of peds? This is standard **** at any halfway decent size children's hospital.

Don't worry I got something for you

 

[ethilo]

... After the surgeon took patient out of suspension, patient was stable at 100% on 6L facemask breathing spontaneously on 300 mcg/kg/min propofol, plan to intubate to go to CT scan.

After pre-o2, rocuronium given at 1 mg/kg to facilitate intubation and transport of patient (minimize chance of child self-extubating). HR starts at 120 and climbs after giving roc. Intubation is carried out uneventfully, however patient's HR continues to climb to 230s, NIBP is no longer detectable. surgical tech looks down at hands and points out they are dusky dark, feet are too. Now you look at the face and it looks ghostly pale.

Differential? Plan?

 

[WholeLottaGame7]

... After the surgeon took patient out of suspension, patient was stable at 100% on 6L facemask breathing spontaneously on 300 mcg/kg/min propofol, plan to intubate to go to CT scan.

After pre-o2, rocuronium given at 1 mg/kg to facilitate intubation and transport of patient (minimize chance of child self-extubating). HR starts at 120 and climbs after giving roc. Intubation is carried out uneventfully, however patient's HR continues to climb to 230s, NIBP is no longer detectable. surgical tech looks down at hands and points out they are dusky dark, feet are too. Now you look at the face and it looks ghostly pale.

Differential? Plan?

Lol.

1) Kick yourself for paralyzing and delivering PPV to a kid who was doing fine breathing spontaneously, all for a 5 min scan.
2) Needle decompression for tension PTX.
3) Call surgery for CT.

 

[Justice4all]

How do you do the rigid bronch then? Take the tube in and out?

Taking it in and out and able to tolerate low 90s . Usually a surgical fellow or resident is scrubbed in . Allow for better oxygenation and ventilation

 

[ethilo]

Lol.

1) Kick yourself for paralyzing and delivering PPV to a kid who was doing fine breathing spontaneously, all for a 5 min scan.
2) Needle decompression for tension PTX.
3) Call surgery for CT.

Hah! Definitely on the differential! However...

Bronchus intermedius was patent after the surgeon came out of suspension. Lungs are clear bilaterally with great air movement throughout. Peak pressures are normal.

 

[Wolverines83]

Taking it in and out and able to tolerate low 90s . Usually a surgical fellow or resident is scrubbed in . Allow for better oxygenation and ventilation

woof....just let the kid breath with supplemental O2

 

[WholeLottaGame7]

Hah! Definitely on the differential! However...

Bronchus intermedius was patent after the surgeon came out of suspension. Lungs are clear bilaterally with great air movement throughout. Peak pressures are normal.

I mean, it's not massive hemorrhage, because the blood would either go into the pleural space and cause a hemothorax, which would still have presented similarly to a pneumo, or into the airways, in which case hopefully you would have noticed and mentioned a circuit full of blood.

The only other thing I can think of that would present like that would be a PE, just not sure where it would have come from. I guess theoretically air, but unless you were using crazy high airway pressures, blood would be more likely to go into the airway than to force air into the pulmonary vasculature. I guess it could also be a foreign body (tumor, whatever created the granuloma, etc), but again, pretty far down the differential. Or true/true unrelated thrombosis from somewhere else in the body.

Still, that presentation is PTX for options A, B, and C. Anything else is getting into the weeds.

 

[Morzh]

Mediastinal mass compressing the great vessels (which could go along with lingering URI sxs... some kind of lymphoma growing), now verging on cardiovascular collapse after paralysis + PPV? Try proning the baby, get back to spontaneous ventilation if possible, and call for help / get ready for ECMO?

Anaphylaxis to roc? Seems less likely with normal airway pressures.

 

[ethilo]

I mean, it's not massive hemorrhage, because the blood would either go into the pleural space and cause a hemothorax, which would still have presented similarly to a pneumo, or into the airways, in which case hopefully you would have noticed and mentioned a circuit full of blood.

The only other thing I can think of that would present like that would be a PE, just not sure where it would have come from. I guess theoretically air, but unless you were using crazy high airway pressures, blood would be more likely to go into the airway than to force air into the pulmonary vasculature. I guess it could also be a foreign body (tumor, whatever created the granuloma, etc), but again, pretty far down the differential. Or true/true unrelated thrombosis from somewhere else in the body.

Still, that presentation is PTX for options A, B, and C. Anything else is getting into the weeds.

THINK, doctor, THINK!

 

[DocMcCoy]

I don’t know if the surgeon banging around could precipitate an SVT but I’m heading down a pals tachyarryrthmia algorithm at this point in the case. This is my worst nightmare as a generalist that gets random stuff like this once in a blue moon. Good case.

 

[ethilo]

I forgot to mention (sorry!!!) we had JUST given the patient nebulized racemic epi after coming out of suspension to help keep swelling down inside the airway. I nebulizer it into ambu mask, it appeared that the kid was pulling the fog into their airway with inspiration. Maybe 10 minutes before paralyzing with roc.

 

[vector2]

Hah! Definitely on the differential! However...

Bronchus intermedius was patent after the surgeon came out of suspension. Lungs are clear bilaterally with great air movement throughout. Peak pressures are normal.

What's the ETCO2 and sat?

 

[WholeLottaGame7]

Mediastinal mass compressing the great vessels (which could go along with lingering URI sxs... some kind of lymphoma growing), now verging on cardiovascular collapse after paralysis + PPV? Try proning the baby, get back to spontaneous ventilation if possible, and call for help / get ready for ECMO?

Anaphylaxis to roc? Seems less likely with normal airway pressures.

I mean, maybe. More likely to cause airway compression, which is apparently not the case. Wouldn't be anaphylaxis with a clear airway exam.

 

[WholeLottaGame7]

What's the ETCO2 and sat?

EtCO2 is not going to help you here. It could be in the toilet from a PTX, PE, or just no cardiac output from compression or hypovolemia.

 

[vector2]

EtCO2 is not going to help you here. It could be in the toilet from a PTX, PE, or just no cardiac output from compression or hypovolemia.

I'm aware the differential is large for no ETCO2. I asked because the rapidity of the loss of ETCO2 is useful for narrowing the differential, and because having positive, repeating ETCO2 within normal limits in the setting of shock is sensitive for ruling those things out (and ruling other things in).

 

[ethilo]

What's the ETCO2 and sat?

Sats starting to drift down, low 90s. EtCO2 holding steady at 50 approx through it all. +palpable brachial pulse.

Peak pressures normal
NIBP on the right lower extremity not registering.
Pulse ox has a good waveform from the right finger.

 

[deleted875186]

I would call for new underwear stat ….

 

[vector2]

Sats starting to drift down, low 90s. EtCO2 holding steady at 50 approx through it all. +palpable brachial pulse.

Peak pressures normal
NIBP on the right lower extremity not registering.
Pulse ox has a good waveform from the right finger.

The tachycardia, inability to get a NIBP cycle, downtrending sat, and 4-extremity duskiness are all consistent with roc anaphylaxis. Only thing that doesn't make sense are the normal lung mechanics and ETCO2, although those abnormalities are not present 100% of the time in all anaphylaxis cases...

 

[Hork Bajir]

Roc anaphylaxis with pulmonary symptoms masked by the recent administration of nebulized epi?

I’d still give a few mcg of IV epi. Potential upside >>> potential downside (recognizing the kid is already tachycardic). Wayyyy less likely, but also need to be thinking about MH -can present in funky ways, and you’ll miss the diagnosis unless you consider it.

If not a weird presentation of anaphylaxis or PTX, then we’re down in the weeds a bit. If still can’t get a NIBP and clinical suspicion is high that something is amiss, I’d be starting an art line both to monitor hemodynamics and check some labs.

Otherwise… Pneumomediastinum? Tamponade? SVT? VAE? Thromboembolism? “SIRS”? Calling for a second set of hands (and eyes) if one is available.

 

[ethilo]

Stay tuned... The dramatic conclusion tomorrow 🙃

 

[daneeka]

Interesting diversity in the airway FB recipes. Generally I'd go:
- gas down (unless you've already got a drip)
- drip in
- remi + propofol infusion
- laryngoscopy with McGills' ready +/- ENT over your shoulder (in case it's right there...)
- Nasal ETT to just past the soft palate
- 4mg/kg lignocaine via MAD; half above and half below the cords
- Spont vent on the NPT via T-piece during the case

For the disaster that unfolds:
2 things have changed: giving roc and giving PPV. Anaphylaxis is possible. Maybe pneumothorax, or incomplete removal of the foreign body, with ball-valve obstruction causing tension physiology. I guess mediastinal mass is possible, but if it wasn't seen on XR and the respiratory tree anatomy wasn't too distorted on bronchoscopy it seems less likely.

Not sure whether the pulse-ox being ok in the right hand (but not elsewhere?) is alluding to a missed coarctation or something.

Exam answer:
Equipment problem? (Need to swap out the ETT? Change circuit? Am I really connected to O2?)
Drug problem? (Was that adrenaline instead of roc?)
Patient problem?
- Respiratory - tension? inflated stomach? bronchospasm? residual FB? chest wall rigidity (not in this age group)
- Cardiovascular - undiagnosed congenital disease? anaphylaxis? air embolism?

I want extra hands (ENT, cardiac surgery and PICU), and a gas and an arterial line if it's dragging on.

If I could rule out a respiratory problem, and we're starting to look for weird and wonderful causes, I'd consider the possibility of missed congenital heart disease. A pink baby in extremis might have L-> R shunt, and need an increase in PVR (high CO2, low O2) and drop in SVR (fentanyl) to encourage forward flow. A blue baby might have R -> L and need the opposite. Here I think I'd give 20mL/kg crystalloid and try a bit of adrenaline (maybe 1microg/kg).

Edit:
Didn't see the post about the granulation tissue in the bronchus intermedius and the biopsy. Sounds less like cardiac weirdness and more like an air leak or an obstructing mass that doesn't like positive pressure. Keen to hear how it turned out.

 

[jonessoda1212]

Since peds airway foreign bodies like this always seem to happen at night after the patients have bounced from the PCP to the ED to finally the OR, I'm gonna assume it's' only the ENT and anesthesia call people available.

First, open fluids and give an epi bolus 1-2 mcg/kg. We do these with precedex bolus and volatile, so make sure gas is off or way way down. Verify breath sounds, have a nurse put on another pulse ox to leg and cuff to RUE and cycle those. Next, let ENT go back in with the rigid bronch to make sure nothing has changed with the mass. Next give 16m/kg sugammadex cause Roc anaphylaxis is at or near the top of my differential and i've always wanted to personally see if suga could reverse roc anaphylaxis as detailed in some case reports.

 

[woopedazz]

I wanna hear more about this mysterious cartilaginous ring

 

[Wolverines83]

Kids shunting. RUE (preductal) perfused but nothing else is. 9 months is old for a PDA so it’s congenital heart disease. Is the sat on the RUE drifting? Below 87-88?

Regardless….the kid is perfusing lungs and RUE so this is a left to right shunt. Need to give this kid some PVR to get some of that blood to the body.

 

[Hork Bajir]

Scimitar syndrome?

 

[ethilo]

LOL ok we're getting into the weeds, thanks for humoring me :-D

So the timing of the sudden cardiovascular collapse was very much timed with the administration of roc, therefore anaphylaxis was the highest at the top of the differential. Having just administered racemic epi for the surgery and decadron an hour ago, I was thinking we were masking lung manifestations.

Other things I considered:
- Pneumothorax - airway pressures fine, normal lung sounds
- Iatrogenic - ?pressor in the tubing that got bolused or drug swap? Checked meds, nothing suspicious
- Air embolism from air in IV tubing? Fluid bag and line were full, meds all delivered on the closest port
- Down in the weeds: ?Paraneoplastic syndrome from tumor release of bad humors? We did residency at a place with a carcinoid specialist surgeon... VERY unlikely

Due to the high suspicion of anaphylaxis, I considered epi but was nervous to give it since HR was already sky high, extremities were dusky, and the pulmonary situation was essentially stable. I thought the best thing to do would be a fluid bolus, so we pushed 20 mL/kg LR.

While that was happening I attempted an A line. Flashed 3 times but couldn't thread a wire each time. We are at that point hunting just for a phlebotomy, primarily to get a tryptase level. The kid was impossible to get access but eventually flashed a saphenous and dripped in a cc of blood into a test tube without threading the catheter.

For those that don't know, tryptase must be collected within 45 mins and immediately put on ice. It gets sent to Mayo (at least if you are in the Pacific Northwest) and results a few days after collection. A normal tryptase does not rule of anaphylaxis.

The fluid bolus worked. Within 30 mins NIBP came back, HR came down as fluid rolled in.

Sent the kid to the scanner: "mass" was consistent with inflammatory tissue. The scary thing to me was: the inflamed obstructing mass was extending around encasing the right PA. If the surgeon took maybe 2 more bites it would have been into the PA.

Culture +moraxella and antibiotic switched to cefdinir. Bronchoscopy performed 2 days later and airway much more patent than before, kid was discharged on antibiotics and rocuronium added to allergy list.

I've heard rocuronium anaphylaxis can manifest as just cardiovascular collapse without pulmonary signs. Wished I thought of giving sugammadex at the time but, you know, heat of the moment...

After more thinking, I was considering musculature relaxation with roc could have collapsed the right PA, causing decreased venous return and thus carcinogenic shock, but wouldn't have been able to predict that in the moment.

I'm pretty convinced it was rocuronium anaphylaxis!

 

[Wolverines83]

I can’t say I fully buy that as the explanation.

Anaphylaxis that doesn’t affect your ability to ventilate and causes selectively reduced perfusion to all parts of the body except a particular limb?

Certainly can have mass effect with relaxation. Was there anything surrounding the aorta distal to the brachiocephalic artery? That could give you a similar picture.

Did you ever get a tte?

 

[ethilo]

I can’t say I fully buy that as the explanation.

Anaphylaxis that doesn’t affect your ability to ventilate and causes selectively reduced perfusion to all parts of the body except a particular limb?

Certainly can have mass effect with relaxation. Was there anything surrounding the aorta distal to the brachiocephalic artery? That could give you a similar picture.

Did you ever get a tte?

I never said we checked bp or spo2 on any other limb, I just told you where the monitors are located. All limbs were dusky including the limbs with monitors on them.

 

[ethilo]

I can’t say I fully buy that as the explanation.

Anaphylaxis that doesn’t affect your ability to ventilate and causes selectively reduced perfusion to all parts of the body except a particular limb?

Certainly can have mass effect with relaxation. Was there anything surrounding the aorta distal to the brachiocephalic artery? That could give you a similar picture.

Did you ever get a tte?

No tte, no other masses. When I get around to it I'll post a slice of the CT.

 

[GassYous]

The real lesson here is don't intubate or paralyze a patient that doesn't need it

 

[Arch Guillotti]

I've heard rocuronium anaphylaxis can manifest as just cardiovascular collapse without pulmonary signs.

I have seen it before.

 

[vector2]

LOL ok we're getting into the weeds, thanks for humoring me :-D

So the timing of the sudden cardiovascular collapse was very much timed with the administration of roc, therefore anaphylaxis was the highest at the top of the differential. Having just administered racemic epi for the surgery and decadron an hour ago, I was thinking we were masking lung manifestations.

Other things I considered:
- Pneumothorax - airway pressures fine, normal lung sounds
- Iatrogenic - ?pressor in the tubing that got bolused or drug swap? Checked meds, nothing suspicious
- Air embolism from air in IV tubing? Fluid bag and line were full, meds all delivered on the closest port
- Down in the weeds: ?Paraneoplastic syndrome from tumor release of bad humors? We did residency at a place with a carcinoid specialist surgeon... VERY unlikely

Due to the high suspicion of anaphylaxis, I considered epi but was nervous to give it since HR was already sky high, extremities were dusky, and the pulmonary situation was essentially stable. I thought the best thing to do would be a fluid bolus, so we pushed 20 mL/kg LR.

While that was happening I attempted an A line. Flashed 3 times but couldn't thread a wire each time. We are at that point hunting just for a phlebotomy, primarily to get a tryptase level. The kid was impossible to get access but eventually flashed a saphenous and dripped in a cc of blood into a test tube without threading the catheter.

For those that don't know, tryptase must be collected within 45 mins and immediately put on ice. It gets sent to Mayo (at least if you are in the Pacific Northwest) and results a few days after collection. A normal tryptase does not rule of anaphylaxis.

The fluid bolus worked. Within 30 mins NIBP came back, HR came down as fluid rolled in.

Sent the kid to the scanner: "mass" was consistent with inflammatory tissue. The scary thing to me was: the inflamed obstructing mass was extending around encasing the right PA. If the surgeon took maybe 2 more bites it would have been into the PA.

Culture +moraxella and antibiotic switched to cefdinir. Bronchoscopy performed 2 days later and airway much more patent than before, kid was discharged on antibiotics and rocuronium added to allergy list.

I've heard rocuronium anaphylaxis can manifest as just cardiovascular collapse without pulmonary signs. Wished I thought of giving sugammadex at the time but, you know, heat of the moment...

After more thinking, I was considering musculature relaxation with roc could have collapsed the right PA, causing decreased venous return and thus carcinogenic shock, but wouldn't have been able to predict that in the moment.

I'm pretty convinced it was rocuronium anaphylaxis!

Any steroids, pepcid, benadryl? Surprised that fluid alone worked. The epi isn't just for hemodynamics but also to stabilize mast cells.

I had an intraop anaphylaxis (in an adult) where before anaphylaxis was recognized pt was getting neo, norepi and vaso pushes for refractory hypotension with no effect at all. Once the epi started going in she stabilized within minutes...