The Journal of Laryngology and Otology August 1992, Vol. 106, pp. 751-752
Management of an unusual presentation of foreign body aspiration HASSAN H. RAMADAN, M.D.,* NICOLAS BU-SABA, M.D.,* ANIS BARAKA, M.D.,t SALMAN MROUEH, M.D.J (Beirut,
Lebanon)
Abstract Foreign body aspiration is a very common problem in children and toddlers and still a serious and sometimes fatal condition. We are reporting on a 2-year-old white asthmatic male who choked on a chick pea and presented with subcutaneous emphysema, and on chest X-ray with an isolated pneumomediastinum but not pneumothorax. On review of the literature an isolated pneumomediastinum without pneumothorax was rarely reported. This presented a challenge in management mainly because of the technique that we had to use in order to undergo bronchoscopy and removal of the foreign body. Apnoeic diffusion oxygenation was used initially while the foreign body was removed piecemeal, and afterwards intermittent positive pressure ventilation was used. The child did very well, and his subcutaneous emphysema and pneumomediastinum remarkably improved immediately post surgery.
Introduction Foreign body aspiration remains a common problem in young children and toddlers where it is still a serious and sometimes fatal condition. However, once recognized, management is easy and relatively simple. We are reporting on a case with an unusual presentation that to our knowledge has not been reported before and where management presented a challenge as far as ventilation was concerned during the procedure.
cough for which he was hospitalized elsewhere and given intravenous antibiotics. He was brought to our emergency room with diffuse neck and upper chest swelling which developed two days prior to arrival. Physical examination showed diffuse subcutaneous emphysema over his neck reaching to his cheeks and down to involve his chest and upper abdomen. Lung examination revealed a marked decrease in breath sounds over the left lung field. A chest X-ray showed a pneumomediastinum with subcutaneous emphysema (Fig. 1). The child was premedicated with intramuscular atropine 0.02 mg/kg. In the operating room, the patient had electrocardiogram monitoring and was pre-oxygenated while breathing spontaneously forfiveminutes prior to induction of anaesthesia. Sleep was then induced with intravenous ketamine 2 mg/kg and
Case presentation A two-year-old white asthmatic male seven days prior to presentation choked on a chick pea with no resultant difficulty in breathing or cyanosis. Later, he started to have paroxysms of
FIG. 1 AP chest X-ray pre-operative showed pneumomediastinum with subcutaneous emphysema.
FIG. 2 AP chest X-ray immediately post-operative showed marked decrease in the pneumomediastinum.
From the Departments of Otolaryngology,* Anesthesiologyt and Pediatrics.^ American University of Beirut, Medical Centre and School of Medicine, Beirut, Lebanon. Paper presented at The American Society of Pediatric Otolaryngology, San Diego, May 1989. Accepted for publication: 22 April 1992. 751
752
FIG. 3 Chest X-ray in thefirstpost-operative day showed almost complete clearance of pneumomediastinum.
muscle relaxation was achieved by succinylcholine intravenous drip. Emergency bronchoscopy using a number 3.5 Storz-Hopkins bronchoscope was performed. In order to avoid possible increase of his mediastinal and neck emphysema, intermittent positive pressure ventilation was initially avoided and the patient was ventilated by apnoeic diffusion oxygentation (ADO), whereby oxygen diffuses to the blood by the oxygen pressure gradient. Oxygen was delivered through the bronchoscope. The arterial carbon dioxide (CO2) tension increased by 3 mmHg (mercury) per minute (Frumin et al., 1959; Fraioli et al., 1973) allowing us a five minutes safety margin. Multiple pieces of chick peas were found packed in the left main stem bronchus obstructing it completely. We had to ventilate the patient twice through the patent right bronchus while removing the foreign bodies. Once all the pieces were removed, ventilation was continued by intermittent oxygen jet technique using the Venturi injector adapted to the proximal end of the bronchoscope. At the end of the procedure, the patient was breathing adequately and the subcutaneous emphysema was markedly decreased. A post-operative chest X-ray (Fig. 2) in the recovery room showed marked decrease in the pneumomediastinum. On the first post-operative day, the subcutaneous emphysema had almost resolved and the chest X-ray (Fig. 3) showed clearance of the pneumomediastinum. Discussion This case presented a challenge in management. In reviewing the literature of over 1000 cases, (Aytac et al., 1977; Schloss et al., 1983; McGuirt et al.,. 1988) isolated pneumomediastinum was never encountered as a presentation and only rarely as a complication of rigid bronchoscopy. The mechanism of pneumomediastinum and subcutaneous emphysema development in this patient is similar to that described in asthmatics (Bierman,
Key words: Foreign body; Aspiration
H. H. RAMADAN, N. BU-SABA, A. BARAKA, S. MROUEH
1967). With obstruction of the airway by a foreign body causing a check valve mechanism, (McGill, 1986) there is a build up of pressure distally that leads to over distension of the alveoli and alveolar ducts. With further distension, the alveolar bases rupture and air egresses dissecting along the blood vessel sheaths towards the hilum and into the mediastinum. From there, air dissects along the fascial planes of the neck or sheath of the subclavian vessels to the axilla to appear as subcutaneous emphysema. The use of positive pressure ventilation during bronchoscopy in this condition could lead to an increase in the size of the pneuomomediastinum and subcutaneous emphysema, possibly causing haemodynamic compromise, cardiac arrest and death. Furthermore, in the absence of a pneumothorax, insertion of a thoracostomy tube would have been ineffective in evacuation of the free air. So, a special ventilatory technique was used with ADO initially followed by intermittent jet ventilation as described above. The patient tolerated the procedure well and the subcutaneous emphysema decreased markedly subsequently. This rapid improvement may be in support of the theory that the obstruction caused the emphysema and pneumomediastinum.
Conclusion A case of foreign body aspiration with an unusual presentation was reported. The pneumomediastinum and subcutaneous emphysema were due to almost complete obstruction of the bronchus. The patient was managed initially by ADO and then by intermittent anaesthesia technique ventilating the patent bronchus only during the procedure which proved successful in this case.
References Aytac, A., Yurdakul, Y., Ikizler, C , Rustem, O., Saylam, A. (1977) Inhalation of foreign bodies in children. Report of 500 cases, Journal of Thoracic and Cardiovascular Surgery, 10: 145-151. Bierman, C. W. (1967) Pneumomediastinum and pneumothorax complicating asthma in children. American Journal of Diseases of Childhood, 114: 42-50. Fraioli, R. L., Sheffer, L. A., Steffenson, J. L. (1973) Pulmonary and cardiovascular effect of apneic oxygenation in man. Anesthesiology, 39; 588-596. Frumin, J., Epstein, R., Cohen, G. (1959) Apneic oxygenation in man. Anesthesiology, 20: 789-798. McGill, T. (1986) Foreign bodies in the aerodigestive tract. Otolaryngology—Head and Neck Surgery, 3:132. McGuirt, F. W., Holmes, K. D., Feehs, R., Browne, J. D. (1988) Tracheobronchial foreign bodies. Laryngoscope, 98: 615-618. Schloss, M. D., Anpham, Dang, H., Rosales, J. K. (1983) Foreign bodies in the tracheobronchial tree—a retrospective study of 217 cases. Journal of Otolaryngology, 12: 212-216. Address for correspondence: Hassan H. Ramadan, M. D., West Virginia University, Dept. of Otolaryngology, 2222 H.S.C.S., Morgantown, WV 26506.
Management of an unusual presentation of foreign body aspiration HASSAN H. RAMADAN, M.D.,* NICOLAS BU-SABA, M.D.,* ANIS BARAKA, M.D.,t SALMAN MROUEH, M.D.J (Beirut,
Lebanon)
Abstract Foreign body aspiration is a very common problem in children and toddlers and still a serious and sometimes fatal condition. We are reporting on a 2-year-old white asthmatic male who choked on a chick pea and presented with subcutaneous emphysema, and on chest X-ray with an isolated pneumomediastinum but not pneumothorax. On review of the literature an isolated pneumomediastinum without pneumothorax was rarely reported. This presented a challenge in management mainly because of the technique that we had to use in order to undergo bronchoscopy and removal of the foreign body. Apnoeic diffusion oxygenation was used initially while the foreign body was removed piecemeal, and afterwards intermittent positive pressure ventilation was used. The child did very well, and his subcutaneous emphysema and pneumomediastinum remarkably improved immediately post surgery.
Introduction Foreign body aspiration remains a common problem in young children and toddlers where it is still a serious and sometimes fatal condition. However, once recognized, management is easy and relatively simple. We are reporting on a case with an unusual presentation that to our knowledge has not been reported before and where management presented a challenge as far as ventilation was concerned during the procedure.
cough for which he was hospitalized elsewhere and given intravenous antibiotics. He was brought to our emergency room with diffuse neck and upper chest swelling which developed two days prior to arrival. Physical examination showed diffuse subcutaneous emphysema over his neck reaching to his cheeks and down to involve his chest and upper abdomen. Lung examination revealed a marked decrease in breath sounds over the left lung field. A chest X-ray showed a pneumomediastinum with subcutaneous emphysema (Fig. 1). The child was premedicated with intramuscular atropine 0.02 mg/kg. In the operating room, the patient had electrocardiogram monitoring and was pre-oxygenated while breathing spontaneously forfiveminutes prior to induction of anaesthesia. Sleep was then induced with intravenous ketamine 2 mg/kg and
Case presentation A two-year-old white asthmatic male seven days prior to presentation choked on a chick pea with no resultant difficulty in breathing or cyanosis. Later, he started to have paroxysms of
FIG. 1 AP chest X-ray pre-operative showed pneumomediastinum with subcutaneous emphysema.
FIG. 2 AP chest X-ray immediately post-operative showed marked decrease in the pneumomediastinum.
From the Departments of Otolaryngology,* Anesthesiologyt and Pediatrics.^ American University of Beirut, Medical Centre and School of Medicine, Beirut, Lebanon. Paper presented at The American Society of Pediatric Otolaryngology, San Diego, May 1989. Accepted for publication: 22 April 1992. 751
752
FIG. 3 Chest X-ray in thefirstpost-operative day showed almost complete clearance of pneumomediastinum.
muscle relaxation was achieved by succinylcholine intravenous drip. Emergency bronchoscopy using a number 3.5 Storz-Hopkins bronchoscope was performed. In order to avoid possible increase of his mediastinal and neck emphysema, intermittent positive pressure ventilation was initially avoided and the patient was ventilated by apnoeic diffusion oxygentation (ADO), whereby oxygen diffuses to the blood by the oxygen pressure gradient. Oxygen was delivered through the bronchoscope. The arterial carbon dioxide (CO2) tension increased by 3 mmHg (mercury) per minute (Frumin et al., 1959; Fraioli et al., 1973) allowing us a five minutes safety margin. Multiple pieces of chick peas were found packed in the left main stem bronchus obstructing it completely. We had to ventilate the patient twice through the patent right bronchus while removing the foreign bodies. Once all the pieces were removed, ventilation was continued by intermittent oxygen jet technique using the Venturi injector adapted to the proximal end of the bronchoscope. At the end of the procedure, the patient was breathing adequately and the subcutaneous emphysema was markedly decreased. A post-operative chest X-ray (Fig. 2) in the recovery room showed marked decrease in the pneumomediastinum. On the first post-operative day, the subcutaneous emphysema had almost resolved and the chest X-ray (Fig. 3) showed clearance of the pneumomediastinum. Discussion This case presented a challenge in management. In reviewing the literature of over 1000 cases, (Aytac et al., 1977; Schloss et al., 1983; McGuirt et al.,. 1988) isolated pneumomediastinum was never encountered as a presentation and only rarely as a complication of rigid bronchoscopy. The mechanism of pneumomediastinum and subcutaneous emphysema development in this patient is similar to that described in asthmatics (Bierman,
Key words: Foreign body; Aspiration
H. H. RAMADAN, N. BU-SABA, A. BARAKA, S. MROUEH
1967). With obstruction of the airway by a foreign body causing a check valve mechanism, (McGill, 1986) there is a build up of pressure distally that leads to over distension of the alveoli and alveolar ducts. With further distension, the alveolar bases rupture and air egresses dissecting along the blood vessel sheaths towards the hilum and into the mediastinum. From there, air dissects along the fascial planes of the neck or sheath of the subclavian vessels to the axilla to appear as subcutaneous emphysema. The use of positive pressure ventilation during bronchoscopy in this condition could lead to an increase in the size of the pneuomomediastinum and subcutaneous emphysema, possibly causing haemodynamic compromise, cardiac arrest and death. Furthermore, in the absence of a pneumothorax, insertion of a thoracostomy tube would have been ineffective in evacuation of the free air. So, a special ventilatory technique was used with ADO initially followed by intermittent jet ventilation as described above. The patient tolerated the procedure well and the subcutaneous emphysema decreased markedly subsequently. This rapid improvement may be in support of the theory that the obstruction caused the emphysema and pneumomediastinum.
Conclusion A case of foreign body aspiration with an unusual presentation was reported. The pneumomediastinum and subcutaneous emphysema were due to almost complete obstruction of the bronchus. The patient was managed initially by ADO and then by intermittent anaesthesia technique ventilating the patent bronchus only during the procedure which proved successful in this case.
References Aytac, A., Yurdakul, Y., Ikizler, C , Rustem, O., Saylam, A. (1977) Inhalation of foreign bodies in children. Report of 500 cases, Journal of Thoracic and Cardiovascular Surgery, 10: 145-151. Bierman, C. W. (1967) Pneumomediastinum and pneumothorax complicating asthma in children. American Journal of Diseases of Childhood, 114: 42-50. Fraioli, R. L., Sheffer, L. A., Steffenson, J. L. (1973) Pulmonary and cardiovascular effect of apneic oxygenation in man. Anesthesiology, 39; 588-596. Frumin, J., Epstein, R., Cohen, G. (1959) Apneic oxygenation in man. Anesthesiology, 20: 789-798. McGill, T. (1986) Foreign bodies in the aerodigestive tract. Otolaryngology—Head and Neck Surgery, 3:132. McGuirt, F. W., Holmes, K. D., Feehs, R., Browne, J. D. (1988) Tracheobronchial foreign bodies. Laryngoscope, 98: 615-618. Schloss, M. D., Anpham, Dang, H., Rosales, J. K. (1983) Foreign bodies in the tracheobronchial tree—a retrospective study of 217 cases. Journal of Otolaryngology, 12: 212-216. Address for correspondence: Hassan H. Ramadan, M. D., West Virginia University, Dept. of Otolaryngology, 2222 H.S.C.S., Morgantown, WV 26506.
