return to: Pediatric Airway or Adult Airway in the Operating Room

Also see: Pediatric Direct Laryngoscopy and Maximum Recommended Doses and Duration of Local Anesthetics

Note: last updated before 2013

PRE-OPERATIVE CHECKLIST

1. Ensure you have the correct sized flexible suction adapter available and, preferably, pre-loaded into the bronch (cumbersome to place once in the airway). These are color-coded (color of tip on suction matches that of the color strip on the bronch handle) to help with identification
2. Consider having a flexible bronch in the room
   1. Optics are much better (and Manaligod prefers) the Olympus tower with pediatric flexible 2.2mm bronchoscope BF XP 190 (plugs into separate tower than the laryngoscope and rigid bronch with interface similar to that which we use in our clinic)
   2. Pentax intubating scope has very poor optics but is good in a pinch as it plugs into same tower as the main bronchoscope
3. Ensure optical forceps tray is in room
   1. Options:
      1. infant (#34) - use with 2.8mm 30cm telescope and 26cm bronch tray
      2. child (#35A) - comes with own telescope in tray - use with the 30cm bronch tray
      3. and a very small (easily damaged) 2mm Pilling optical forceps tray (rarely used) which comes with own 2mm telescope
   2. pre-select the forcep appropriate for the foreign body you are trying to remove and load the camera/lightsource into this
4. Consider having the Foreign body forceps tray (Pillings 30-35cm OR 40-50cm trays) for additional tip options (the longer one has a magnet included)
   1. OR the peds endoscopy forceps tray (non-optical; #36; will fit through 2.5 and 3.0 mm bronchoscopes)

OPERATIVE PROCEDURE

1. Patient is masked down by Anesthesia, and the bed is turned 90 degrees toward the surgeon.
2. A MAC or Miller blade is used to evaluate the glottis, while the true vocal cords are sprayed with 1% Lidocaine at dosage of 4 mg/kg (see Pediatric Direct Laryngoscopy)
3. The Larynx is again visualized using the MAC or Miller blade, and with adequate exposure, the rigid bronchoscope with the 0 degree endoscope is advanced.
   1. As the rigid bronchscope nears the larynx, the scope is turned 90 degrees to avoid damage to the true vocal cords. 
      1. This allows the leading edge of the bronchoscope to be parallel to the true vocal cords upon entry so that the edge does not catch on the cords.
4. Once the Brochoscope is in position, the MAC or Miller blade is removed.
   1. The Bronchoscope is again reoriented at this time.
5. It is important at this time to connect the rigid bronchoscope to the ventilation circuit.
   1. The appropriately sized suction catheter may also be placed at this time (ideally, it is already in place and only requires advancing)
6. The scope is advanced, with evaluation of the trachea and main bronchi.
7. Once the foreign body is visualized, the rigid bronchoscope is held into place while the 0 degree endoscope, and extension bridge is removed.
8. The optical forceps are then placed. The forceps are advanced, and the foreign object is grasped. The object is then removed from the airway.
   1. The entire scope, and object are removed as a unit.
9. Once the object has been removed, the bronchoscope is again used to evaluate for any remaining foreign objects. Place the scope as previously described, and rotate the head to the right for evaluation of the left main bronchus, while rotating the head to the left for evaluation of the right main bronchus.
10. Suction the trachea using a #7 French suction tubing through the rigid bronchoscope upon removal of the scope.
11. Evaluate the upper esophagus for possible foreign objects in the upper esophagus.

POSTOPERATIVE CARE

1. Patient should be monitored post-operatively for postobstructive pulmonary edema (POPE).
2. POPE generally presents with an immediate onset of respiratory distress occurring after relief of airway obstruction, but delayed presentation up to 24 hours later has been reported.
   1. POPE I - follows sudden, severe upper airway obstruction (as with removal of foreign bodies).
      1. This is from a negative pressure pulmonary edema that occurs when an attempted inspiration occurs against on occluded airway. (see
   2. POPE II - occurs after surgical relief of chronic upper airway obstruction (see tonsillectomy).
      1. Correlates more on expiration against an obstructed airway. 
         1. Sudden relief following an adenotonsillectomy creates an abrupt fall in airway pressure, increase in venous return, and consequent increase in preload. The left ventricle cannot compensate for these changes from increased hydrostatic pressure in the pulmonary circuit. 

REFERENCES

Shlizerman L, Mazzawi S, Rakover Y, Ashkenazi D. Foreign body aspiration in children: the effects of delayed diagnosis. Am J Otolaryngol. 2009 Apr 22. [Epub ahead of print]

Ringold S, Klein EJ, Del Beccaro MA.  Postobstructive pulmonary edema in children.  Pediatr Emerg Care. 2004 Jun;20(6):391-5.

Van Kooy MA, Gargiulo RF. Postobstructive pulmonary edema.  Am Fam Physician. 2000 Jul 15;62(2):401-4.

P.P. McConkey, Postobstructive pulmonary oedema: a case series and review, Anaesth Intensive Care 28 (1) (2000), pp. 72-76.