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return to: Pediatric Airway

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




PREOPERATIVE PREPARATIONS

 

  1. 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 Direct Laryngoscopy Protocol)
    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. 
    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 extention 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.



      Please see the pediatric Bronchoscope video here.
  2. 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. 
  3. SUGGESTED READING
    1. 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]
    2. Ringold S, Klein EJ, Del Beccaro MA.  Postobstructive pulmonary edema in children.  Pediatr Emerg Care. 2004 Jun;20(6):391-5.
    3. Van Kooy MA, Gargiulo RF. Postobstructive pulmonary edema.  Am Fam Physician. 2000 Jul 15;62(2):401-4.
    4. P.P. McConkey, Postobstructive pulmonary oedema: a case series and review, Anaesth Intensive Care 28 (1) (2000), pp. 72-76.


*Informed written consent regarding photo usage and documentation has been obtained for all photographic materials used in this protocol. These photos are for educational use by UIHC only.