Background: In order to reduce the irritation of the airway during tracheobronchial foreign body (TFB) removal, tracheal surface anesthesia is usually performed using a laryngotracheal topical anesthesia (LTA) kit (LTA20, Highgreen Medical Technology Company, China), but difficulty in withdrawing the LTA kit is rarely reported. We present a case of a difficulty to withdraw the LTA kit due to its entrapment by the movement of a TFB. Case presentation: A 1-year-old girl was undergoing TFB removal. After the surgeon completed the tracheal surface anesthesia, the girl suddenly suffered from bucking, leading to the dislodgment of the TFB to the subglottic region, complicating the withdrawal of the LTA applicator. At the same time, the girl’soxygen saturation (SpO ) decreased to 91% and her heart rate dropped from 150 to 100 bpm. Atropine and succinylcholine were administered intravenously immediately, then the surgeon tried to free the TFB by pushing it back into the trachea, after which the LTA applicator was easily withdrawn, and TFB was removed successfully. The girl was discharged from hospital without any complications 2 days later. Conclusion: This case report draws our attention to a significant anesthetic clinical consideration during the application of topical anesthesia on the trachea for TFB removal. The possibility of coughing or bucking can lead to migration of the TFB with subsequent airway obstruction, so the depth of anesthesia must be sufficient to prevent harmful reflexes. Also, strong teamwork and good communication are paramount to avoid serious complications. Keywords: Child, Foreign body, Anesthesia, Airway Background tracheal surface anesthesia, so as to relieve the likelihood TFB aspiration is a common life-threatening accident in of a harmful reflex induced by rigid tracheobronchoscopy. children, especially those under age 4 . Rigid tracheo- To date,however,difficultiesin withdrawingaLTA bronchoscopy is considered the gold standard technique applicator due to its entrapment by movement of a for the management of TFB removal. Because of im- TFB, with the potential to lead to serious complications, mature protective mechanisms and relatively narrow has not been reported. airways, severe complications, such as desaturation, laryngeal edema, bronchospasm, pneumothorax, pneu- Case presentation momediastinum, tracheal or bronchial laceration, and The patient’s father provided written consent to the use even cardiac arrest, can occur with attempting at TFB the patient’s medical information for research and removal . LTA applicator (LTA20, Highgreen Medical publication. Technology Company, China) is usually used to perform A 1-year-old girl (weight 10 kg) had suffered from a cough with sputum production for more than 2 days. * Correspondence: firstname.lastname@example.org She had a medical history of having swallowed a TFB Xi-Yang Zhang, Yun Han and Ya-Bing Zhang contributed equally to this work. 2 days earlier. The physical examination was normal, ex- Department of Anesthesiology, Nan Fang Hospital, Southern Medical cept for a wheezing sound in the right lung. A chest University, Guangzhou, Guangdong, China Full list of author information is available at the end of the article computed tomography scan revealed an 8 × 4 × 21 mm © The Author(s). 2018 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Zhang et al. BMC Anesthesiology (2018) 18:60 Page 2 of 3 mass in the trachea near the carina, which given the pa- tient’s history, was suggestive of the diagnosis of a TFB aspiration. After careful preoperative preparation, we scheduled the patient to undergo an emergency rigid tracheobronchoscopy to remove the TFB under general anesthesia. In order to keep the patient in spontaneous breathing, the combination of intravenous and inhalant anesthesia with propofol, fentanyl, and sevoflurane was planned to be administered. In the operating room, standard monitoring was installed, including SpO , non- invasive blood pressure, and an electrocardiogram. Before administration of anesthesia, the child was pre- medicated with atropine (0.1 mg) and dexamethasone (2 mg)intravenously. Then anesthesia induction was per- formed with 8% sevoflurane carried by 6 L/min oxygen Fig. 1 Laryngotracheal topical anesthesia (LTA) kit and tracheobronchial flow. After the patient became unconscious, anesthesia foreign body (TFB) was maintained with 3–5% sevoflurane and 1 L/min oxy- gen flow for more than 5 min. Before rigid tracheo- bronchoscopy introduced into the trachea, the child result in complete airway obstruction. However, when received propofol (20 mg) and fentanyl (10 μg) intraven- using this technique, the anesthetist is challenged to ously to deepen the anesthesia. After 1–2 min, when her maintain the anesthetic depth, and they usually add top- lower jaw was flabby, the surgeon introduced a LTA ical anesthesia to suppress airway reflexes. The use of applicator into the trachea under the guidance of rigid controlled ventilation with a muscle relaxant may facili- tracheobronchoscopy, and then sprayed topical 1% lido- tate the avoidance of patient coughing and bucking, and caine on the surfaces of the vocal cords and trachea. facilitate the extraction of a TFB, but this technique has After the surgeon applied the topical anesthetic to the some potential risks, such as barotrauma and dislodgment trachea, the girl suddenly suffered from bucking, which of the foreign body, especially when using jet ventilation made it difficult to withdraw the LTA applicator. The through a thin catheter. surgeon quickly examined the opening of the main tra- The retrospective study of Chai et al. suggests that ap- chea using rigid tracheobronchoscopy, and found the plying topical lidocaine to the oropharynx, glottic struc- TFB had migrated to the subglottic region against the tures, or the subglottic region is helpful and reduces the LTA applicator. In this situation, manual ventilation be- amount of anesthetics needed to remove a TFB , but came impossible and within half a minute, the patient’s existing data on the effectiveness of this technique re- SpO decreased to 91% and her heart rate dropped from mains mixed . Although our hospital commonly uses 150 to 100 bpm. We administered an intravenous injec- a LTA kit to carry out tracheal surface anesthesia, the tion of atropine (0.3 mg) and succinylcholine (10 mg). use of topical lidocaine anesthesia may sometimes result Meanwhile, the surgeon tried to free the TFB by pushing in adverse events, such as bucking, breath holding, lar- it back into the trachea, after which the LTA kit was eas- yngospasm, and body movement. We report a rare, but ily withdrawn. We then mask-ventilated the lungs suc- potentially serious incident of an LTA applicator becom- cessfully. The patient’s SpO quickly increased to 97% ing entrapped by a TFB. and her heart rate rose to 140 bpm. After deepening the In our case, the LTA kit together with the TFB almost anesthesia with propofol (20 mg) intravenously, the sur- completely blocked the subglottic region, leading to a geon successfully grabbed and removed the TFB under potentially life-threatening situation. We speculate that jet ventilation (Fig. 1). Afterwards, the girl’s condition the cause for this obstruction was inadequate anesthesia improved quickly and she recovered uneventfully. She depth. We used general anesthesia with spontaneous was discharged from the hospital 2 days later without respiration, so the anesthesia was not deep enough to complications. prevent harmful reflexes to the topical lidocaine spray, such as bucking and body movement. These reflexes Discussion and conclusions resulted in the movement of the TFB and airway There are 2 primary ventilatory models for guiding obstruction. anesthetic management during TFB removal: spontan- The complication rates associated with controlled ven- eous respiration and controlled ventilation . Gener- tilation vs. spontaneous respiration are similar, except ally, the use of spontaneous respiration without a muscle for lower incidence of laryngospasm when controlled relaxant provides continuous ventilation, and may not ventilation is performed . In our case, the surgeon Zhang et al. BMC Anesthesiology (2018) 18:60 Page 3 of 3 was able to extract the LTA kit after the administration Consent for publication Written informed consent was obtained from the patient’s father for of succinylcholine; nevertheless, attention should be paid publication of this case report. A copy of the written consent is available for to the possibility of complete airway obstruction when review by the Editor of this journal. surgeons prepare for such procedure. In another re- Competing interests ported case, a foreign body was lodged in the subglottic The authors declare that they have no competing interests. region, but unlike us, the surgeon successfully removed the seed in pieces without using succinylcholine . Publisher’sNote As reported, strong teamwork, especially good com- Springer Nature remains neutral with regard to jurisdictional claims in munication between the medical care providers, is vital published maps and institutional affiliations. to the improvement of patient outcome, the prevention Author details of potentially avoidable complications, and thus the re- 1 Department of Anesthesiology, Nan Fang Hospital, Southern Medical duction of morbidity and mortality . Therefore, as for University, Guangzhou, Guangdong, China. The First Clinical Medical College, Southern Medical University, Guangzhou, China. Department of the enhanced intraoperative management in our case, Anesthesiology, West China Hospital of Sichuan University, Chengdu, China. we thought that frequent communication between the anesthesiologist and the surgeon throughout the case Received: 8 January 2018 Accepted: 25 May 2018 was extremely important, as insertion of rigid tracheo- bronchoscopy, spraying topical 1% lidocaine, clamping References of the TFB, and other stimulation required to maintain 1. Fidkowski CW, Zheng H, Firth PG. The anesthetic considerations of tracheobronchial foreign bodies in children: a literature review of sufficient anesthetic depth. 12,979 cases. Anesth Analg. 2010;111(4):1016–25. In a word, we present a case of a difficulty withdrawing 2. Wen WP, Su ZZ, Wang ZF, Zhang JJ, Zhu XL, Chai LP, Feng X, Liu KX, Jiang a LTA applicator during attempted TFB removal. This AY, Lei WB. 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Abbreviations LTA: Laryngotracheal topical anesthesia; SpO : Oxygen saturation; TFB: Tracheobronchial foreign body Funding This work was financially supported by the President Foundation of Nanfang Hospital, Southern Medical University (No. 2017C014, to Dr. Xiyang Zhang) and the National Natural Science Foundation of China (No. 81671955, to Dr. Kexuan Liu), but the funding bodies did not play any roles in the design of the study and collection, analysis, and interpretation of data and in writing the manuscript. Availability of data and materials All data and materials described in the manuscript will be freely available to any scientist wishing to use them for non-commercial purposes. Authors’ contributions ZXY, HY and ZYB contributed equally to this paper. ZXY and HY were responsible for preparation of the manuscript; ZYB was in charge of collecting the date of patient; LB participated in patient care; LKX involved in the case and drafted the manuscript. All authors read and approved the final manuscript. Ethics approval and consent to participate Not applicable.
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Published: Jun 1, 2018