So… you are on call with that new ear, nose, and throat surgeon—the one who is new to your hospital and maybe new to the profession (just out of residency!). He wants you in to anesthetize a 10-month-old little girl who choked on “something she picked up off the rug” about 12 hours ago. Her chest X-ray is clear. She has had an intermittent cough and sounds wheezy in Mom’s arms. You don’t do a lot of little children and wonder if this is the right thing to do. You try talking to the surgeon, but he is distracted as he tries to piece together the seldom-used pediatric rigid bronchoscope. The surgeon assures you he did a “bunch of these” as a resident. Do you proceed or call the hospital administrator on call?

The potential for total airway obstruction, as well as the need to share the airway with the surgeon, makes anesthesia for foreign-body removal challenging. Commonly aspirated foods include peanuts, beans, hotdogs, watermelon seeds, and popcorn. Peanuts are the most common and can be difficult to remove because of the tendency to break into pieces upon attempted retrieval. Aspirated beans are challenging because they often swell once inside the airway and lead to further obstruction and edema. Nonfood items are more commonly aspirated by older children and include small plastic toys, balloon pieces, balls, and marbles.

Foreign-body aspiration should be considered in any child presenting with respiratory distress or with a pulmonary infection that is not responding to standard interventions. A history of a choking episode is found in 80% to 90% of confirmed cases. Chest radiographs are often normal during the first 24 hours. In one large retrospective series of 1,068 cases of foreign-body aspiration in children, radiographs were normal in nearly two thirds of cases. If an inspiratory film is normal, an expiratory film or fluoroscopy may be helpful. These views may demonstrate expiratory mediastinal shift away from the lung field containing the foreign body or postobstructive hyperinflation secondary to air trapping distal to the foreign body.

When foreign-body aspiration is suspected, rigid bronchoscopy is the gold standard. Rigid bronchoscopy permits control of the airway, good visualization, and manipulation of the object with a wide variety of forceps.
Removal of a foreign body from the airway is considered an urgent to emergent procedure, depending on the degree of respiratory distress. A fasting patient is optimal, but the procedure should not be delayed if the airway is compromised or if the foreign body is of organic origin because of its potential to swell and produce asphyxia. The anesthesiologist should decide between using mask induction and intravenous (IV) induction on an individual basis. Most experts recommend mask induction followed by IV placement; however, rapid-sequence induction should be considered if the child has a full stomach. The use of nitrous oxide is a relative contraindication in the presence of air trapping, although most authors conclude that its use during a mask induction poses little risk. Using atropine or glycopyrrolate is recommended to reduce secretions before bronchoscopy, and a dose of a glucocorticoid can be given to reduce inflammation. After a deep plane of anesthesia is obtained, the airway should be examined with a laryngoscope to exclude any posterior pharyngeal foreign bodies and to spray the vocal cords and trachea with lidocaine in order to reduce irritation once the rigid bronchoscope is introduced.