Near-fatal grape aspiration with complicating acute lung injury successfully treated with extracorporeal membrane oxygenation

Postmortem computed tomography imaging of negative pressure pulmonary edema induced by rice cakes: A case report

Airway obstruction by foreign bodies or laryngospasms often results in negative pressure pulmonary edema (NPPE). NPPE can develop despite the removal of airway obstruction. This is well-known among clinicians, particularly anesthesiologists, emergency physicians, pediatricians, and radiologists. Computed tomography (CT) features of NPPE include diffuse central ground-glass opacities and thickening of the bronchovascular bundles and bronchial walls. NPPE can also occur after strangulation or smothering with a plastic bag, and is sometimes fatal. Nevertheless, no reports of NPPE are available in forensic journals, and forensic practitioners may not be dedicating the necessary attention to this condition. Recently, the use of postmortem CT as an auxiliary imaging modality for autopsies has increased among forensic institutions in Japan. Understanding the mechanisms and CT findings of NPPE will be useful for forensic practitioners. Herein, we present a case wherein the postmortem CT image revealed NPPE resulting from the obstruction of the airway induced by rice cakes.

A Predictive Model of Major Postoperative Respiratory Adverse Events in Pediatric Patients Undergoing Rigid Bronchoscopy for Exploration and Foreign Body Removal

Background: No nomogram has been established to predict the incidence of major postoperative respiratory adverse events (mPRAEs) in children undergoing rigid bronchoscopy for airway foreign bodies (AFB) removal and exploration of the airway, though some studies have confirmed the risk factors. Methods: 1214 pediatric patients (≤3 years old) undergoing rigid bronchoscopy for AFB from June 2014 to December 2020 were enrolled in this study. The primary outcome was the occurrence of mPRAEs, including laryngospasm and bronchospasm. Following that, a nomogram prediction model for the mPRAEs was developed. Results: The incidence of mPRAEs was 84 (6.9%) among 1214 subjects. American Society of Anesthesiologists physical status (ASA-PS), intraoperative desaturation (SpO2 < 90%), procedural duration and ventilatory approach were all independent risk factors of mPRAEs. The area under the receiver operating characteristic curve (AUC) value of the nomogram for predicting mPRAEs was 0.815 (95% CI: 0.770-0.861), and the average AUC for ten-fold cross-validation was 0.799. These nomograms were well calibrated by Hosmer-Lemshow (p = 0.607). Decision curve analysis showed that the nomogram prediction model is effective in clinical settings. Conclusions: Combining ASA-PS, intraoperative desaturation, procedural duration, and ventilatory approach, the nomogram model is adequate for predicting the risk of developing mPRAEs, followed by rigid bronchoscopy for AFB removal and exploration.

Extracorporeal membrane oxygenation in critical airway interventional therapy: A review

Introduction

Extracorporeal membrane oxygenation (ECMO) is widely used during refractory cardiac or respiratory failure, and some case reports described ECMO utilization in critical airway interventional therapy.

Methods

Eligible reports about patients receiving airway interventional therapy under ECMO were retrieved from Web of Science, Embase, Medline, and Cochrane databases up to 1 August 2022.

Results

Forty-eight publications including 107 patients who underwent ECMO for critical airway problems met the inclusion criteria. The critical airway problem that was reported the most was tumor-associated airway obstruction (n = 66, 61.7%). The second most reported etiology was postoperative airway collapse or stenosis (n = 19, 17.8%). The main interventional therapies applied were airway stent placement or removal (n = 61, 57.0%), mass removal (n = 22, 20.6%), and endotracheal intubation (n = 12, 11.2%) by bronchoscopy. The median ECMO duration was 39.5 hours. Eleven patients had ECMO-associated complications, including seven cases of airway hemorrhage, one case of arteriovenous fistula, one case of vein rupture and hematoma, one case of foot ischemia, and one case of neuropraxia of the cannulation site. In total, 91.6% of the patients survived and were discharged from the hospital.

Conclusion

ECMO appears to be a viable form of life support for patients undergoing interventional therapy for critical airway problems.

The Use of Extracorporeal Membrane Oxygenation in Life-Threatening Foreign Body Aspiration: Case Series, Review of Extracorporeal Life Support Organization Registry Data, and Systematic Literature Review

BACKGROUND

Foreign body aspiration (FBA) is a common cause of morbidity and mortality in children < 3 years of age. Guidelines recommend performing a bronchoscopy in any suspected or confirmed FBA. Extracorporeal membrane oxygenation (ECMO) can be used as a rescue mode of support in children with life-threatening FBA for stabilization before, during, and after removal.

CASE REPORT

We present a series of children with life-threatening FBA who were placed on ECMO for stabilization before or after FB removal and a review of the literature and the Extracorporeal Life Support Organization database. Foreign bodies were removed without complications, and all patients survived ECMO support and were promptly discharged home. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: ECMO can be safely used in the stabilization of children with life-threatening FBA before, during, and after bronchoscopic removal. ECMO should be considered in the stabilization of children presenting with FBA to facilitate removal.

Airway obstruction due to sticky rice cake (mochi): a case series and review of the literature

BACKGROUND

Foreign body airway obstruction is a significant public health issue around the world. Mochi, a traditional sticky rice cake in Japan, has gained popularity in many countries including the USA. However, the associated aspiration danger has not yet been well recognized.

CASE PRESENTATION

We describe three cases of foreign body airway obstruction due to mochi. Case 1 was an elderly man who was brought to the emergency department by an ambulance after he choked on mochi. Despite extensive efforts to remove pieces of mochi including use of Magill forceps, bronchoscopy, and endotracheal intubation, he suffered severe hypoxia and died. Case 2 was a middle-aged man who was found unconscious in a park. The rhythm upon arrival was pulseless electrical activity. During intubation, large pieces of mochi were found in the oropharynx and removed with Magill forceps. He developed aspiration pneumonitis and hypoxic brain injury. The patient was discharged to a skilled nursing facility with severe neurological disability. Case 3 was an elderly man who choked while eating soup with mochi at home. His initial cardiac rhythm was asystole. During intubation, obvious foreign body was found in the oropharynx. Several pieces of mochi were removed by suctioning through the endotracheal tube. He suffered severe hypoxic injury and died.

CONCLUSIONS

All of our cases resulted in death or poor neurological outcome. As the popularity of mochi continues to increase, it is likely that cases of aspiration from mochi will also increase. Emergency physician should be aware of the potential danger of mochi and be familiar with the techniques to remove mochi from the airway.

Fatal choking in infants and children treated in a pediatric intensive care unit: A 7- year experience

INTRODUCTION

Foreign bodies aspiration can lead to significant morbidity, few have examined in detail the deaths resulting from foreign bodies aspiration.

METHODS

We conducted a review of children who presented to the pediatric intensive care unit of a university hospital due to fatal foreign bodies aspiration during the period of 2010-2017.

RESULT

Of the 28 patients, 17 (61%) patients were male and 11 (39%) were female. The range of age was 1-63 months, with mean of 15.2 months. The common foreign bodies included milk, nuts and fruits. Majority of them had round shapes. All the patients died due to asphyxia or serious complications after foreign bodies aspiration.

CONCLUSIONS

Prevention and early recognition remains a critical factor to reduce the mortality of foreign bodies aspiration.

Extracorporeal support in airway surgery

Extracorporeal life support (ECLS) is increasingly used for major airway surgery. It facilitates complex reconstructions and maintains gas exchange during endoscopic procedures in patients with critical airway obstruction. ECLS offers the advantage of an uncluttered surgical field and eliminates the need for crossing ventilation tubes, thus, making precise surgical dissection easier. ECLS is currently used for hemodynamic and respiratory support in lung transplantation as well as extended tumor resections with an acceptable risk profile. This work reviews the published experience of ECLS in airway surgery both in adults and in pediatric patients. It highlights currently available devices and their indications.

Treatment of bronchial foreign body aspiration with extracorporeal life support in a child: A case report and literature review

We present a case in which extracorporeal life support treatment of a 6-year-old girl asphyxiated by aspiration of an elliptic plastic ball is described. The attempts for extraction of the foreign body by conventional bronchoscopy under critically ill conditions had failed. Thus, a skin incision was made in the midline, and an emergency open-chest cardiopulmonary bypass (CPB) with aortic, superior vena cava and inferior vena cava cannulation was performed for circulatory support. Following tracheal extubation, a video-assisted rigid bronchoscope was inserted to clear the airway and remove the foreign body. The CPB lasted for 68 min, and the endotracheal tube was pulled out 6 h after the surgery. On the 10th day, the patient was discharged and followed up for 3 months when no neurological symptoms or other complications were documented. The removal of the aspirated bronchial foreign body under extracorporeal life support has been rarely reported. Here, we review the indication, cannulation method, support mode, surgical procedure, and patient outcome in the 8 papers retrieved from the PubMed database and compare their clinical characteristics with those of our case to justify the safe and effective use of CPB for critically ill patients with bronchial foreign body aspiration.

The anesthesia of trachea and bronchus surgery

The trachea and bronchus surgery is generally performed due to stenosis, traumatic injury, foreign body and tumors. Preoperative evaluation and anesthesia management are very important issues because of higher mortality and morbidity rates. Patients may be asymptomatic, but airway difficulties, hypoxia, stridor, cough, hemoptysis are common conditions in these patient population. The collaboration between the surgeon and the anesthesiologist is very substantial and necessary. Anesthetic techniques include various applications such as one lung ventilation, fiberoptic intubation, jet ventilation, and apneic oxygenation, general anesthesia with or without neuromuscular blockade. In this review, anesthesia management of the trachea and bronchus surgery is evaluated in the light of new knowledge.

Life-threatening check valve formation due to tracheobronchial aspergillosis

A 12-year-old girl receiving chemotherapy for acute myeloid leukemia had a fever of unknown origin in spite of administration of micafungin. Her respiratory condition suddenly deteriorated. Her trachea was intubated, and positive pressure ventilation was initiated; however, her respiratory condition further deteriorated. Expiratory volume was considerably lower than inspiratory volume. Simultaneously, she developed severe hypotension and bradycardia, and tension pneumothorax was suspected. Emergent chest decompression was subsequently performed; however, her airway resistance was still high. Bronchoscopy was performed to remove a foreign body in the carina. Subsequently, her respiratory status improved. Histopathological examination revealed that the foreign body was a fibrinous blood clot mixed with fungal hyphae of Aspergillus niger. Life-threatening check valve formation due to tracheobronchial aspergillosis under positive-pressure ventilation may be rare; however, once it occurs, prompt establishment of an escape route for trapped air, such as thoracentesis, may be required.

Fatal and near-fatal grape aspiration in children

Choking remains an important cause of morbidity and mortality in young children. Whole seedless grapes are a popular fruit snack to give to young children.We present 3 cases of grape aspiration, discussing the emergency care from basic life support to specialist treatment.The lessons learned will be applicable to a wide range of health professionals from frontline emergency medical service personnel to physicians and nurses working in a hospital.

Management of complicated airway foreign body aspiration using extracorporeal membrane oxygenation (ECMO)

OBJECTIVES

Successful removal of an airway foreign body can be very challenging. We present three patients with airway foreign body aspiration successfully treated using extracorporeal membrane oxygenation (ECMO). Their clinical presentation and findings will be reviewed to determine when ECMO should be considered for treatment.

STUDY DESIGN

Retrospective multi-institutional review of a case series of patients with airway foreign body who underwent successful treatment using ECMO.

METHOD

After institutional review board approval, the use of ECMO during airway foreign body procedures in children was reviewed from the pediatric research in otolaryngology (PRO) network. This network comprises of over 20 Children's hospitals to improve the health of and healthcare delivery to children and their families with otolaryngology conditions. Specific parameters were recorded for each patient.

RESULTS

Three children presented with airway foreign body and required ECMO for successful removal. Mean age was 18 months. Presenting symptoms included severe and worsening respiratory distress. Indications for ECMO included an inability to perform rigid bronchoscopy due to the child's unstable respiratory status and an airway foreign body lodged in the trachea that could not be removed without potential loss of airway support. All three children underwent successful removal of their airway foreign bodies. There were no complications from ECMO or bronchoscopy.

CONCLUSION

ECMO may be a useful adjunct in cases of life threatening airway foreign body aspiration.

The anesthetic considerations of tracheobronchial foreign bodies in children: a literature review of 12,979 cases

Asphyxiation by an inhaled foreign body is a leading cause of accidental death among children younger than 4 years. We analyzed the recent epidemiology of foreign body aspiration and reviewed the current trends in diagnosis and management. In this article, we discuss anesthetic management of bronchoscopy to remove objects. The reviewed articles total 12,979 pediatric bronchoscopies. Most aspirated foreign bodies are organic materials (81%, confidence interval [CI] = 77%-86%), nuts and seeds being the most common. The majority of foreign bodies (88%, CI = 85%-91%) lodge in the bronchial tree, with the remainder catching in the larynx or trachea. The incidence of right-sided foreign bodies (52%, CI = 48%-55%) is higher than that of left-sided foreign bodies (33%, CI = 30%-37%). A small number of objects fragment and lodge in different parts of the airways. Only 11% (CI = 8%-16%) of the foreign bodies were radio-opaque on radiograph, with chest radiographs being normal in 17% of children (CI = 13%-22%). Although rigid bronchoscopy is the traditional diagnostic "gold standard," the use of computerized tomography, virtual bronchoscopy, and flexible bronchoscopy is increasing. Reported mortality during bronchoscopy is 0.42%. Although asphyxia at presentation or initial emergency bronchoscopy causes some deaths, hypoxic cardiac arrest during retrieval of the object, bronchial rupture, and unspecified intraoperative complications in previously stable patients constitute the majority of in-hospital fatalities. Major complications include severe laryngeal edema or bronchospasm requiring tracheotomy or reintubation, pneumothorax, pneumomediastinum, cardiac arrest, tracheal or bronchial laceration, and hypoxic brain damage (0.96%). Aspiration of gastric contents is not reported. Preoperative assessment should determine where the aspirated foreign body has lodged, what was aspirated, and when the aspiration occurred ("what, where, when"). The choices of inhaled or IV induction, spontaneous or controlled ventilation, and inhaled or IV maintenance may be individualized to the circumstances. Although several anesthetic techniques are effective for managing children with foreign body aspiration, there is no consensus from the literature as to which technique is optimal. An induction that maintains spontaneous ventilation is commonly practiced to minimize the risk of converting a partial proximal obstruction to a complete obstruction. Controlled ventilation combined with IV drugs and paralysis allows for suitable rigid bronchoscopy conditions and a consistent level of anesthesia. Close communication between the anesthesiologist, bronchoscopist, and assistants is essential.

A case report of severe tracheal obstruction requiring extracorporeal membrane oxygenation

The authors describe the case of a near-fatal airway obstruction requiring extracorporeal membrane oxygenation. The patient presented with severe respiratory distress owing to a bean impacted in the distal trachea. The foreign body could not be removed by bronchoscopy because of instability of the patient. The patient was placed on extracorporeal membrane oxygenation for temporary pulmonary support, and the foreign body was removed using a rigid bronchoscope. The patient had a full recovery and suffered no neurologic sequelae.

A Kansas wheat harvest: near-fatal asphyxiation with wheat grains

We present a patient who had a near-fatal asphyxiation with wheat particles. A previously healthy 11-year-old boy slipped into wheat being unloaded from a transport wagon and was immediately submersed. On arrival at the hospital, he was found to have grain impacted in both mainstem bronchi. A combination of flexible and rigid bronchoscopy with optical forceps and Fogarty balloon catheters was successful in clearing the airways. The removal of the particles through the use of small bronchoscopic instruments is a tedious and delicate procedure, but in this case, it resulted in a life saved.

Extending the limits of extracorporeal membrane oxygenation: lung rest for a child with non-specific interstitial pneumonia

OBJECTIVE

Veno-venous extracorporeal membrane oxygenation (ECMO) is an established therapy for the treatment of respiratory failure. Traditionally ECMO has been used to support patients with an acute, reversible disease process, with a predictable outcome. We report the successful use of veno-venous ECMO for an unusual indication.

PATIENT

A 10-year old girl was admitted to intensive care with severe, hypoxic respiratory failure on the background of a 2-month history of worsening respiratory symptoms. She required high levels of conventional positive pressure ventilation, and high frequency oscillation. Lung biopsy confirmed a non-specific interstitial pneumonia, and the patient was commenced on immune suppressive therapy. Her clinical course was further complicated by pulmonary haemorrhage and severe air leak.

INTERVENTIONS

On day 20 after admission the patient was placed on veno-venous ECMO for lung rest while awaiting a response to continued medical treatment. She required ECMO for 20 days, during which time sedation was reduced, and she was able to interact with those around her. The patient's ventilatory requirements after decannulation were minimal, and she subsequently made a steady clinical recovery.

CONCLUSIONS

ECMO was safely and successfully used to provide a period of lung rest and time for medical therapy to take effect in a child with an unusual indication for support: a rare disease with an uncertain outcome on the background of prolonged mechanical ventilation.