Foreign body aspiration in a child
Stem
A 2-year-old girl, 12 kg, choked while eating peanuts yesterday and has coughed since. She now has right-sided wheeze and reduced breath sounds on the right. Chest radiograph shows a hyperinflated right lung with the mediastinum shifted to the left. SpO2 is 95% on room air, she is playing, and she has no IV. She ate breakfast four hours ago. ENT plans rigid bronchoscopy.
Question
How will you anesthetize her for removal of the foreign body?
Ideal answer
HeadlineA stable right bronchial ball-valve is urgent, not an emergency: one attempt, good conditions, experienced ENT, after six hours' fasting for solids unless she deteriorates.1
- Plan agreed with the bronchoscopist beforehand, because we share the airway.
- Sevoflurane in 100% oxygen, IV once asleep, breathing spontaneously: no technique is proven superior, but positive pressure at induction can turn a partial obstruction into a complete one.1
- Deep, then cords sprayed with lidocaine, about 20 mg, as laryngoscopy is very stimulating; then a propofol infusion with oxygen insufflated through the ventilating bronchoscope's side port.2
- Dexamethasone, about 6 mg, for airway edema;2 I watch the oximeter and chest movement, because end-tidal CO2 is unreliable with an open airway.2
- Intubation tray, tension pneumothorax plan, suction for pus released behind the nut;2 she emerges by mask or tube as her airway allows, watched for stridor in recovery.
Breaking down the answer
- Stable means daylight and fasting — if bronchoscopy is not urgent, fasting six hours for solids and two for clear fluids lowers aspiration risk during an open-airway procedure.1
- Spontaneous versus controlled ventilation — the literature shows no clear winner; spontaneous propofol-remifentanil techniques have caused movement, cough and desaturation. Either is acceptable if I can defend it.1
- The doses — topical lidocaine 1–2 mg/kg, which is how I reach her 20 mg; propofol infusion 100–300 mcg/kg/min.2
- Rigid bronchoscopy is the standard — it gives ventilation, suction and airway control for retrieval; flexible scopes help with diagnosis and distal objects.1 3
- Nuts are worse than plastic — oily foods inflame the mucosa and organic material swells and fragments, which prolongs extraction.2
- Full stomach versus open airway — RSI with a tube protects the lungs but blocks the bronchoscope; small tubes may not pass the scope. Naming that trade-off shows judgment.2
- Know what can go wrong — laryngospasm, bronchospasm, tension pneumothorax from air trapping, contralateral soiling with pus, and post-extubation stridor.2
Follow-up question
As the surgeon withdraws the forceps, the peanut slips and lodges in the trachea. She cannot be ventilated through the bronchoscope, SpO2 is 78% and falling, and her heart rate is slowing. What do you do?
Follow-up answer
HeadlineComplete tracheal obstruction from a dislodged foreign body; I tell the surgeon directly: "Push it into the right mainstem."
Advancing the object back into one bronchus opens the trachea so we can ventilate the other lung.1 2 I ventilate with 100% oxygen through the bronchoscope, give atropine for the bradycardia and epinephrine if it does not respond, and deepen the anesthetic once she is oxygenated. If her right chest becomes silent and her blood pressure falls, I decompress for tension pneumothorax. When she has recovered, the surgeon retrieves the peanut again, and I reassess both lungs for fragments and soiling before waking her.
Pitfalls that cost points
- Rushing a stable child at night with a fresh meal.
- Giving nitrous oxide to a child with a ball-valve and air trapping.
Rapid-fire
Q: What age group is most affected? A: Children under 5, with a peak between 6 months and 3 years.1
Q: What are the classic radiograph findings? A: Hyperinflation of the affected lung and mediastinal shift away from it,2 but most objects are not radio-opaque and the film can be normal.1
Q: How is post-extubation stridor treated? A: Racemic epinephrine and steroids, with prolonged observation for rebound and readiness to reintubate.2
Q: What is the typical presentation? A: Coughing, dyspnea and wheezing after a choking episode; stridor and cyanosis are rare.1
Numbers to know
| Item | Value |
|---|---|
| Topical lidocaine to larynx | 1–2 mg/kg2 |
| Dexamethasone | 0.2–1 mg/kg, max 20 mg2 |
| Propofol infusion | 100–300 mcg/kg/min2 |
| Fasting if not urgent | 6 h solids, 2 h clear fluids1 |
| Peak age | 6 months–3 years1 |
Links
- Pediatric airway anatomy and equipment, Epiglottitis and croup, aspiration, laryngospasm, Pneumothorax and tension pneumothorax, Intraoperative bronchospasm
- SPA Case Guide: Airway Foreign Body (2022)
Sources
- 1.The anaesthetic consideration of tracheobronchial foreign body aspiration in children · J Thorac Dis, 2016 · jtd.amegroups.orgKendigelen, J Thorac Dis 2016;8(12):3803-7.
- 2.Airway Foreign Body (SPA Case Guide) · SPA, 2022 · www2.pedsanesthesia.org
- 3.Anaesthesia for diagnostic and therapeutic bronchoscopy · BJA Education, 2026 · ebi.ac.ukFull text via Europe PMC (PMC13589902); table of procedures, rigid bronchoscopy for foreign body removal.
Facts on this page were checked against these sources on Oct 15, 2026. Guidelines change; confirm doses against current institutional protocols.