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Education  |   February 2015
Near-complete Upper Airway Obstruction from a Grape
Author Notes
  • From the Department of Anesthesiology, Pennsylvania State University Milton S. Hershey Medical Center, Hershey, Pennsylvania.
  • Address correspondence to Dr. Lamberg: jlamberg@hmc.psu.edu
Article Information
Education / Images in Anesthesiology / Airway Management / Respiratory System
Education   |   February 2015
Near-complete Upper Airway Obstruction from a Grape
Anesthesiology 2 2015, Vol.122, 435. doi:10.1097/ALN.0000000000000091
Anesthesiology 2 2015, Vol.122, 435. doi:10.1097/ALN.0000000000000091
A 3-YR-OLD boy presented to our facility for evaluation of inspiratory stridor and respiratory distress. Lateral neck radiograph revealed a foreign body posterior to the aryepiglottic folds causing severe narrowing of the glottic inlet (fig., arrow indicates epiglottis and star indicates aryepiglottic folds). The child was transferred to the operating room and positioned to comfort, which was slight left lateral recumbent with head elevated. Spo2 ranged from 88 to 92% at initial evaluation on room air and greater than 98% through transfer to the operating room on 100% oxygen by facemask. Inhalational anesthesia was induced with 8% sevoflurane in oxygen. Spontaneous breathing was maintained and Spo2 remained greater than 98%. Direct laryngoscopy was performed and a grape was removed from the upper airway using Magill forceps.
There is no consensus on optimal technique for an airway foreign body removal with regard to spontaneous versus controlled ventilation, intravenous versus inhalational induction, and use versus avoidance of muscle relaxants.1  Maintenance of spontaneous ventilation is commonly used for foreign bodies proximal to the carina due to the risk of converting a partial obstruction into a complete obstruction.2  Deep levels of anesthesia or muscle relaxants can be beneficial for foreign bodies distal to the carina for rigid bronchoscopy1 ; however, ablation of spontaneous ventilation for proximal foreign bodies risks dislodgement and complete airway obstruction. The narrow pediatric glottis and cricoid ring structures are anatomical landmarks at which foreign bodies can be trapped proximally.3  Positive-pressure ventilation can potentially cause worsening of the airway obstruction via a ball-valve phenomenon and lead to tension pneumothorax. Avoidance of nitrous oxide is reasonable as it decreases Fio2 and can increase gas volume if air trapping is present.
Competing Interests
The authors declare no competing interests.
References
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