What is the recommended airway management for a patient with a subglottic foreign body aspiration, considering factors such as age, respiratory conditions like asthma or chronic obstructive pulmonary disease (COPD), and stability of the patient?

Airway Management for Subglottic Foreign Body Aspiration

For subglottic foreign body aspiration, rigid bronchoscopy under controlled conditions with immediate availability of front-of-neck access (FONA) is the definitive management approach, performed by the most experienced operator in a controlled setting with full monitoring and rescue equipment. 1, 2

Initial Assessment and Stabilization

Patient Stability Determines Approach

• Unstable patients with respiratory distress, stridor, or desaturation require immediate intervention with emphasis on removing the obstructing foreign body while securing the airway 2, 3
• Stable patients should undergo CT imaging to confirm foreign body presence and location before proceeding to bronchoscopy, avoiding unnecessary procedures 1
• The most experienced available operator must manage the airway in critically ill patients with potential airway obstruction 2

Critical Warning Signs

• Dyspnea, desaturation, and stridor are indications for urgent intubation 2
• Subglottic foreign bodies are commonly misdiagnosed as other causes of upper airway obstruction, requiring high clinical suspicion 4

Definitive Management: Rigid Bronchoscopy

Why Rigid Bronchoscopy is Preferred

• Rigid bronchoscopy is the gold standard for subglottic foreign body removal because flexible bronchoscopy is deemed difficult or impossible for foreign bodies that cannot pass through the subglottic region 1, 5
• The rigid scope allows for larger instrument passage and better control during extraction 1

Procedural Requirements

• Perform in a negative pressure room when possible (particularly relevant during infectious disease considerations) 1
• Controlled ventilation is preferred, using the rigid bronchoscope as an endotracheal tube 1
• Air leaks should be minimized using rubber caps on ports and plastic coverings 1
• Modified rapid sequence intubation (RSI) is the most appropriate technique for patients with airway obstruction 2

Alternative Approaches Based on Clinical Context

When Rigid Bronchoscopy Through Tracheotomy is Needed

• If the foreign body is too large to pass through the subglottic region or too sharp to risk injury during extraction, cervical tracheotomy with endoscopic control is indicated 5
• This approach allows safe removal under direct visualization while protecting the airway 5
• The trachea can be sutured after foreign body removal without requiring permanent tracheostomy 5

For Intubated Patients

• Foreign bodies can be removed through existing endotracheal intubation using bronchial fiberscope under general anesthesia with dexmedetomidine and ketamine, without extubation 6
• Multiple backup strategies must be planned before attempting removal to cope with unexpected airway troubles 6

Essential Safety Measures

Immediate Backup Plans Required

• Videolaryngoscopy must be available if the operator is skilled 2
• Front-of-neck access (FONA) with scalpel technique must be immediately available if intubation or extraction fails 2
• Magill forceps should be available for appropriately skilled healthcare providers 1

Equipment and Personnel

• Full monitoring and rescue equipment must be available in the controlled setting 2
• Specialist consultation (otolaryngology, pulmonology, or anesthesiology) should assist in retrieving the foreign body and managing the airway 3

Critical Pitfalls to Avoid

• Never perform blind finger sweeps in patients with foreign body airway obstruction 1
• Avoid routine use of suction-based airway clearance devices 1
• Do not delay intervention in unstable patients for imaging studies 3
• Limit the number of attempts at any single technique to avoid injury and complications 1
• Be aware of passage of time and oxygen saturation throughout the procedure 1

Age-Specific Considerations

• In children >1 year and adults with complete obstruction and ineffective cough, backslaps are used initially, followed by abdominal thrusts if backslaps are ineffective 1
• Chest thrusts are suggested in unconscious patients with foreign body airway obstruction 1
• Most foreign body aspirations occur in children <3 years of age, though the actual aspiration event is frequently not witnessed 4