References
1 Fagan T, Mathewson RJ. Unusual nasal foreign body detected
by panoramic dental radiography: case report. Pediatr Dent
1990; 12: 43–44.
2 Yassin OM, Hattab FN. Unusual nasal foreign body detected on
routine dental radiography: case report. J Clin Pediatr Dent 1996;
20: 155–157.
3 Tay ABG. Long-standing intranasal foreign body: an incidental
finding on dental radiograph. Oral Surg Oral Med Oral Pathol
Oral Radiol Endod 2000; 90: 546–549.
4 Mayumi T, Horikawa D, Miyabe M et al. Complete endotra-
cheal tube obstruction after nasotracheal intubation. Can Ana-
esth Soc J 1984; 31: 344–345.
Anesthesia for removal of inhaled foreign
bodies in children
doi:10.1111/j.1460-9592.2005.01641.x
SIR—We read with interest the article by Soodan et al. (1)
describing anesthesia for the removal of inhaled foreign
bodies in children and we congratulate the authors for
addressing the question of superiority of technique.
We agree that the high incidence of coughing and
bucking experienced in the spontaneous ventilation group
is because of the inadequacy of depth of anesthesia,
despite the high endtidal halothane concentrations used.
We suggest that inadequate use of local anesthetic may
also have contributed to the high failure rate. However,
the authors’ conclusion that it is not possible to maintain
an adequate depth of anesthesia with spontaneous respir-
ation during rigid bronchoscopy contradicts several pre-
vious studies (2,3) as well as clinical experience with this
technique. Furthermore, the advantages and safety of
maintaining spontaneous ventilation were not sufficiently
emphasized. Although the authors mention the risks of
foreign body displacement with controlled ventilation,
they did not mention the risk of ball-valve hyperinflation
and potential rupture of the lung distal to the obstruction.
We question if the sample size studied is sufficient to make
any recommendations on the safety or superiority of
anesthetic technique.
The authors also failed to mention the option of
maintaining spontaneous ventilation with the use of
intravenous anesthetic agents, as is the practice in our
institution. We have been successful in employing a total
intravenous anesthetic technique for our rigid bronchos-
copies, including for the removal of foreign bodies. Our
patients undergo either a mask or intravenous induction.
With routine monitors, patients are maintained with an
FiO2 of 1.0 with oxygen flows of 4–6 lÆmin
)1 as they receive
a mixture of propofol (10 mgÆml)1) with 2.5–5 lgÆml)1 of
remifentanil. This mixture is delivered to the patient via an
infusion pump at a rate of 200–400 lgÆkg)1Æmin)1 of
propofol (0.05–0.2 lgÆkg)1Æmin)1 remifentanil). Once depth
of anesthesia is adequate-measured clinically by response
to insertion of an oral airway and laryngoscope blade,
lidocaine 1 mgÆkg)1 is sprayed onto the vocal cords under
direct laryngoscopy before the surgeon is allowed to
proceed. With this anesthetic technique, spontaneous
ventilation is maintained, hemodynamics are stable, and
depth of anesthesia can be rapidly adjusted as required.
We have been impressed with the success of this tech-
nique, even in infants. In addition, it also minimizes
operating room pollution.
In conclusion, we feel that the principal recommenda-
tion of this study, counseling against maintaining sponta-
neous ventilation, is contrary to the practice of many
institutions. The authors’ increased complication rate is
explained by inadequate application of the technique
rather than the inherent risks. Finally, we believe that the
sample size was insufficient to confirm the increased
safety of controlled ventilation, in light of the rare severe
complications associated with this technique.
Natalie T Buu
Mark Ansermino
Department of Anesthesiology, University of British Columbia,
British Columbia’s Children Hospital, Vancouver, Canada
(email: nbuu@cw.bc.ca)
References
1 Soodan A, Pawar D, Subramanium R. Anesthesia for removal
of inhaled foreign bodies in children. Pediatr Anesth 2004; 14:
947–952.
2 Meretoja OA, Taivainen T, Raiha L et al. Sevoflurane-nitrous
oxide or halothane-nitrous oxide for pediatric bronchoscopy
and gastroscopy. Br J Anaesth 1996; 76: 767–771.
3 Inglis AF, Wagner DV. Lower complication rates associated
with bronchial foreign bodies over the last 20 years. Ann Otol
Rhinol Laryngol 1992; 101: 61–66.
Authors’ reply
doi:10.1111/j.1460-9592.2005.01655.x
SIR—Thank you for the opportunity to reply to the letter of
Dr Buu and Dr Ansermino.
Recommendations based on institutional practice, per-
sonal impressions on a technique or analysis of retrospec-
tive data have limitations as scientific evidence. Although
our recommendations are not as strong as those of
Motoyama in Smith’s text book of Pediatric Anesthesia
that ‘The technique of spontaneous breathing for bronch-
oscopy is not suitable for procedures such as removal of a
foreign body in the bronchus’ (1,2), they are not biased but
based on the conclusions drawn from a prospective
randomized controlled study.
CORRESPONDENCE 533

2005 Blackwell Publishing Ltd, Pediatric Anesthesia, 15, 529–535