Laryngo-tracheo-bronchial foreign bodies

LARYNGO-TRACHEAL-BRONCHIAL FOREIGN BODIES
CLINICAL FEATURES OF LARYNGO-TRACHEAL-BRONCHIAL FOREIGN BODIES
  • Foreign body inhalation is most common cause of acute collapse with peak age incedence in 1-2 years.
  • Infants and toddlers use their mouths to explore their surroundings.
  • So, they are very prone to aspirate a foreign body.
  • The most common age group is 6 months to 4 years.Most common foreign body aspirated is nuts (peanuts).
  • A foreign body is more likely to get aspirated into the right lung as the right bronchus is wider, shorter and more vertical than the left principal bronchus,Right inferior lobar bronchus is in continuation with the right principal bronchus and Tracheal bifurcation directs the foreign body to the right lung. In erect posture commonest site of foreign body is in Right posterior basal bronchus. Foreign body aspiration in supine position commonly affects Apical part of right lower lobe.
  • A foreign body completely obstructing the right main bronchus causes decreased Ventilation-perfusion ratio.
  • A foreign body in trachea may move up and down the trachea between the carnia and the undersurface of vocal cords causing "audible slap" and "palpatory thud."
  • Manner of death during foreign body found in the respiratory tract in Autopsy is Accidental Death.
  • Three stages of symptoms may results : 
  1. Stage I - Initial event —> Violent paroxysm of coughing (most common symptom), choking, gagging,dyspnea and wheeze immediately after aspiration.
  2. Stage II Asmptomatic —> The foreign body becomes lodged, reflex fatigue and immediate irritating symptoms subside.
  •  This stage is most tracherous and account for a large percentage of delayed diagnosis and overlooked foreign bodies.
  • Commonest sign of intrabronchial foreign body in children is Cough.
  • Hoarseness, croupy cough and aphonia,along with dyspnea and wheezing seen in Laryngeal foreign body.
  • If obstruction is complete, child may be unable to vocalize (aphonia) and there may be cyanosis. If obstruction is incomplete drooling and stridor may occur.
    3. Stage III - Complications —> Obstruction, erosions or infection can cause           fever, hemoptysis, pneumonia and atelectasis.
  •  The most serious complication of foreign body aspiration is complete airway obstruction.
MANAGMENT OF LARYNGEAL FOREIGN BODY
  • Heimlich's maneuvers: Sudden thrust directed upwards and backwards, below the epigastrium, squeezes the air from the lungs, sufficient to dislodge a foreign body.Cricothyrotomy or emergency tracheostomy should be done if Heimlich's maneuvers fails.
  • For foreign body causing sudden choking, most appropriate first line of management is Heimlich's Maneuvre.
  • Once acute respiratory emergency is over, foreign body can be removed by direct laryngoscopyor by laryngofissure, if found impacted
MANAGEMENT OF TRACHEAL AND BRONCHIAL FOREIGN BODY
  • The treatment of choice for airway foreign bodies is prompt endoscopic removal with a Bronchoscope
  • Emergency removal of these foreign bodies may not be indicated unless there is airway obstruction or they are of the vegetable nature (e.g. seeds) and likely to swell up. Methods to remove tracheobronchial foreign body:
  • Conventional rigid bronchoscopy.Rigid bronchoscopy with telescopic aid.
  • Treatment of choice is removal of foreign body in the lower respiratory tract by rigid bronchoscope
  1. Bronchoscopy with C-arm fluoroscopy.
  2. Use of Dormia basket or Fogarty's balloon for rounded objects.
  3. Tracheostomy first and then bronchoscopy through the tracheostome
  4. Thoracotomy and bronchotomy for peripheral foreign bodies.
  5. Flexible fiber optic bronchoscopy 
  6. Fibreoptic bronchoscopy can be easily performed and is rarely associated with complications.
  • It has surpassed rigid bronchoscopy as the instrument of choice for evaluvating the tracheocbronchial tree
  • As compared to rigid bronchoscopy,flexibile bronchoscope allows for more complete exploration of the airway.It has a good view.
Exam Question
  • For foreign body causing sudden choking, most appropriate first line of management is Heimlich maneuver.
  • A 2-year-old child is brought by his parents to emergency with acute onset of respiratory distress and stridor. The chest examination reveals decreased breath sounds and wheeze in the right side. The chest X-Ray showed an opaque right hemithorax. Most probable diagnosis is Foreign body in airway.
  • Heimlich manoeuver is done to remove upper airway obstruction by foreign body.
  • A child with acute respiratory distress shows hyperinflation of unilateral lung in chest X-ray. Most likely cause for above presentation is Foreign body aspiration.
  • Advantage of fibreoptic bronchoscopy over rigid bronchoscopy is Good View.
  • The incidence of a foreign body being aspirated into the right lung is higher than into the left lung due to following reasons:Acute onset of cough, stridor ,wheeze and dysponea in a child is mostly due to Foreign body.
  • Right inferior lobar bronchus is in continuation with the right principal bronchus,Right principal bronchus is more vertical than the left bronchus,Tracheal bifurcation directs the foreign body to the right lung.
  • The treatment of choice for airway foreign bodies is prompt endoscopic removal with a Bronchoscope
  • In child, foreign body in lung is removed by rigid bronchoscopy.
  • Commonest sign of intrabronchial foreign body in children is Cough.
  • A 4-year child presents with a history of hoarseness, croupy cough and aphonia, the child has dyspnoea with wheezing. The most probable diagnosis is Laryngeal foreign body.
  • In erect posture commonest site of foreign body is in Right posterior basal bronchus.
  • Foreign body aspiration in supine position commonly affects Apical part of right lower lobe.
  • A foreign body completely obstructing the right main bronchus causes decreased Ventilation-perfusion ratio.
  • Palpatory thud audible slap is seen in Tracheal foreign body.
  • A 2 year old child with intercostal retraction and increas­ing cyanosis was brought with a history of foreign body aspiration. Heimlich's Maneuvre might be lifesaving in this situation.
  • During autopsy, foreign body is found in respiratory tract; manner of death is Accident.

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