Laryngo Tracheo Bronchial Foreign Bodies

Maj Supreet Singh Nayyar, Gd Spl (ENT)

5 Air Force Hospital

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2 yrs 9 mths old, s/o serving soldier Presenting complaint

Cough X

4 mths

Gets tired easily

Decreased growth

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Multi Disciplinary Approach

Radiology Anaesthesia ENT Paediatric

Team meeting held

Problems discussed

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Anaesthesia difficulties

Less age with low SpO2 Ventilation of one lung compromised No endotracheal tube Shared airway with ENT Chances of O2 desaturation during surgery

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ENT challenges

Age group Deviated trachea

Involvement of left lobe

History of 4 months Shared airway with limited time before bringing out the endoscope

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Paediatric challenges

Less age with compromised function of one lung High possibility of Oxygen desaturation during surgery Post op Pulmonary oedema

Manipulation of airway
Bronchial lavage Residual FB particles

Post op pneumonitis

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The Surgery

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Surgery Evening

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July 2013

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Introduction

Orifices Curiosity of children Minor irritation / Life threatening Problem

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Applied anatomy
Site of Lodging of Foreign Body Right Main Bronchus

The diameter of the right main bronchus is larger than the left, The angle of divergence from the tracheal axis is smaller on the right, Airflow through the right lung is greater than through the left, The carina is more likely to be located to the left of midline rather than to the right.
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Paediatric airway

All cartilaginous supporting framework are soft, pliable & prone to collapse.

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Rapid Subglottic Edema

Supraglottis : surrounded by loose connective tissue, prone to edema which grows rapidly

Inflammation from epiglottis can spread quickly to pre-epiglottic & para-glottic spaces.

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Rapid Subglottic Edema

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Aetiology

Age/Sex Predisposing factors Interference with deglutition reflex Unconscious patient Pharyngeal / laryngeal paralysis Improper mastication with hurried swallowing Types Inert Non inert (incl button batteries) Region
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Presentation

Typical History immediately after aspiration

Choking

episode/sudden coughing

Breathlessness/ Palapatory Sudden

stridor/ hoarseness/ aphonia

thud/ asthmatoid wheeze

death

Presenting after respiratory complications 20%

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Pathogenesis of bronchial obstruction

Stop valve

Bypass valve

Oneway valve

Hence clinical features will vary

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Immediate assessment

Quick history and physical examination

Vital parameters
SpO2 monitoring ABG
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Specific

Indirect Laryngoscopy

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Specific

Fibreoptic Laryngoscopy

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Specific

Direct Laryngoscopy Fibreoptic & Rigid Bronchoscopy

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Diagnosis
Radiology in Foreign Body

The plain chest radiography Sensitivity 66% Specificity 51% Both AP & Lat view required for exact localization May be still useful in radiolucent foreign bodies due to features of obstructive emphysema (or the ball valve mechanism)

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Radiology in Foreign Body

Radiopaque FB (23.3%)* Hyperinflation or obstructive emphysema (21.8%)* Hyperinflation or obstructive emphysema with atelectasis in the same hemithorax (18%)* Lobar atelectasis (12.8%)* Whole-lung atelectasis (6.8%)* Shift of mediastinal shadow (11%)* Aeration within an area of atelectasis (6%)*
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* Girardi G, Contador AM, Castro-Rodriguez JA.Pediatr Pulmonol. 2004 Sep;38(3):261-4

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CT Scan
Normal HRCT

CT

Reconstruction
Virtual

Scopy

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Reconstruction

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Virtual Imaging:
Volume

rendered

images
Navigation

beyond obstruction

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Magnetic Resonance Imaging

Better Better

sequences

characterization of lesion

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Complications
Respiratory Hemoptysis Pneumonia Bronchiectasis Bronchial

distress
Asphyxia
Cardiac Fever Laryngeal

arrest edema

stricture

Surgical

emphysema

Pneumothorax
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Emergency Management
< one year: blows/abdominal thrusts Back

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Emergency Management
Small Child: Back blows

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Emergency Management
Older Children /Adults: Heimlich manouvere

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Emergency management
Finger

Sweeping Not recommended* might be required

Tracheostomy

* Scot Brown Otorhinolaryngology 7th Ed pg 1188

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Endoscopic removal

Rigid bronchoscopy

Fibre-optic

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Endoscopic removal

Sniff

position for aligning axes

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Endoscopic removal

Distorted anatomy at depths

Study x-rays, lie/ diameter

Approach carefully, bleeding+ Create forceps space Inorg. Fbs USUALLY TRAILING Careful at glottis, tongue can strip foreign body Good bronchial toilet required
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Endoscopic removal

Use

of Fogarty catheter

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Endoscopic removal

Flexible bronchoscopic view of a large foreign body (mini light bulb lodged in the right main bronchus of a 7year-old boy (left, A).
The ureteral stone basket inserted through the 1.2-mm working channel of the bronchoscope has grasped the foreign body (right, B), Proximal portion of the foreign body is pulled in to distal end of the endotracheal tube by the flexible bronchoscope (right, C). Once the foreign body is thus secured,the entire apparatus (endotracheal tube, flexible bronchoscope, and basket with the foreign body in it) is removed en masse from the airways.
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Endoscopic Removal

Use of laryngeal mask airway with fibreoptic bronchoscope

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Endoscopic Removal

New instruments Optical Grabbing Forceps

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Post op care
Oxygen Watch

SpO2 asthalin / steroids

Steroids
Nebulized Chest

physiotherapy

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Summary
Most

common among children

life threatening manouveres

Potentially Immediate Early Diagnosis Post

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removal to prevent oedema & imaging

Endoscopes

& Training
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op care
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References

Scott Brown ORL HNS,7th Edition Cummings ORL HNS, 4th Edition Grays Anatomy, 38th Edition Various sources from internet (http://chestjournal.chestpubs.org) Previous presentations on similar topics in department Use of a Fogarty catheter for bronchoscopic removal of a foreign body. J

M Wiesel, R Chisin, R Feinmesser and I Gay Chest 1982;81;524a524

Flexible Bronchoscopic Management of Airway Foreign Bodies in Children

James P. Utz, John C. McDougall and W. Mark Brutinel Chest 2002;121;1695-1700

Retrieval of Aspirated Foreign Bodies in Children Using a Flexible Bronchoscope and a Laryngeal Mask Airway Avraham Avital, M.D.,
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David Gozal, M.D., Kamal Uwyyed, M.D.,and Chaim Springer, M.D. 7/13/201

Thank you

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