Laryngo Tracheo Bronchial Foreign Bodies

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Laryngo Tracheo Bronchial Foreign Bodies

Dr. Supreet Singh Nayyar, AFMC

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7/22/2012

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OverviewIntroductionApplied anatomyAetiologyPresentationPathologyAssessmentDiagnosisComplicationsManagementPost Op CareSummaryReferences

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IntroductionOrifices

Curiosity of children

Minor irritation / Life threatening Problem

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http://en.wikipedia.org/wiki/File:SnowWhite.png

Applied anatomy


• 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.

Site of Lodging of Foreign Body Right Main Bronchus

Infant larynxMore anterior &

higher in neckEpiglottis larger,

longer & angled more over glottis

Larynx cone-shaped: narrowest at cricoid ring

Trachea 57mm long, diam 4 mm


Paediatric airway

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


Rapid Subglottic EdemaSupraglottis :

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

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


Rapid Subglottic Edema


Aetiology Age/Sex

Predisposing factors-◦ Interference with deglutition reflex ◦ Unconscious patient◦ Pharyngeal / laryngeal paralysis◦ Improper mastication with hurried swallowing

Types ◦ Inert / Non inert

Region


PresentationTypical History immediately after

aspirationPresenting after respiratory

complications


Pathogenesis of bronchial obstruction

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Stop valve Bypass valve Oneway valve

Hence clinical features will vary

Immediate assessmentQuick history and physical

examination

Vital parameters

SpO2 monitoring

ABG


SpecificIndirect Laryngoscopy


SpecificFibreoptic Laryngoscopy


SpecificDirect LaryngoscopyFibreoptic & Rigid Bronchoscopy


Diagnosis

The plain chest radiography Sensitivity 66%Specificity 51%Both AP & Lat view required for exact

localizationMay be still useful in radiolucent foreign

bodies due to features of obstructive emphysema (or the ball valve mechanism)


Radiology in Foreign Body

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%)** Girardi G, Contador AM, Castro-Rodriguez JA.Pediatr Pulmonol. 2004 Sep;38(3):261-4



CT Scan

Normal CTHRCTReconstructionVirtual Scopy


Reconstruction


Virtual Imaging:◦ Volume rendered

images◦ Navigation beyond

obstruction


Magnetic Resonance Imaging◦Better sequences◦Better characterization

of lesion


ComplicationsRespiratory

distressAsphyxiaCardiac arrestFeverLaryngeal edemaPneumothorax

HemoptysisPneumoniaBronchiectasisBronchial

strictureSurgical

emphysema


Emergency Management


< one year: Back blows/abdominal thrusts



Small Child: Back blows



Older Children /Adults: Heimlich manouvere

Emergency managementFinger Sweeping – Not

recommended*Tracheostomy might be required

* Scot Brown Otorhinolaryngology 7th Ed pg 1188


Endoscopic removal


Rigid bronchoscopy Fibre-optic

Endoscopic removal

Sniff position for aligning axes


Endoscopic removal Distorted anatomy at depthsStudy x-rays, lie/ diameterApproach carefully, bleeding+Create forceps spaceInorg. Fbs –USUALLY TRAILINGCareful at glottis, tongue– can

strip foreign body Good bronchial toilet required


Endoscopic removal

Use of Fogarty catheter


Endoscopic removal Flexible bronchoscopic view of a

large foreign body (mini light bulb lodged in the right main bronchus of a 7-year-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.


Endoscopic RemovalUse of laryngeal

mask airway with fibreoptic bronchoscope


Endoscopic removalUnder fluoroscopic

control


A foreign body (straight pin, arrows), aspirated into the right middle lobe of a 6-year-old girl, is seen on posteroanterior (A) and right lateral (B) radiographs

The foreign body could not be visualized by paediatric flexible bronchoscopy. It was, however, extracted by using a paediatric flexible bronchoscope and a ureteral stone forceps under fluoroscopic guidance.

Endoscopic Removal

New instruments – Optical Grabbing Forceps


Post op careOxygenWatch SpO2SteroidsNebulized asthalin / steroidsChest physiotherapy


SummaryMost common among childrenPotentially life threateningImmediate ManouveresEarly removal to prevent oedemaDiagnosis & imagingEndoscopes & TrainingPost op care


References Scott Brown ORL HNS,7th Edition Cummings ORL HNS, 4th Edition Gray’s 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;524a-524 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., David Gozal, M.D., Kamal Uwyyed, M.D.,and Chaim Springer, M.D.


Thank you

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Laryngo Tracheo Bronchial Foreign Bodies