Presented To : Presented By :Mrs. Maheshwari Miss Tina Ann JohnM.Sc (N) II M.Sc(N)H.O.D, Pediatric Nsg,Goutham College of Nursing

The upper respiratory tract warms, humidifies & filters the air that enters the body.

The structures of the upper respiratory tract constantly comes into contact with a barrage of foreign organisms, including pathogens which can sometimes lead to airway irritation & illness.

Upper Airway Differences: The airway is shorter & narrower than an adult The infant’s airway is approximately 4mm in

diameter in contrast to the adult’s airway diameter of 20 mm.

The trachea primarily increases in length rather than diameter in the first 5 yrs of life.

The tracheal division of the right & left bronchi is higher in a child’s airway & at a different angle than the adult.

The cartilage that supports the trachea is more flexible & can compress the airway if head & neck is not positioned appropriately.

Narrower airway causes a greater increase in airway resistance.

Until 4 wks of age, newborns are obligatory nose-breathers.

Mouth- breathing is controlled by maturing neurologic pathways.

Acute respiratory infections (ARI) are a major cause of morbidity and mortality in young children world wide.

They account for nearly 3.9 million deaths every year globally.

On an average a child has 5 to 8 attacks of ARI annually.

ARI accounts for 30-40% of the hospital visits by children in office practice.

Acute nasopharyngitis is the most common respiratory infection in infants & children.

The accessory paranasal sinuses & the middle ear are generally involved.

Infections spread quickly & serious complication can result if the child is malnourished.

Nasopharyngitis can be acute & chronic condition that affects the nasopharyngeal passage of the upper respiratory tract.

It is the inflammation of the nasopharynx.

The commonest cause of nasopharyngitis is the rhino virus.

In infants & younger children- H.influenza & staphylococci.

In older children – group A streptococci.

The rhinovirus are the most common infectious agents

The Pathophysiology changes that occurs include edema & vasodilation in the sub mucosa, mononuclear cell infiltration that becomes polymorphonuclear

Separation & possible sloughing off the superficial epithelial cells & the production of mucus that is profuse and later becomes thick & purulent.

The child is infectious from a few hrs before 1 to 2 days after the infection appears.

Complications may occur in infants .

Clinical manifestations are more severe in infancy than during childhood.

Young infants: may not have an elevated temperature. Infants & young children between 3 mths &

3yrs may have a sudden onset of fever of 39-400 C (102-1040 F)

Febrile convulsions may occur during infancy if the temperature rises upto 400.

Infants may become irritable, restless & fretful.

Profuse nasal discharge.

Moderate respiratory difficulty may occur in very young infants.

Poor feeding Gastrointestinal disturbances.

In Older Children: Irritation & dryness of the mucus membrane of

nose & throat. Child feels chilly, sneeze & cough may be

present Thin nasal discharge later purulent discharge Slight fever Headache General malaise & muscle aches Anorexia The acute symptoms may subside in 6-10

days.

Thorough clinical history Thorough clinical examination Nasal & throat swabs for culture

sensitivity.

Cared at home generally Nursing intervention is that of parent

education & problem solving Serious complications require admission. Vital signs are frequently assessed Nasal decongestants are given Antibiotics are not used unless evidence

of bacterial infections.

Occur more frequently in infants than younger children. Otitis media Laryngitis Bronchitis Pneumonia

Recovery is good for both infants & older children

Effective vaccines are not yet developed for prevention of common cold

Maintain good nutrition & wellness. Hand washing of caregivers & children

after every activity

Acute pharyngitis refers to infection primarily involving the throat. It may also include acute conditions such as tonsillitis & pharyngotonsillitis.

Streptococcal pharyngitis is uncommon in infants but accounts for 10% of all respiratory & febrile illnesses in children between 5 to 16 yrs.

Frequency of positive throat culture in children seen by physicians ranges from 35-50%

Frequency of streptococcal pharyngitis increases during the winter & spring.

Viral infections constitute 80% of the underlying cause.

Bacterial pharyngitis is commonly known as strep throat. (GABHS)

Other bacteria include non-group A streptococci.

Other viruses, such as rhinovirus and corona virus

Streptococci is round, gram positive bacteria.

With infectious pharyngitis, bacteria or viruses may directly invade the pharyngeal mucosa, causing a local inflammatory response.

Streptococcal infections are characterized by local invasion and release of extracellular toxins and proteases

VIRAL PHARYNGITIS STREP THROAT

Nasal congestion Mild sore throat Conjunctivitis Cough Hoarseness Mild pharyngeal redness Minimal tonsillar

exudate Mildly tender anterior

cervical lymphadenopathy

Fever < 38.30C (1010F)

Abrupt onset Tonsillar exudate Painful cervical

lymphadenopathy Anorexia, nausea,

vomiting, abdominal pain

Severe sore throat Headache, malaise Fever Petechial mottling of

soft palate.

Posterior pharynx with petechiae and exudates in a 12-year-old girl. Both the rapid antigen

detection test and throat culture were positive for group A beta-hemolytic streptococci.

Throat culture A throat culture remains the criterion standard for

diagnosis, although results can take as long as 48 hours

Throat culture results are highly sensitive and specific for group A beta-hemolytic streptococci (GABHS)

Imaging studies are usually not necessary unless a retropharyngeal, parapharyngeal, or peritonsillar abscess is suspected. In such cases, a plain lateral neck film can be used as an initial screening tool

Honikman & Massell criteria for throat culture

Penicillin is the typical therapy for group A beta-hemolytic streptococci (GABHS) pharyngitis, in conjunction with prevention of dehydration and supportive care for pain.

Improved compliance with regimens has been noted when penicillin treatment is administered 2-3 times daily, as compared with traditional regimens with 4 daily doses.

Administer a minimum of 30,000 units/kg body wt to a maximum of 1.2 million units for 10 days.

Children allergic to penicillin are given oral erythromycin for 10 days.

Sulfonamides suppress but do not eradicate the streptococci from the pharynx & do not prevent fever.

Acute glomerulonephritis is a possible complication.

It may appear in 1 to 2 wks after pharyngitis

Urine specimen is assessed after two wks of treatment for protein to avoid the development of glomerulonephritis.

Children with viral pharyngitis recover in 24 hrs to 5 days.

Purulent otitis media is a rare complication Streptococcal pharyngitis recovery occurs

in 1-14 days. Follow-up is essential to avoid the risk of

developing glomerulonephritis & rheumatic fever.

Mesenteric adenitis- abdominal pain with or without vomiting.

Rarely occurs Results from infection of the sinuses,

adenoids or tonsils. In acute episodes, children complain of

throat discomfort including dryness & irritation.

The lymphoid tissue is usually hypertrophied-pebbled appearance

Blood vessels may be prominent on inflamed mucus membrane.

Muco-purulent secretions are present in the pharyngeal wall.

Failure of the nasal cavities to open posteriorly into the nasopharynx (choanae) during fetal development is called Choanal Atresia.

The average rate of Choanal Atresia is 0.82 cases per 10,000 individuals. Unilateral Atresia occurs more frequently on the right side. The ratio of unilateral to bilateral cases is 2:1. A slightly increased risk exists in twins. Maternal age or parity does not increase the frequency of occurrence. Chromosomal anomalies are found in 6% of infants with Choanal Atresia.

Choanal Atresia occurs with equal frequency in people of all races.

More studies report significantly more females than males affected

The nasal cavities extend posteriorly during development under the influence of the posteriorly directed fusion of the palatal processes.

Thinning of the membrane occurs, which separates the nasal cavities from the oral cavity.

By the 38th day of development, the 2-layer membrane consisting of nasal and oral epithelia ruptures and forms the choanae (posterior nares).

Failure of this rupture results in Choanal Atresia. In 2008, Barbero et al suggested that prenatal use

of antithyroid (methimazole, carbimazole) medications was linked to Choanal Atresia.

A number of theories have been proposed to explain the occurrence of Choanal Atresia, and they can be summarized as follows: Persistence of the buccopharyngeal membrane. Failure of the bucconasal membrane to rupture. Medial outgrowth of vertical and horizontal

processes of the palatine bone. Abnormal mesodermal adhesions forming in the

Choanal area. Misdirection of mesodermal flow due to local

factors.

The process may be unilateral or bilateral Bilateral Choanal Atresia usually presents

in the neonate immediately after birth with respiratory distress. Cycles between spells of cyanosis & crying

occurs Unilateral Choanal Atresia may be

present later in infancy or early childhood with unilateral nasal discharge or blockage.

Complete physical examination- A small feeding tube could be used to determine the patency of the choana, but a complete nasal and nasopharyngeal examination should be performed using a flexible fiber optic endoscope to assess the deformity.

Symptoms of severe airway obstruction and cyclical cyanosis are the classic signs of neonatal bilateral Atresia. When crying alleviates respiratory distress in an obligate nasal breather

Unilateral Atresia may not be detected for years, and patients may present with unilateral rhinorrhea or congestion.

Associated malformations occur in 47% of infants without chromosome anomalies.

Nonrandom association of malformations can be demonstrated using the CHARGE association.

The components of the CHARGE association are as follows: Coloboma of the iris, choroid, and/or microphthalmia Heart defect such as atrial septal defect (ASD) and/or

conotruncal lesion Atresia of choanae Retarded growth and development Genitourinary abnormalities such as cryptorchidism,

microphallus, and/or hydronephrosis Ear defects with associated deafness (The external,

middle, and/or inner ear may be involved. Only a small proportion of infants with Choanal Atresia and related components probably represent this entity.)

CT scanning is the radiographic procedure of choice in the evaluation of Choanal Atresia. For good results, careful suctioning is performed to clear excess mucus, and a topical decongestant is applied. The purpose of CT scanning is outlined as follows: Confirm the diagnosis of Choanal Atresia

(unilateral or bilateral). Evaluate Choanal Atresia (vomer bone width and

Choanal airspace distance). Exclude other possible nasal sites of obstruction. Determine the degree of bony, membranous, or

mixed Atresia. Delineate abnormalities in the nasal cavity and

nasopharynx.

Diagnostic Procedures: Failure to pass an 8F catheter through the nasal

cavity more than 5.5 cm from the alar rim The lack of movement of a thin wisp of cotton

under the nostrils while the mouth is closed The absence of fog on a mirror when it is placed

under the nostrils Acoustic rhinometry Listening for breath sounds with either a

stethoscope or a Toynbee auscultation tube Gently blowing air into each nasal cavity with a

Politzer bag Administering into the nose a colored solution that

is visible in the pharynx

Bilateral Choanal Atresia in a neonate is an emergency

Bilateral Choanal Atresia in the newborn requires prompt diagnosis and airway stabilization. An oral airway, McGovern nipple, and intubation are viable options.

Transnasal puncture. The transseptal technique

Following surgical repair of Choanal Atresia, patients may require operative debridement or periodic dilatations. Periodic dilations can sometimes be performed as an outpatient procedure with local decongestant and topical anesthesia using urethral sounds.

Epistaxis, or nosebleed, is a common pediatric complaint.

Most incidents are rarely life threatening but cause significant parental concern.

Most nosebleeds are benign, self-limiting, and spontaneous but may also be recurrent. Many uncommon causes are also noted.

Epistaxis usually occurs in children aged 2-10 years.

Occurrence is unusual in infants in the absence of a coagulopathy or nasal pathology (e.g., Choanal Atresia, neoplasm).

Local trauma (e.g., nose picking) does not occur until later in the toddler years.

Older children and adolescents also have a less frequent incidence.

Consider cocaine abuse in adolescent patients.

The primary cause of epistaxis in children is minor trauma, such as nose picking (frequently in the setting of dry nasal membranes).

Other common causes of nosebleeds include: direct trauma with or without nasal or facial fractures,

foreign body, rhinitis. exposure to warm and dry air causing dry membranes

(rhinitis sicca). Medications such as nonsteroidal anti-inflammatory

drugs (NSAIDs) and chronic use of nasal steroids for treatment of allergic rhinitis are also frequently involved.

Some less common causes include leukemia, Osler-Weber-Rendu syndrome, nasal tumors, and coagulopathies, both intrinsic (e.g., hemophilia, Von Willebrand disease) and acquired (e.g., accidental warfarin ingestion).

Excessive coughing causing nasal venous hypertension may be observed in pertussis or cystic fibrosis.

Arterial hypertension rarely causes epistaxis Children with migraine headaches have a higher

incidence of recurrent epistaxis than children without the disease.

Young infants with gastroesophageal reflux into the nose may have epistaxis secondary to inflammation.

Etiologies such as liver disease, which can lead to clotting factor deficiencies (II, VII, IX, X); Osler-Weber-Rendu syndrome, which causes capillary fragility; and nasal foreign bodies that cause local trauma can be responsible for rare cases of epistaxis.

Intranasal rhabdomyosarcoma, although rare, often begins in the nasal, orbital, or sinus area in children.

Juvenile nasal angiofibroma in adolescent males may cause severe nasal bleeding as the initial symptom

Epistaxis can be divided into 2 categories, anterior bleeds and posterior bleeds, based on where the bleeding originates.

Bleeding typically occurs when the mucosa is eroded and vessels become exposed and subsequently break. More than 90% of bleeds occur anteriorly and arise from the Little area, where the Kiesselbach plexus forms on the septum. These capillary or venous bleeds provide a constant ooze, rather than the profuse pumping of blood observed from an arterial origin.

Posterior bleeds arise further back in the nasal cavity, are usually more profuse, and are often of arterial origin. A posterior source presents a greater risk of airway compromise, aspiration of blood, and greater difficulty controlling bleeding.

Skin: Examine the skin for evidence of bruises or petechiae that may indicate an underlying hematologic abnormality.

Vital signs High blood pressure (HBP) rarely, if ever,

causes epistaxis on its own; however, HBP may impede clotting. Check blood pressure and complete a workup if HBP is present.

Persistent tachycardia must be recognized as an early indicator of significant blood loss requiring intravenous fluid and, potentially, transfusion.

Nasal examination Use of a large-sized, otologic, handheld speculum (shown

in the image below) can be helpful. Begin the examination with inspection, looking

specifically for any obvious bleeding site on the septum that may be amenable to direct pressure or cautery.

Anterior bleeds from the nasal septum are most common, and the site can frequently be identified if bleeding is active.

Carefully remove by suction any large amount of clot. Pharynx examination

Observe the posterior pharynx for constant dripping of blood that may signify a posterior rather than an anterior bleed.

After placement of an anterior pack (see images below), reassess this area and, if bleeding is noted in the pharynx with an anterior pack in place, strongly consider a posterior bleed.

Laboratory Studies For the most part, laboratory studies are not

needed for first-time or infrequent recurrences with a good history of nose picking or trauma to the nose.

If significant blood loss, leukemia, or malignancy is suspected or if recurrent bleeding occurs, perform a CBC count with differential.

If a coagulopathy is suspected, perform CBC count and obtain prothrombin time (PT)/activated partial thromboplastin time (aPTT) and bleeding time.

Procedures Direct visualization with a good directed light

source, nasal speculum (see image below), and nasal suction should be sufficient in most patients.

Insertion of nasal packing or cautery may be indicated

Medical Care Initial treatment begins with direct pressure by

squeezing the nostrils together for 5-30 minutes straight, without frequent peeking to see if the bleeding is controlled. Usually only 5-10 minutes is required.

Patients should keep their heads elevated but not hyperextended because hyperextension may cause bleeding into the pharynx and possible aspiration. This maneuver works more than 90% of the time.

If bleeding is caused by excessive dryness in the home (e.g., from radiator heating), patients may benefit from the following care options: Humidify the air with a cool mist vaporizer in the

bedroom.

Alternately, a metal basin of water may be placed on top of a radiator to humidify the ambient air.

Nasal saline sprays are useful. Oxymetazoline (Afrin) may also be used, with fewer cardiac adverse effects.

local application of bacitracin or petrolatum ointment directly to the Kiesselbach area with a cotton applicator to prevent further drying (studies recommend 2 wk).

If direct pressure is not sufficient, gauze moistened with epinephrine at a ratio of 1:10,000 or phenylephrine (Neo-Synephrine) may be placed in the affected nostril to help vasoconstrict and achieve hemostasis

Surgical Care Cauterization of an identified small

bleeding area: Can be performed with silver nitrate sticks Caution advised not to burn the entire septum

or cause perforation (septal perforation is a risk) Performed in only one nostril at a time Used very judiciously; must avoid nasal tissues

other than the bleeding site of septum Presents risk of nasal stenosis of the vestibule Oxycel cotton with bacitracin, which dissolves

and does not have to be removed, preferred by some (especially helpful in patients with leukemia)

other tampon like packing that expands when water is injected into it

Antibiotic agents Antibiotics with staphylococcal and

streptococcal coverage are required if nasal packing is placed. The oral route is used most commonly because most patients are treated on an outpatient basis. If the patient requires admission, initially use intravenous medications. Continue all antibiotics until the packing is removed

One complication is excessive bleeding to the point of shock requiring transfusion.

Airway compromise is another potential complication. Excessive bleeding into the pharynx causes coughing and gagging. If this occurs in an infant who is unable to roll over and clear the blood, aspiration and subsequent respiratory arrest occur.

Nose picking is difficult to deter and is going to occur. Keeping the child's nails well trimmed may be helpful.

Protection from direct trauma from some sports activities occurs with helmet and/or face piece use.

A hot dry home environment may benefit from humidifiers, better thermostatic control, saline spray, and antibiotic ointment on the Kiesselbach area.

Consider drug education relating to use or accidental ingestion of aspirin, warfarin (e.g., rat poison in toddlers), or drug abuse in adolescents.

Patients with epistaxis that occurs from dry membranes or minor trauma do well with no long-term effects.

Patients with bleeding from a hematologic problem or cancer have a variable prognosis.

Tonsils are masses of lymphoid tissue located in the pharyngeal cavity.

The tonsils filter & protect the respiratory & alimentary tract from invasion by pathogenic organisms.

Antibody formation. Children generally have larger tonsils.

Tonsillitis is the term commonly used to refer to infection & inflammation of the palatine tonsils.

Adenitis refers to the infection & inflammation of the adenoid (pharyngeal) tonsils.

Often occurs with pharyngitis. Causative organisms may be viral or

bacterial.

PATHOPHYSIOLOGY

Edema of the palatine tonsils (kissing tonsils)

Difficulty in swallowing & breathing. Adenoid enlargement causes nasal

obstruction. Offensive mouth odour & impaired sense

of taste & smell. Voice may be nasal & muffled quality. Persistent cough

Complete health assessment Physical examination with focus on the

respiratory system

Medical Care: Symptomatic management Antibiotic treatment

Surgical Care: Tonsillectomy

Indications: Conservative Controversial

Adenoidectomy Indications:

Conservative

Contraindications: Cleft palate Acute infections at time of surgery Uncontrolled systemic diseases or blood

dyscrasias. Nursing Intervention:

Reducing Fear Pre-operative Post Operative Home Care

Acute infections of the larynx & trachea are more frequent in toddlers than in older children

Primarily affected sites are the larynx & trachea

The term croup syndrome includes acute epiglotittis, acute infectious pharyngitis, acute laryngotracheobronchitis & acute spasmodic laryngitis.

Occur in infancy & toddler period with exception for epiglotittis.

Viral infections are the common causative agent

Haemophilus influenza are one of the common pathogen.

Condition Pathophysiology &Onset

Assessment

Acute Epiglotittis (epiglotittis,supraglotittis, obstructive supraglottic laryngitis)

Maximum obstruction above the vocal chords (supraglottic) Rapid onset over a period of 4-12 hrs.

•Child with high fever of 39.4 C(103 F)•Sore throat- pain on swallowing•Drooling of saliva•Muffled voice•Young child may assume position of hyperextension of neck•Older children may lean forward while sitting up, with mouth open & tongue protruding.•Rapidly increasing inspiratory & sometime expiratory stridor.

Condition Pathophysiology &Onset

Assessment

•Possible inspiratory suprasternal & substernal retractions•Irritability & restlessness•Mild hypoxia with pallor to obvious coma & cyanosis•Rapid total airway obstruction may occur within minutes during first 6-12 hr of onset.

Acute Infectious Laryngitis

Maximum obstruction at larynx (glottic) & subglottic area.Gradual onset with upper respiratory tract infection.

•Possible slight temp. elevation•Few symptoms to severe obstructive laryngitis•Mild hoarseness to loss of voice with ‘brassy cough’•If severe, restlessness, inspiratory stridor, retractions & dyspnea.

Condition Pathophysiology &Onset

Assessment

Acute Spasmodic Laryngitis (spasmodic croup, midnight croup, spasmodic laryngitic allergic croup)

Maximum obstruction at the vocal cords (glottic) laryngeal spasm vary with sudden onsetTypically occur at night.

•Paroxysmal attacks of laryngeal obstruction•Barking or brassy cough•Hoarseness•Sever inspiratory stridor, without fever•Inspiratory retractions sometimes evident.•Restless, anxious•May have some cyanosis•Clinical manifestations may persist for several hrs, if untreated may have only hoarseness & cough the next morning but symptoms may recur the next 1 or 2 nights.

Initially a mild barking or brassy cough with intermittent stridor.

Hypoventilation becomes severe-hypoxemia-hypercapnea

Dyspnea- flaring of alae nasi, use of accessory muscles, suprasternal, infrasternal & intercostal retractions

Emotionally stressed- respiratory difficulty

Prefers sitting position or held upright.

X-ray of the neck Nasopharyngeal culture Blood culture Examination of the Epiglottis.

Acute Epiglottis: Endotracheal intubation or tracheostomy Antibiotic administration.

Acute Laryngitis: Self-limited without long-term sequelae Symptomatic relief Fluids Humidified air.

Acute Laryngotracheobronchitis: Medical care of infection High humidity with cool mist Fluid maintenance in absence of respiratory

difficulty. Nebulized epinephrine Corticosteroid therapy.

Acute Laryngitis: Self-limited disease. Cool mist therapy Nebulized epinephrine Corticosteroid therapy

It is an acute, self-limiting infectious disease that is common among young people under 25 yrs of age.

Usually mild but occasionally can be severe or rarely accompanied by serious complications.

The disease is characterized by an increase in the mononuclear elements of the blood & by symptoms of an infectious process.

The herpes-like Epstein Barr (EB)virus is the principal cause.

Appears in both sporadic & epidemic forms.

Transmitted through direct intimate contact with oral secretions.

It is contagious & the period of communicability is unknown.

The incubation period following exposure is 4-6 wks.

The diagnosis is established on the basis of clinical manifestations.

Heterophil antibody test Spot test (Monospot)

No specific treatment Symptomatic management Bed rest Regulation of activities Short course of oral penicillin for sore

throat. Warm gargles, hot drinks, analgesics

including opiods or anaesthetic troches

Self-limiting disease Prognosis is generally good. Live vaccines are avoided for several

months after recovery.

Inflammation of the middle ear. It is the second most common disease of

infants & young children after upper respiratory infections.

• To clear secretions produced within the middle ear into the nasopharynx

• To equilibrate the air pressure with the atmospheric pressure in the middle ear by replenishing the oxygen that has been absorbed.

• To protect the middle ear from nasopharyngeal secretions.

Length of the Eustachian tube. Cartilaginous support. Muscles. Lymphoid tissues. Humeral defense mechanism. Frequency of URI. Position.

Acute Otitis Media Chronic Otitis Media Serous Otitis Media

Infant tugs & pulls the affected ear. Screams with pain during night. Child stops crying when carried upright. Toddlers tilt head to one side Irritability & lethargic Sucking or chewing leads to increase the

discomfort. Physical examination.

Otoscopy Tympanocentesis Tympannometry

Analgesic & antipyretic such as acetaminophen.

Myringotomy

approximately 3000 deaths occur each year from foreign body aspiration, with most deaths occurring before hospital evaluation and treatment.

Most airway foreign body aspirations occur in children younger than 15 years

children aged 1-3 years are the most susceptible.

Vegetable matter tends to be the most common airway foreign body.

peanuts are the most common food item aspirated.

The incidence of metallic foreign body aspirations, particularly of safety pins, has decreased in frequency secondary to the advent of disposable diapers.

Young children comprise the most common age group for foreign body aspiration because of the following: They lack molars for proper grinding of food. They tend to be running or playing at the time

of aspiration. They tend to put objects in their mouth more

frequently. They lack coordination of swallowing and

glottic closure.

After foreign body aspiration occurs, the foreign body can settle into 3 anatomic sites, the larynx, trachea, or bronchus. Of aspirated foreign bodies, 80-90% become

lodged in the bronchi. Several studies have demonstrated equal

frequency of right and left bronchial foreign bodies in children.

Larger objects tend to become lodged in the larynx or trachea.

In general, aspiration of foreign bodies produces the following 3 phases: Initial phase - Choking and gasping, coughing,

or airway obstruction at the time of aspiration Asymptomatic phase - Subsequent lodging of

the object with relaxation of reflexes that often results in a reduction or cessation of symptoms, lasting hours to weeks

Complications phase - Foreign body producing erosion or obstruction leading to pneumonia, atelectasis, or abscess

Clinical presentation depends on the location of the foreign body. A large foreign body lodged in the larynx or trachea can produce complete airway obstruction from either the dimensions of the object or the resulting edema. Laryngeal foreign bodies present with airway

obstruction and hoarseness or aphonia. Tracheal foreign bodies present similarly to laryngeal

foreign bodies but without hoarseness or aphonia. Tracheal foreign bodies can demonstrate wheezing similar to asthma.

Bronchial foreign bodies typically present with cough, unilateral wheezing, and decreased breath sounds, but only 65% of patients present with this classic triad.

Foreign body aspiration can mimic other respiratory problems, such as asthma. Foreign body aspiration differs in the presence of unilateral wheezing and decreased breath sounds.

Imaging Studies High-kilovolt anteroposterior and lateral radiographs of the

airway are the tests of choice in patients in whom laryngeal foreign bodies are suspected

Posteroanterior and lateral chest radiographs are an adjunct to the history and physical examination in patients in whom foreign body aspirations are suspected. Radiopaque objects are visible, but radiolucent objects (e.g.,

plastic) are not.1

Chest radiographs may reveal obstructive emphysema or hyperinflation, atelectasis, and consolidation.

Lateral decubitus chest films may be helpful in children in whom the dependent lung remains inflated with bronchial obstruction.

Chest radiographs (inspiratory and expiratory films) demonstrate atelectasis on inspiration and hyperinflation on expiration with a foreign body obstructing the bronchus.

Biplane fluoroscopy uses intraoperative fluoroscopic evaluation while identifying and locating a foreign body within the lung periphery

Diagnostic Procedures Chest auscultation is critical in the evaluation

of a patient in whom a foreign body aspiration is suspected. Typically, these patients have wheezing, decreased breath sounds, or both on the side of the foreign body. Patients may have normal examination findings despite having a foreign body within the airway because it may partially obstruct the airway.

Medical therapy:

Patients with complete airway obstruction require immediate medical attention and typically are aphonic and unable to breathe. Patients who are coughing, gagging, and vocalizing have partial obstruction.

Use of the Heimlich maneuver has improved the mortality rate of patients with complete airway obstruction, but use of it in patients with partial obstruction may produce complete obstruction.

Most patients who arrive at the hospital are beyond the acute stage and are not in respiratory distress.

After a complete history and physical examination are completed and radiographic studies are performed, a decision is made in regard to the need for surgical intervention.

In most cases, antibiotics and steroids are not administered initially.

  

Surgical Therapy An operating room well equipped with proper

endoscopic equipment of various sizes, personnel familiar with the use of the instrumentation, and anesthesiologists experienced in foreign body removal are critical for safe removal of airway foreign bodies.

Follow-up Follow-up care is necessary if the patient's

signs and symptoms return after discharge.

Most complications are the result of a delay in diagnosis.

Of patients with laryngotracheal foreign bodies, 67% experience associated complications when the removal delay is more than 24 hours.

Pneumonia and atelectasis are the most common complications secondary to and after removal of bronchial foreign bodies.

Bleeding can occur from granulation tissue surrounding the foreign body or erosion into a major vessel.

Pneumothorax and pneumomediastinum can result from an airway tear.