1. Laryngo Tracheo Bronchial Foreign Bodies Maj Supreet Singh Nayyar, Gd Spl (ENT) 7/13/2013 5 Air Force Hospital 1

2. 2 yrs 9 mths old, s/o serving soldier Presenting complaint Cough X 4 mths Gets tired easily Decreased growth 7/13/201 3 5 Air Force Hospital 2 3. 7/13/201 3 5 Air Force Hospital 3 4. 7/13/201 3 5 Air Force Hospital 4 5. Multi Disciplinary Approach Radiology Anaesthesia ENT Paediatric Team meeting held Problems discussed 7/13/201 3 5 Air Force Hospital 5 6. 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 7/13/201 3 5 Air Force Hospital 6 7. ENT challenges Age group Deviated trachea Involvement of left lobe History of 4 months Shared airway with limited time before bringing out the endoscope 7/13/201 3 5 Air Force Hospital 7 8. 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 7/13/201 3 5 Air Force Hospital 8 9. The Surgery 7/13/201 3 5 Air Force Hospital 9 10. Surgery Evening 7/13/201 3 5 Air Force Hospital 10 11. July 2013 7/13/201 3 5 Air Force Hospital 11 12. Introduction Orifices Curiosity of children Minor irritation / Life threatening Problem 7/13/2013 5 Air Force Hospital 12 13. Applied anatomy 7/13/201 3 5 Air Force Hospital 13 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 14. Paediatric airway All cartilaginous supporting framework are soft, pliable & prone to collapse. 7/13/201 3 5 Air Force Hospital 14 15. 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. 7/13/201 3 5 Air Force Hospital 15 16. Rapid Subglottic Edema 7/13/201 3 5 Air Force Hospital 16 17. 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 7/13/201 3 5 Air Force Hospital 17 18. Presentation Typical History immediately after aspiration Choking episode/sudden coughing Breathlessness/ stridor/ hoarseness/ aphonia Palapatory thud/ asthmatoid wheeze Sudden death Presenting after respiratory complications 20% 7/13/201 3 5 Air Force Hospital 18 19. Pathogenesis of bronchial obstruction 7/13/2013 5 Air Force Hospital19 Stop valve Bypass valve Oneway valve Hence clinical features will vary 20. Immediate assessment Quick history and physical examination Vital parameters SpO2 monitoring ABG 7/13/201 3 5 Air Force Hospital 20 21. Specific Indirect Laryngoscopy 7/13/201 3 5 Air Force Hospital 21 22. Specific Fibreoptic Laryngoscopy 7/13/201 3 5 Air Force Hospital 22 23. Specific Direct Laryngoscopy Fibreoptic & Rigid Bronchoscopy 7/13/201 3 5 Air Force Hospital 23 24. Diagnosis 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) 7/13/201 3 5 Air Force Hospital 24 Radiology in Foreign Body 25. 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 7/13/201 3 5 Air Force Hospital 25 26. 7/13/201 3 5 Air Force Hospital 26 27. CT Scan Normal CT HRCT Reconstruction Virtual Scopy 7/13/201 3 5 Air Force Hospital 27 28. Reconstruction 7/13/201 3 5 Air Force Hospital 28 29. Virtual Imaging: Volume rendered images Navigation beyond obstruction 7/13/2013 5 Air Force Hospital 29 30. Magnetic Resonance Imaging Better sequences Better characterization of lesion 7/13/201 3 5 Air Force Hospital 30 31. Complications Respiratory distress Asphyxia Cardiac arrest Fever Laryngeal edema Pneumothorax Hemoptysis Pneumonia Bronchiectasis Bronchial stricture Surgical emphysema 7/13/201 3 5 Air Force Hospital 31 32. Emergency Management 7/13/201 3 5 Air Force Hospital 32 < one year: Back blows/abdominal thrusts 33. Emergency Management 7/13/201 3 5 Air Force Hospital 33 Small Child: Back blows 34. Emergency Management 7/13/201 3 5 Air Force Hospital 34 Older Children /Adults: Heimlich manouvere 35. Emergency management Finger Sweeping Not recommended* Tracheostomy might be required * Scot Brown Otorhinolaryngology 7th Ed pg 1188 7/13/201 3 5 Air Force Hospital 35 36. Endoscopic removal 7/13/201 3 5 Air Force Hospital 36 Rigid bronchoscopy Fibre-optic 37. Endoscopic removal Sniff position for aligning axes 7/13/201 3 5 Air Force Hospital 37 38. 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 7/13/201 3 5 Air Force Hospital 38 39. Endoscopic removal Use of Fogarty catheter 7/13/201 3 5 Air Force Hospital 39 40. 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. 7/13/201 3 5 Air Force Hospital 40 41. Endoscopic Removal Use of laryngeal mask airway with fibreoptic bronchoscope 7/13/201 3 5 Air Force Hospital 41 42. Endoscopic Removal New instruments Optical Grabbing Forceps 7/13/201 3 5 Air Force Hospital 42 43. Post op care Oxygen Watch SpO2 Steroids Nebulized asthalin / steroids Chest physiotherapy 7/13/201 3 5 Air Force Hospital 43 44. Summary Most common among children Potentially life threatening Immediate manouveres Early removal to prevent oedema Diagnosis & imaging Endoscopes & Training Post op care 7/13/201 3 5 Air Force Hospital 44 45. 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;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.7/13/201 3 5 Air Force Hospital 45 46. Thank you 7/13/201 3 5 Air Force Hospital 46