Monday, 3 March 2014

Management Of Foreign Body In Respiratory Tract

Nature of Foreign Bodies
(a) Non-irritating type. Plastic, glass or metallic foreign
bodies are re latively non-irritating and may remain
symptomless for a long time.
(b) Irritating type. Vegetables or foteign bodies like
peanuts, beans, seeds, etc. set up a diffuse violent
reaction leading to congestion and oedema of the
tracheobronchi al mucosa-"vegetal bronchitis".
They also swell up with time causing ai rway obstruction
and later suppurat ion in the lung.
Clinical Features
Symptomatology of foreign body is divided into 3 stages:
1. Initial period of choking, gagging and wheezing.
This las ts for a short time. Foreign body may be coughed
out or it may lodge in the larynx or further down in the
tracheobronchial tree .
2. Symptomless interval. T he respiratory mucosa
adap ts to the presence of foreign body and initial symptoms
disappear. Symptomless interval will vary with the
size and nature of the foreign body ..
3. Later symptoms. They are caused by obstruction
to the airway, inflammation or trauma induced by the foreign
body and would depend on the site of its lodgement.
(a) Laryngeal foreign body A large foreign body may
totally obstruct the airway lead ing to sudden death
unless resuscitative measures are taken urgently. A
partially obstructive foreign body will cause discomfort
or pain in the throat, hoarseness of voice,
croupy cough, aphonia, dyspnoea, wheezing and
haemoptysis.
(b) Tracheal foreign body. A sharp foreign body will only
produce cough and haemoptysis. A loose foreign body
like seed may move up and down the trachea between
the carina and the undersurface of vocal cords causing
"audible slap" and "palpatory thud". Asthmatoid
wheeze may also be present. It is best heard at patient's
open mouth
(c) Bronchial foreign body. Most foreign bodies enter the
right bronchus because it is wider and more in line
with the tracheal lumen. A foreign body may totally
obstruct a lobar or segmental bronchus causing atelectasis
or it may ptoduce a check valve obstructionallowing
only ingress of air but, not egress, lead ing to
obstructive emphysema. For pathogenesis and clinical
picture of bronchial foreign body (see Fig. 63.2).
Emphysematous bulla may ruptu re causing spontaneous
pneumothorax. A foreign body may also shift from
one side to the other caUSing change in the physical
signs. A retained foreign body in the lung may la ter give
rise to pneumonitis, bronchiectasis or lung abscess.
Diagnosis
It can be made by detailed history of the foreign body
"ingestion", physical examinat ion of the neck and
chest and radiographs. X-rays of the following areas are
advised:
1. Soft tissue posteroanterior and lateral view of the
neck in its extended pOSition. T his can show radioopaque
and sometimes even the rad io lucent foreign
bodies in the larynx and trachea
2. Posteroanterior and lateral view of the chest.
3. X-ray chest at the end of inspiration and expiration .
Atelectasis and obstructive emphysema can be seen.
They also give indirect evidence of radiolucent
foreign bodies.
4. Fluoroscopy / videofluoroscopy. Evaluation during
inspiration and expiration can be made.
5. Bronchograms. To delineate radiolucent foreign bodies
or to evalu ate bronchiectasis.
Laryngeal foreign body. A large bolus of food
obstructed above the cords may make the patient totally
aphonic, unable to cry for help. He may die of asphyxia
unless immediate first aid measures are taken. The measures
consist of pounding on the back, turning the patient
upside down and foll owing Heimlich manoeuvre. These
measures should not be done if patient is only partially
obstructed, for fear of causing total obstruction.
Heimlich's manoeuvre. Stand behind the person, and
place your arms around his lower chest and give four
abdominal thrusts. The res idual air in the lungs may dislodge
the foreign body providing some airway.
Cricothyrotomy or emergency tracheostomy should
be done if Heimlich's manoeuvre fails. Once acute respiratory
emergency is over, foreign body can be removed
by direct laryngoscopy or by laryngofissure, if found
impacted.
Tracheal and bronchial foreign bodies can be removed
by bronchoscopy with full preparation and under general
anaesthesia. Emergency removal of these foreign bodies is
not 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:
1. Conventional rigid bronchoscopy.
2. Rigid bronchoscopy with telescopic aid.
3. Bronchoscopy with C-arm fluoroscopy.
4. Use of Dormia basket or Fogarty's balloon for rounded
objects.
5. Tracheostomy first and then bronchoscopy through
the tracheostome.
6. Thoracotomy and bronchotomy for peripheral foreign
bodies.
7. Flexible fibre optic bronchoscopy in selected adult
patients.

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