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Laryngo Tracheo Bronchial Foreign Bodies

Laryngo Tracheo Bronchial Foreign Bodies. Dr. Supreet Singh Nayyar, AFMC For more topics & ppts , visit www.nayyarENT.com. Overview. Introduction Applied anatomy Aetiology Presentation Pathology Assessment Diagnosis Complications Management Post Op Care Summary References.

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Laryngo Tracheo Bronchial Foreign Bodies

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  1. LaryngoTracheo Bronchial Foreign Bodies Dr. Supreet Singh Nayyar, AFMC For more topics & ppts, visit www.nayyarENT.com www.nayyarENT.com

  2. Overview • Introduction • Applied anatomy • Aetiology • Presentation • Pathology • Assessment • Diagnosis • Complications • Management • Post Op Care • Summary • References www.nayyarENT.com

  3. Introduction • Orifices • Curiosity of children • Minor irritation / Life threatening Problem www.nayyarENT.com

  4. 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. www.nayyarENT.com

  5. Infant larynx • More anterior & higher in neck • Epiglottis larger, longer & angled more over glottis • Larynx cone-shaped: narrowest at cricoid ring • Trachea 57mm long, diam 4 mm www.nayyarENT.com

  6. Paediatric airway • All cartilaginous supporting framework are soft, pliable & prone to collapse. www.nayyarENT.com

  7. 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. www.nayyarENT.com

  8. Rapid Subglottic Edema www.nayyarENT.com

  9. Aetiology • Age/Sex • Predisposing factors- • Interference with deglutition reflex • Unconscious patient • Pharyngeal / laryngeal paralysis • Improper mastication with hurried swallowing • Types • Inert / Non inert • Region www.nayyarENT.com

  10. Presentation • Typical History immediately after aspiration • Presenting after respiratory complications www.nayyarENT.com

  11. Pathogenesis of bronchial obstruction Stop valve Bypass valve Oneway valve Hence clinical features will vary www.nayyarENT.com

  12. Immediate assessment • Quick history and physical examination • Vital parameters • SpO2 monitoring • ABG www.nayyarENT.com

  13. Specific • Indirect Laryngoscopy www.nayyarENT.com

  14. Specific • Fibreoptic Laryngoscopy www.nayyarENT.com

  15. Specific • Direct Laryngoscopy • Fibreoptic & Rigid Bronchoscopy www.nayyarENT.com

  16. 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) Radiology in Foreign Body www.nayyarENT.com

  17. 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.PediatrPulmonol. 2004 Sep;38(3):261-4 www.nayyarENT.com

  18. www.nayyarENT.com

  19. CT Scan • Normal CT • HRCT • Reconstruction • Virtual Scopy www.nayyarENT.com

  20. Reconstruction www.nayyarENT.com

  21. Virtual Imaging: • Volume rendered images • Navigation beyond obstruction www.nayyarENT.com

  22. Magnetic Resonance Imaging • Better sequences • Better characterization of lesion www.nayyarENT.com

  23. Complications • Respiratory distress • Asphyxia • Cardiac arrest • Fever • Laryngeal edema • Pneumothorax • Hemoptysis • Pneumonia • Bronchiectasis • Bronchial stricture • Surgical emphysema www.nayyarENT.com

  24. Emergency Management < one year: Back blows/abdominal thrusts www.nayyarENT.com

  25. Emergency Management Small Child: Back blows www.nayyarENT.com

  26. Emergency Management • Older Children /Adults: Heimlich manouvere www.nayyarENT.com

  27. Emergency management • Finger Sweeping – Not recommended* • Tracheostomy might be required • * Scot Brown Otorhinolaryngology 7th Ed pg 1188 www.nayyarENT.com

  28. Endoscopic removal Rigid bronchoscopy Fibre-optic www.nayyarENT.com

  29. Endoscopic removal • Sniff position for aligning axes www.nayyarENT.com

  30. 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 www.nayyarENT.com

  31. Endoscopic removal • Use of Fogarty catheter www.nayyarENT.com

  32. 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. www.nayyarENT.com

  33. Endoscopic Removal • Use of laryngeal mask airway with fibreoptic bronchoscope www.nayyarENT.com

  34. Endoscopic removal • Under 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. www.nayyarENT.com

  35. Endoscopic Removal • New instruments – Optical Grabbing Forceps www.nayyarENT.com

  36. Post op care • Oxygen • Watch SpO2 • Steroids • Nebulized asthalin / steroids • Chest physiotherapy www.nayyarENT.com

  37. Summary • Most common among children • Potentially life threatening • Immediate Manouveres • Early removal to prevent oedema • Diagnosis & imaging • Endoscopes & Training • Post op care www.nayyarENT.com

  38. 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 BrutinelChest 2002;121;1695-1700 • Retrieval of Aspirated Foreign Bodies in Children Using a Flexible Bronchoscope and a Laryngeal Mask Airway AvrahamAvital, M.D., David Gozal, M.D., KamalUwyyed, M.D.,andChaim Springer, M.D. www.nayyarENT.com

  39. Thank youfor more topics & ppts, visit www.nayyarENT.com www.nayyarENT.com

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