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  2. ENT Emergencies Ashutosh Kacker, MBBS, MS, MD, FACS Associate Professor Department of Otorhinolaryngology Weill Medical College of Cornell University New York-Presbyterian Hospital—Weill Cornell Center

  3. Foreign Bodies of the Upper Aerodigestive Tract

  4. Background • Majority occur in children under age 5 • 4300 deaths in the US in 2003 (national safety council) • Most deaths occur before arrival in the hospital • Up to 2% mortality reported • Vegetable matter in 70-80% of cases (peanut most common)

  5. Background • Suffocation and aspiration is the 3rd leading cause of death in children under one • 4th leading cause of death in children ages 1 to 6

  6. Background • Most common age – 1-3 years old: • Oral exploration of environment • Lack molars • Poor swallow coordination

  7. Background • 1897 – Gustav Killian - 1st reported endoscopic foreign body removal • Early 1900’s - Chavalier Jackson: • Invented the science of upper airway endoscopy • Hollow tubes with distal illumination • Techniques for safe removal of airway foreign bodies • 1970’s - development of the Hopkins rod telescope - magnified endoscopic view of the airway • Combine with endoscopic instruments  increased safety and precision

  8. History • Choking, coughing, or gagging episode • Shortness of breath • Respiratory distress • Drooling or cough

  9. Laryngeal Foreign Bodies • 8-10% of airway foreign bodies • Highest risk of death before arrival to the hospital • Additional history/physical: • Complete airway obstruction • Hoarseness • Stridor • dyspnea

  10. Tracheal Foreign Bodies • Additional history/physical: • Complete airway obstruction • Audible slap • Palpable thud • Asthmatoid wheeze Jackson and Jackson

  11. Bronchial Foreign Bodies • 80-90% of airway foreign bodies • Right main stem most common (controversial) • Additional history/physical: • Diagnostic triad (<50% of cases): • unilateral wheezing • decreased breath sounds • cough • Chronic cough or asthma, recurrent pneumonia, lung abscess

  12. Esophageal Foreign Bodies • Complete esophageal obstruction with overflow of secretions leading to drooling • Odynophagia • Dysphagia • In young infants respiratory symptoms including stridor, croup, pneumonia– caused by compression of the tracheal wall • Typically at level of cricopharyngeus muscle

  13. Bronchial Foreign Bodies

  14. Diagnostic Tests • High KV ap and lateral views of the larynx: • Radio-opaque laryngotracheal object • AP and lateral views of the chest: • Radio-opaque object • Hyperinflation or collapse of involved lung • Decubitis films: • Involved lung may not collapse when dependent • Inspiratory/expiratory films: • Involved lung may remain hyperinflated on expiration • Fluoroscopy • Differential dynamic inflation of lungs • CT/ MR complications

  15. Chest X-Ray

  16. Decision for Surgery • 3 factors to consider: • History • Physical exam • Radiology • Negative bronchoscopy – 20-50% • Stool’s rule: • If 2/3 factors are positive  OR for bronchoscopy and possible removal

  17. Decision for Surgery • Even et al., Journal of Ped Surg 2005: • Positive history but negative physical and radiology  foreign body in 45% • Doubtful history  foreign body in 9.5% (regardless of radiology findings) • Increased yield of physical exam and radiology findings after 24 hours

  18. Decision for Surgery • Aydogen et al., Int Journal Ped Oto 2006: • Review of 1887 bronchoscopies for suspicion of foreign bodies over 31 years • 79.1% with positive bronchoscopy • Positive history  93% with foreign body • Negative history  28.1% with foreign body • Foreign body  93.2% with positive history

  19. Management • Complete airway obstruction: • < 1 year – back or chest thrusts • Small children – abdominal thrusts • Larger children – heimlich maneuver • Partial airway obstruction: • OR for endoscopic removal • Wait appropriate NPO times to avoid aspiration of stomach contents

  20. Laryngeal Foreign Bodies

  21. Management urgent or emergent situations • Actual or potential airway obstruction • Aspiration of dried beans or peas • Ingestion of disc batteries • Signs or symptoms of a perforation

  22. Operative Considerations • Endoscopic foreign body forceps: • Peanut grasper • Alligator • bronchoscope size • Practice on duplicate foreign body if known • Ventilation port • Anesthetic technique

  23. Anesthetic technique • Spontaneous ventilation • Neuromuscular blockade- short acting, medium actng • Newer agents (combination of inhahation and intravenous medications • Avoid vigorous positive pressure ventilation • Topical lidocaine • Role of intubation

  24. Bronchoscope

  25. Hopkins Rod Telescope

  26. Optical Forceps

  27. Operative Considerations • Flexible suction catheter via suction port • Suction secretions around foreign body • Orient graspers for removal • Attempt retraction of foreign body into bronchoscope • If not possible  remove as one unit • Repeat bronchoscopy to assess for multiple objects

  28. Difficult Objects • Embedded in tissue or granulation: • Afrin (avoid epinephrine) • Debride granulation • Flexible biopsy forceps • Fogarty Catheter • Wait 72 hours • Thoracotomy • Unable to pass through larynx: • Tracheotomy incision • Break object and remove pieces

  29. Complications • Higher risk of complications when object present for > 24 hours • Atelectasis • Pneumonia • Pneumothorax • Pneumomediastinum • Laryngeal edema

  30. Postoperative Management • Uncomplicated removal  discharge home without medication • Traumatic bronchoscopy – steroids +/- racemic epinephrine and observation • Pneumonia – antibiotics, chest PT, and observation • Atelectasis – chest PT +/- nebulizers and observation

  31. Prevention • Parental education • Physician awareness • Timely bronchoscopy

  32. Prevention • Milkovitch et al., Int Journal Ped Oto 2003: • RAM consulting group • 7000 data points since 1988 • 51 children’s hospitals • 15 countries • Injury prevention criteria: • Spherical objects 38.10mm diameter • Non-spherical objects 44.50mm diameter

  33. Conclusions • Airway foreign bodies are a relatively common cause of morbidity and mortality • A high index of suspicion should be present in order to make the diagnosis • Proper instrumentation and technique are essential for effective and a-traumatic removal of foreign bodies • Cooperation/communication between the surgeon and anesthesiologist allows for a safe environment for treatment and avoidance of an airway catastrophe

  34. Tracheotomy • Tracheostomy vs Tracheotomy

  35. INTRODUCTION • Ancient Egypt – 3500 BC • Earliest Recorded Surgical Tracheotomy • Chevalier Jackson – Early 20th Century • Modern Surgical Tracheotomy • Percutaneous Tracheotomy – 1950s and 1960s • High Rate of Complications • Ciaglia et al - 1985 • Modern Percutaneous Dilatational Tracheotomy

  36. INTRODUCTION • Expanding Indications • Upper Airway Obstruction - Prolonged Ventilation • Pulmonary Toilet - Airway Protection • Modern Trends • Shorter Interval Between Intubation and Tracheotomy • Performance at the Bedside Instead of the OR • Percutaneous Versus Surgical

  37. MATERIALS AND METHODS • Surgical Tracheotomy • Local Injection / Shoulder Roll • Midline Vertical Incision • Division of Midline Raphe • Retraction or Division of Thyroid Isthmus • Cricoid Hook Stabilization • Horizontal Inter-Tracheal Incision • Dilation of Stoma • 6.0 DCT (Female) and 8.0 DCT (Male) Shiley

  38. PERCUTANEOUS TRACHEOTOMY • Procedure : • Percutaneous Needle Placement into the Trachea • Passage of Guide Wire • Serial Dilation (Seldinger Technique) • Placement of Tracheotomy Tube • ? Bronchoscopic Guidance • ? Forceps Dilation (Griggs Method) • ? Airway Management

  39. PERCUTANEOUS TRACHEOTOMY • Contra-Indications • Medical Factors • High Ventilation/ Oxygen Requirements • Difficult Intubation / Non-Intubated • Emergency Tracheotomy • Coagulopathy • Age less than 18 • Anatomic Factors • Short or Obese Neck – Poor Landmarks • Tracheotomy Site Infection / Mass or Goiter • Unstable Cervical Spine • History of Previous Tracheotomy • Sonographically Detected Excess Vascularity

  40. PERCUTANEOUS TRACHEOTOMY • Potential Advantages • Technical Ease - Less Invasive • Shorter Procedure Time - Multiple Specialists • Less Cost - Bedside • Complications : Percutaneous versus Surgical • Conflicting Reports in Literature

  41. MATERIALS AND METHODS • Percutaneous Tracheotomy • Pre-Operative Bedside Neck Sonogram • Local Injection / Shoulder Roll • Direct Laryngoscopy - Withdrawal of ETT to Sub-Glottis • 2-3 cm Midline Vertical Incision • Midline Needle Puncture of Trachea • Passage of Guide Wire • Dilation and Placement of Tracheotomy Tube • 6.0 DCT (Female) and 8.0 DCT (Male) Shiley

  42. MATERIALS AND METHODS Thyroid Notch Cricoid Cartilage Crico- Sternal Distance Sternal Notch

  43. MATERIALS AND METHODS Needle Placement Guide Wire Placement Tracheotomy Tube Placement Serial Dilation