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Pediatric airway foreign body
- 1. Pediatric aero-digestive tract foreign body Presenter: Dr. Ayesha/Dr. Abhijeet Moderator: Prof. Satya sree/Prof. SP Agarwal AIIMS
- 2. Foreign Bodies • Foreign body ingestion • Foreign body aspiration • Toddlers (M>F) • Curiosity/ distractibility • Exploring natural orifices • Underdeveloped molars swallowing reflex • Cognitive development (edible?) • Narrow airway
- 3. Foreign Body Ingestion • Coins – 75% • Meat • Vegetable matter • Pea • Seed • Toys • Present in <24 hours
- 4. Foreign Body Ingestion • Parental suspicion (witnesses choking) • Playful Crying/irritable • Symptoms • Choking, coughing, dysphagia, odynophagia
- 5. Foreign Body Ingestion • Physical exam • Drooling, refuses p.o., irritable child • Respiratory compromise • Tracheal compression
- 6. Foreign Body Ingestion • Oropharynx • Hypopharynx • Esophageal locations • Cricopharyngeus • Aorta/left mainstem bronchus • Gastroesophageal junction
- 7. Foreign Body Ingestion • Radiopaque • Coins • Cartilage/bones • Radiolucent • Vegetable matters • Barium swallow
- 8. Foreign Body Ingestion • Barium Swallow • Cotton pieces • Teddy bear eye • Outline even radiolucent FB • Cross sectional imaging+/- • Diagnostic dilemma • Sx plan • Medico-legal
- 9. Foreign Body Ingestion • Observation • Recent ingestion • Blunt object • Stool in diapers • Endoscopy • Complete obstruction • Airway compromise • Impacted • Caustics • Anomalies
- 10. Foreign Body Ingestion • Disc batteries • “Sun Shouldn’t set” • NaOH, KOH, Mercury • 1 hour – mucosal damage • 2 to 4 hours – muscular layers • 8 to 12 hours – perforation • Esophagoscopy • Observation for gastric location for 4-7 days • Laparotomy for bowel perforation
- 11. Foreign Body Ingestion • Removal • General anesthesia • Intubation+/- • Esophagoscopy • Examine for ulceration/ perforation • Cervical esophagotomy ?
- 12. Foreign Body Ingestion • Postoperative management • Check scopy • NPO for 4-12 hours • Perforation • Tachycardia • Tachypnea • Fever • Chest pain
- 13. Foreign Body Ingestion • Balloon Catheter Extraction • Controversial effectivity • Endoscopy for failures • Complications • Emesis • Epistaxis • Tracheal placement • Laryngospasm • Airway compromise
- 15. Foreign Body Aspiration • Frequent death prior to 20th century • Gross “bronchotomy in all cases” • Killian – 1897 – 1st bronchoscopic removal • Early 1900s – distal illumination • Chevalier Jackson – revolutionized field of bronchoesophagology • 1970s – rod lens telescopes
- 16. Foreign Body Aspiration • Male> female • Vegetable matter in 70-80% • Peanuts & other nuts (35%) • Hot dogs • Carrot pieces, beans, sunflower & watermelon seeds • Metallic objects • Plastic objects
- 17. Foreign Body Aspiration • Bronchi – 80-90% • Right mainstem most common • Carina • Less divergent angle • Greater diameter • Trachea • Larynx • Larger objects, irregular edges • Conforming objects
- 18. Foreign Body Aspiration • History • Choking (witnessed) • Gagging • Wheezing (U/L>B/L) • Hoarseness • Retractions • Mimic asthma, croup, pneumonia • “A positive history must never be ignored, while a negative history may be misleading”
- 19. Foreign Body Aspiration • Choking episode with coughing, gagging or wheezing • Asymptomatic interval • 20-50% not detected for one week • Long standing • Cough • Hemoptysis • Pneumonia • Lung abscess • Fever
- 20. Foreign Body Aspiration • Physical exam • Larynx/cervical trachea • Inspiratory or biphasic stridor • Intrathoracic trachea • Prolonged expiratory wheeze • Bronchi • Unequal breath sounds • Diagnostic triad - <50% • Unilateral wheeze • Cough • Ipsilaterally diminished breath sounds
- 21. Foreign Body Aspiration • Radiography • PA & lateral views of chest & neck • Inspiration & expiration • Lateral decubitus views • Airway fluoroscopy • 25% have normal radiography
- 27. Foreign Body Aspiration •Goal • Prompt endoscopic removal under conditions of maximal safety and minimal trauma
- 28. Foreign Body Aspiration • Complete airway obstruction • Respiratory distress • Inability to speak or cough • Rush to OT • Partial airway obstruction • Coughing • Gagging • Throat clearing • probing hypopharynx- NO
- 29. Foreign Body Aspiration • Complete airway obstruction • < one year • Back blows/Mofenson maneuver • > one year • Gentle abdominal thrusts while supine • Older children/adults • Heimlich maneuver
- 30. Foreign Body Aspiration • Usually NOT A DIRE EMERGENCY • Trained personnel • Instruments assembled and checked • Await for emptying of stomach • Find duplicate FB to test instruments and techniques
- 31. Foreign Body Aspiration • General anesthesia • Spontaneous ventilation • Laryngoscopes • Bronchoscopes • Suction • Forceps • Rod-lens telescopes
- 32. Foreign Body Aspiration • Ready to assume airway during induction • Laryngoscopy • Examination of upper airway • Atraumatic insertion of bronchoscope • Topical anesthesia • Bronchoscopy • Attached to ventilating circuit
- 33. Foreign Body Aspiration • Bronchoscopy • Suction opposite bronchus • Advance to foreign body • Atraumatically grasp foreign body • Check bronchoscopy • Suction bronchus • Multiple foreign bodies in 5-19% • Remove granulation tissue • Topical vasoconstrictors
- 34. Foreign Body Aspiration • Slipped foreign body • Push back into bronchus • Sharp foreign body • Advance bronchoscope over FB
- 35. Foreign Body Aspiration • Complications • Pneumonia • Antibiotics, physiotherapy • Atelectasis • Expectant management, physiotherapy • Pneumothorax • Pneumomediastinum
- 36. Foreign Body Aspiration • Postoperative Care • Chest physiotherapy for retained secretions • Antibiotics • Steroids • Not routine • Traumatic insertion or removal
- 37. Take Home • FB can be life threatening • Prevention is key • Awarness & high index of suspicion • Parental education NO LOLLIPOP
- 38. THANK YOU!