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1 : fiazfazili et al
2 : fiazfazili et al FOREIGN BODIES OF AIRWAYS IN CHILDREN- A PREVENTABLE SURGICAL EMERGENCY DR Fiaz M Fazili & Dr Abdullah R.Allam Dept Of CardioThoracic, King Fahad Hospital Medina
3 : fiazfazili et al FOREIGN BODIES OF AIRWAYS IN CHILDREN Dept Of Cardio-Thoracic, King Fahad Hospital Medina
4 : fiazfazili et al FOREIGN BODIES OF THE AIRWAY –A preventable Emergency in Children DR FIAZ M Fazili Consultant Cardio Thoracic Surgery, SIMS KASHMIR UNIVERISY.
5 : fiazfazili et al Magnitude of Problem The diagnosis and treatment for foreign bodies in the airway are challenging for all-Thoracic, Otolaryngologists, Paedia surgeons,Anesthetists especially when it involves children. Despite improvements in medical care and public awareness,approximately 3000Deaths occur each year from body aspiration, with most deaths occurring before hospital evaluation and treatment. A high index of suspicion is needed for foreign body aspiration to allow for prompt treatment and avoidance of complications.
6 : fiazfazili et al F-BODY Airways Foreign body aspiration;common problem in children, most common cause of accidental death in the home in children under six years of age Almost 600 children under 15 years of age die per year in the USA following aspiration of foreign bodies. In fact, choking on food has been the cause of between 2500 to 3900 deaths per year in the USA, when taking both children and adults into consideration.4 The most common foreign body inhaled by Saudi children in the Eastern region has been reported to be watermelon seeds, and in Western countries, it is said to be peanuts. In Saudi Arabia, as in many other countries, there are no available statistics regarding the contribution of foreign body aspiration as a cause of death. This is probably due to the fact that many patients succumb well before reaching the hospital(KFSH-rprt)
7 : fiazfazili et al HISTORY OF PROCEDURE UNTIL LATE 1800S, AIRWAY FOREIGN BODY REMOVAL WAS PERFORMED BY BRONCHOTOMY.Frequent Deaths before<20 Century 1897-First endocsopic removal of FB occurred Early 1900-Chevalier Jackson revolutionized endocsopic FB removal,(distal illumination) Principles and Practices still followed. 1970s Rod lens telescope by Karl storz and improvement in anesthesia technique made FB removal safer
8 : fiazfazili et al FB ASPIRATIONS-Nature Most airway FB aspiration occur in children-age 1-3 yrs are most susceptible. Vegetable matter(70-80%) tends to be most common found airway FB- PEANUTS and other nuts(35%) are the most common food item aspirated.KSA melon seeds.(KFH experience) Incidence of metallic FB like coins,pins aspirations especially safety(folding) pins has decreased secondary to advent of diapers. Others-plastic ,balloons
9 : fiazfazili et al ETIOLOGY Young children comprise the most common age group of FB aspiration because of; The lack molars for proper grinding of food They tend to be running or playing at the time of aspiration They tend to put objects in their mouth more frequently They lack coordination of swallowing and glottic closure
10 : fiazfazili et al Foreign Body Aspiration History Choking Gagging Wheezing Hoarseness Dysphonia Can mimic asthma, croup, pneumonia “A positive history must never be ignored, while a negative history may be misleading”
11 : fiazfazili et al PATHOPHYSIOLOGY After FB aspiration,FB can settle into3 anatomic sites, the larynx,trachea,or bronchus. Of aspirated FB 80-90% become lodged in the bronchi Comparison in adults bronchial FB tend to be lodged in R main bronchi because of its lesser angle of convergence compared to L bronchus and because of location of the carina left of midline. Children-reports have demonstrated equal frequency of R nd L bronchial . Large objects tend to become lodged in the larynx or trachea.
12 : fiazfazili et al RELEVANT ANATOMY &MECHANICS Airway FB can become lodged in larynx, trachea,or bronchus Size and shape of the object determine site of obstruction; Large, round or expandable objects produce complete obstruction Irregularly shaped objects allow air passage around object resulting in partial obstruction
13 : fiazfazili et al F Body Aspiration Bronchi – 80-90% Right main stem is most common Carina Less divergent angle Greater diameter Trachea Larynx Larger objects, irregular edges Conforming objects
14 : fiazfazili et al FB Aspiration-cause & effect Depends on location, dimensions of FB . FB in larynx or Trachea can produce Complete airway obstruction Respiratory distress Inability to speak or cough Partial airway obstruction Coughing Gagging Throat clearing Back blows/probing hypopharynx not recommended
15 : fiazfazili et al FB Aspiration-phases in presentation Initial phase-Choking episode with coughing, gagging or wheezing,or airway obstruction at the time of aspiration Asymptomatic interval(lasting Hrs –weeks) Irritation subsides,reflexes relax,cessation of symptoms Delay in diagnosis- 20-50% not detected for one week- Complications;(Erosion /Obstruction) Cough/or Hemoptysis Pneumonia Lung abscess Fever
16 : fiazfazili et al FB-CLINICAL PRESENTATION Large FB in the larynx or trachea can produce complete airway obstructi.n from either the dimensions of object or the resulting edema. Laryngeal FB ; Airway obstruction Hoarseness or aphonia.Stridor Tracheal FB; similar to laryngeal FB but without Hoarseness or Aphonia. Tracheal FB can demonstrate wheezing similar to Asthma. Bronchial FB-typically present with Cough, Unilateral wheezing, and Decreased breath sounds ipsilaterally, but only 65% present with classic diagnostic triad FB aspiration can mimic/or misdiagnose as other respiratory problems such as asthma.
17 : fiazfazili et al PHYSICAL EXAM; Chest auscultation is very important in evaluation in whom FB is suspected. Classically, these pts have wheezing and/or decreased breath sounds on the side of the FB. Pts may have a normal exam findings despite having a FB within airway because it may partially obstruct airways.
18 : fiazfazili et al Foreign Body Aspiration-GOAL High degree of suspicion,recognition Prompt removal under conditions of maximal safety and minimal trauma
19 : fiazfazili et al INDICATIONS OF BRONCHOSCOPY History/witness of FB aspiration is enough Radiographic evidence Of FB Classic signs/symptoms of FB aspiration History and physical exam is important for intervention A strong history of suspected FB aspiration prompts an endocsopic evaluation, even if clinical findings are inconclusive or are not present
20 : fiazfazili et al CONTRAINDICATIONS IN children NO contraindications exist to remove an airway FB. If necessary some medical problems can be optimized before intervention. Even children at high risk need intervention for removal of airway FB
21 : fiazfazili et al WORKUP-Radiography AP and lateral(highKV) X-ray of airways are test of choice for laryngeal FB suspected.High kV produces greater definition of airway while reducing the effect of the surrounding bony structures. PA and lateral CXR are an adjunct to History and physical exam.At least have them as a base line for future comparison 25% have normal radiography
22 : fiazfazili et al Radiological Presentation Radio opaque objects are visible, but radio lucent objects (e.g.; plastic) are not. Chest X-rays may reveal obstructive emphysema or hyperinflation,atelactasis, consolidation Lateral decubitus chest films may be helpful in children whom the depending lung remains inflated with bronchial obstruction. Typically, the dependant lung collapses.
23 : fiazfazili et al Radiology -contd CXR (inspiratory and expiratory films) demonstrate atelactasis on inspiration and hyperinflation on expiration with a FB obstructing the bronchus. Biplane fluoroscopy uses intraoperative fluoroscopic evaluation while identifying and locating a FB within the lung periphery
24 : fiazfazili et al FB Aspiration-spring in R br
25 : fiazfazili et al Foreign Body Aspiration
26 : fiazfazili et al Foreign Body Aspiration
27 : fiazfazili et al TREATMENT-MEDICAL THERAPY Pts with complete obstruction require immediate attention,typically they are aphonic and unable to breathe. Pts who are coughing, gagging and vocalizing have partial obstruction
28 : fiazfazili et al Fn Body Aspiration-Initial step Complete airway obstruction < one year Back blows > one year Gentle abdominal thrusts while supine Older children/adults Heimlich maneuver TAUGHT IN CPR COURSE in KFH medina
29 : fiazfazili et al You r Taught in CPR course
30 : fiazfazili et al Course in Hospital Heimlich maneuver has improved the mortality rate of pts with complete airway obstruction BUT use of it in pts with partial obstruction(refer CPR course) Most pts who arrive at the hospital are beyond the acute stage and are not in respiratory distress. After a complete History and physical exam are completed and radiographic studies are performed a decision is made regarding the need for intervention In most cases antibiotics and steroids are not administered initially.
31 : fiazfazili et al PRE REQUISITS-INTERVENTION Well equipped OR with proper bronchoscopic equipment of various sizes and means of temperature regulation,especially for children Personnel(OR/Anesthesia/Recovery/ward ) familiar with the use of Instruments, Procedure , and Paedia care. Anesthesiologists experienced in pediatric cases and FB removal are critical for safe removal of airway FB
32 : fiazfazili et al FB aspiration-equipment General anesthesia Spontaneous ventilation Laryngoscopes Bronchoscopes Suction Forceps Rod-lens telescopes
33 : fiazfazili et al PREOP-CHECK LIST Select and organize age appropriate equipment before pt enters OR. Various FB forceps should be available Prior to intervention pt should be NPO to prevent aspiration exception acute respiratory distress cases Communication between anesthetist and Surgeon Preop chk list-consent ,prep, identification etc.
34 : fiazfazili et al INTRAOPERATIVE DETAILS Use of inhalational anesthetics is preferred. Apply lidocaine 1-2% to larynx to reduce reflexes and prevent laryngospasm. Use of SPO2 monitor throughout procedure Pt is oxygenated with 100% oxygen before any attempt at removal
35 : fiazfazili et al Bronchoscopy-Technical points Bronchoscopy Suction opposite bronchus –improve oxygenation Advance to foreign body-Atraumatically grasp foreign body After removal ,reassess airways by Repeat bronchoscopy Suction bronchus Multiple foreign bodies in 5-19% Remove granulation tissue Topical vasoconstrictors for bleeding
36 : fiazfazili et al Technical challenges Sharp objects –as pointed end tends to engage in the mucosa causing the object to tumble with the point trailing.Advance Bronchoscope over FB Pointed objects tend to be bendable or breakable. Safety pin removal is uniquely challenging, removal is performed by technical skills Soft objects-peanuts grasping is difficult, removed by suction Slipped FB-push back into bronchus
37 : fiazfazili et al FB _removal (Failures) Occasionally easy retrieval not possible .Large objects unable to pass through larynx can be broken into pieces before removal. In case object cant pass larynx a tracheotomy can be performed,depends on experience. At times object embedded into surrounding mucosa because of edema caused by object or because of multiple failed attempts to remove.Surgical removal/thoracotomy may be indicated.
38 : fiazfazili et al Foreign Body Aspiration Postoperative Care Chest physiotherapy for retained secretions Antibiotics Not routinely used Steroids Not routinely used Indication-Traumatic insertion or removal CXR performed post op
39 : fiazfazili et al FOLOW UP CARE F up care is necessary if pts signs and symptoms return after discharge
40 : fiazfazili et al COMPLICATIONS Most complications are the result of inexperience, or not taking necessary perioperative precautions. Delay in diagnosis Pts with Laryngotrachael FBs 67% experience associated complications when removal delay is more than 24 hrs. Pneumonia and Atelactasis are the most common –post FB removal.Need antibiotics,chest physiotherapy. Pneumothorax and Pneumomediastinum - airway tear
41 : fiazfazili et al FUTURE AND CONTROVERSIES Literature describes other means of FB removal. Chest physio and bronchodilators have been suggested in the past but currently are not recommended as treatment. Flexible bronchoscopic removal has been advocated in literature describing in literature in adult pts but is not recommended in children because of poor airway control
42 : fiazfazili et al PREVENTIVE MEASURES  For avoiding the accidents with foreign bodies in the airways we recommend: Don't give nuts, unless ground, to children below 5-7 years of age. The toys you buy must not be able to be taken apart and in no case containing small particles (which is the case with some rattles). Children must be taught not to laugh and talk while eating. Mothers have to know that the child must not be fed against his will while crying
43 : fiazfazili et al THANK YOU


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