Чужди тела в бронхите

Основен курс Образна Диагностика

МУ-Варна

Д-р Радослав Георгиев

Епидемиология

•1500-3000сл с възможна причина за смърт в САЩ

•80% педиатрични случаи

•При възрастни- 80% заболявания на хранопровода

•При педиатричните само 10% имат патология на хранопровода

•м/ж при децата=2/1

•При 1%- се налага операция

Ефекти

• Пълна обструкция на ГДП=смърт!• Частична на ГДП:• -хрипове• -гръдна болка• -при мукозна травма- кървене• Обструкция на ДДП:• -ателектаза• -пневмония• -редуцирано дишане

Най-чести тела, обект на аспирация при децата

• Hot dog(най-честа фатална аспирация)

• Фъстъци(най-честа причина за ДДП ателектаза)

• Монети

• Кости

• Балони

• Играчки

• Камъчета

• бутони

Foreign Body Aspiration

• Vegetable matter in 70-80%

– Peanuts & other nuts (35%)

– Carrot pieces, beans, sunflower & watermelon seeds

• Metallic objects

• Plastic objects

• Organic f.b are more liable to evoke larangospasm, tracheobronchitis and lung infection. Hence, when patient presents, often has fever.

• vegitable FB are slippery,hard to grip and friable. They usually get swollen, struk at subglottis, may lead to complete obstruction.

Foreign Body Ingestions :

Most Common Types

ƒ Meat : most common in adults

ƒ Chicken bones : most common cause

of perforation

ƒ Sewing needles

ƒ Safety pins

ƒ Pills

–Doxycycline & AZT can cause esophageal

ulcers if impacted

ƒ Other objects listed on slide # 4

PATHOPHISIOLOGY

• Bronchi – 80-90%– Right mainstem most common

• Carina

• Less divergent angle

• Greater diameter

• Trachea

• Larynx• Larger objects, irregular edges

• Conforming objects

• Relevant Anatomy

• Airway foreign bodies can become lodged in the larynx, trachea, and bronchus. The size and shape of the object determine the site of obstruction.

• large, round, or expandable objects produce complete obstruction, and irregularly shaped objects allow air passage around the object, resulting in partial obstruction.

TYPES OF OBSTRUCTION.

• 1. check valve: air can be inhaled but not exhaled.[emphysema]. 2. ball valve: air can be exhaled but not inhaled.[broncho pul segment collapse].

• 3. bypass valve: FB partially obstructs both in insp. and exp. 4. stop valve: total obstruction, airway collapse and consolidation.

• Presentation

• In general, aspiration of foreign bodies produces the following 3 phases:

• Initial phase - Choking and gasping, coughing, or airway obstruction at the time of aspiration

• Asymptomatic phase - Subsequent lodging of the object with relaxation of reflexes that often results in a reduction or cessation of symptoms, lasting hours to weeks

• Complications phase - Foreign body producing erosion or obstruction leading to pneumonia, atelectasis, or abscess

X-RAY FINDINGS

• Obstructive emphysema

• Normal x-ray

• Pneumonitis

• Collapse with mediastinal shift

• Foreign body. If still a diagnostic delima,CT scan is advised.

Foreign Body Aspiration

Foreign Body Aspiration

Symptoms of Foreign Body Aspiration into the Tracheobronchial Tree

Respiratory arrest

Stridor

No symptons (up to 40 %)

Classic triad (in 40 %)

wheezing

coughing

dyspnea

Types of Bronchial Obstruction

Bypass valve obstruction

–air passes in and out

–no radiographic changes

–may cause no symptoms

Check valve obstruction

–exhalation around object prevented

–obstructive emphysema results

Stop valve obstruction

–both inspiration and expiration blocked

–distal atelectosis results

–pneumonitis may occur

Check valve obstruction

Stop valve obstruction

Chest X-ray for Aspirated Foreign Bodies

ƒ Foreign object radiopaque in 6 to 20 %

ƒ CXR normal in 18 to 33 %

ƒ CXR findings:

–obstructive emphysema

–atelectasis

–pneumonia

ƒ Expiratory film enhances CXR yield

Inspiratory film on left, expiratory film on right ; Foreign body in left mainstem

bronchus

Inspiratory film on left, expiratory film on right ; Stop valve obstruction in left

mainstem bronchus

Left X-ray shows air trapping ; right X-ray (different patient) shows atelectasis

Inspiratory film on left ; expiratory film on right ; foreign body in right

bronchus

Other Studies to Consider to Demonstrate Aspirated Foreign Bodies

ƒ Fluoroscopy : may enhance yield to 76 %

ƒ Xerotomography

ƒ Computed tomography

ƒ Contrast bronchography : usually not

useful

Management After Diagnosis of Aspirated Foreign Body

ƒ Bronchoscopy : 99 % success rate

–rigid : often preferred in kids

–flexible

ƒventilation more difficult

ƒcan extract more distal objects

ƒ Patient should be observed 12 to 24 hours

post procedure (till CXR normal)

Differential Diagnosis of Partial Airway Obstruction in Children

ƒ Foreign bodies

ƒ Iatrogenic

–laryngeal nerve paralysis

–tracheal ulceration or

granuloma

–vocal cord granuloma

ƒ Infections

–croup/epigloititis

–diphtheria

–retropharyngeal or

peritonsillar absess

ƒ Neoplasms

–hemangiomas

–angiofibromas

–teratomas

–lymphangiomas

–recurrent respiratory

papillomatosis

ƒ Other

–Lingual thyroid

–Congenital craniofacial

anomalies

–allergic edema

Fatal aspiration of an old Christmas bow buttonФатален случай на аспирация с коедна украса-пластмасов бутон за връх

Fatal laryngeal obstruction from a coin

Фатален слуачй на аспирация на монета и ларингеална обструкция

1. Emergency Treatment for Aspirated Foreign Bodies

ƒ -Heimlich maneuver

ƒ -Back blows

ƒ -Chest thrusts

–note : none of these should be applied if

patient is able to speak or cough

ƒ -Finger sweep / grasp

–should be done only if object is visible and will

not be wedged deeper

Chest thrusts for

pregnant victims

Foreign Body Aspiration

• General anesthesia

• Spontaneous ventilation

• Laryngoscopes

• Bronchoscopes

• Suction

• Forceps

• Rod-lens telescopes

Благодаря за вниманието !