MANAGEMENT OF

LARYNGO-TRACHEOBRONCHIAL FOREIGN
BODIES
SRI HERAWATI
DEPT. OTORHINOLARYNGOLOGY HEAD & NECK
SURGERY
SCHOOL OF MEDICINE AIRLANGGA UNIVERSITY
DR. SOETOMO HOSPITAL - SURABAYA

INTRODUCTION

Diagnosis and treatment of FB in the

laryngo-trachea-bronchus (LTB) are
continue to be a challenge

A high index of suspicion is needed

to allow for : prompt treatment
avoidance of complications

Baharloo,2000; Murray,2002

LARYNGO-TRACHEO-BRONCHIAL FOREIGN BODIES

AT DR. SOETOMO HOSPITAL SURABAYA
IN 2000 - 2010
.
.

ORGANIC
NON ORGANIC
------------------------------------------------------------------------------------------------No. %
No.
%
------------------------------------------------------------------------------------------------Peanut 82
42.27 Scarf pin
50
25.77
Fruit seed
14
7.22 Plastic whistle 12
6.18
Chicken bone
4
2.06 Ballpoint cap
5
2.57
Fish bone
4
2.06 Nail
4
2,07
Porridge
3
1.55 Molar / denture 3
1.55
Bean
2
1.02 Screw
2
1.02
Biscuit
1
0.52 Safety pin
2
1.02
Injection needle
1
0.52
Lamp bulb
1
0.52
Flower seed 1
0.52
Ballpoint
spring
1
0.52
Metal pin
1
0.52
Shell 1
0.52
------------------------------------------------------------------------------------------------Total
110
56.70 84
43.30
------------------------------------------------------------------------------------------------3

AGE DISTRIBUTION
OF PATIENTS WITH LTB FOREIGN BODIES
AT DR. SOETOMO HOSPITAL SURABAYA
IN 2000 - 2010

DURATION
BETWEEN ASPIRATION - DR. SOETOMO
-------------------------------------------------------------------------HOSPITAL
%
IN 2000Duration
- 2010Px
-------------------------------------------------------------------------------0 6 hrs 66
34,01
> 6 12 hrs
38
19,59
> 12 18 hrs
19
9,79
> 18 24 hrs
12
6,19
> 1 2 days
23
11,86
> 2 3 days
16
8,25
> 3 4 days
6
3,09
> 4 5 days
1
0,52
> 5 6 days
6
3,09
> 6 - 7 days 2
1,03
> 7-14 days 2

2,06

3 months 1
1,52
--------------------------------------------------------------------------

CLINICAL MANIFESTATION

FB can lodge into 3 anatomic sites :

larynx
trachea
bronchus

80-90% : bronchus
adults tend to be lodge in the main br. D
children : equal
Murray,2002; Munter,2005
6

clinical manifestation

Clinical presentation depends on :

Site, size and shape of FB

- large, sharp or have irregular borders FB

tend
to lodge in the larynx or trachea
complete airway obstruction
due to : . dimentions of the FB
. resulting edema
- large, round or expandable FB
complete obstruction
- irregularly shaped FB partial obstruction
Murray,2002; Toliver,2004
7

clinical manifestation

Complete obstruction

At : laryngeal inlet, trachea & carina

Causes acute onset of respiratory distress
the patient is unable to speak, cough or cry
clutch their neck reflexively
(place their thumbs & index fingers around
their neck)
Seldom observed in a hospital setting
If they do : become partially obstructive
need urgent care
Toliver,2004
8

clinical manifestation

Incomplete obstruction

Upper airway is partially occluded

or if obstruction occurs distal to the carina
Sudden onset of coughing, gagging, difficulty in
breathing, wheezing, or stridor
Attempts done by emergency personnel to aid :
- unnecessary
- potentially catastrophic
finger swipe & back blows :
may transform a partial into
a complete obstruction
Toliver,2004
9

clinical manifestation

Three Stages in LTB Foreign Bodies

1. Acute stage / initial symptoms :
- choking, gasping, coughing
- occasionally : airway obstruction

2. Asymptomatic / silent stage :

- relaxation of the reflexes
reduction / cessation of symptoms
lasting hours - days - weeks - months

3. Complications stage :
- erosion
- obstruction leading to pneumonia, atelectasis, abscess
10

Murray, 2002

clinical manifestation

In children :

Choking or coughing : 95 %
Stridor : a partial upper airway or tracheal occl.
- upper airway or upper tracheal FB
- inspiratory stridor or
- expiratory wheezing
- medium-to-coarse rhonchi
Tachypnea, nasal flaring
Intercostal, subcostal & suprasternal retraction
Differences in percussion between
hemithoraces
11
Munter,2005

clinical manifestation

LARYNGEAL FOREIGN BODY

Paroxismal cough
Choking
Gagging
Hoarseness
Aphonia
Inspiratoir stridor
Retraction of respiratory muscles
Cyanosis

Murray, 2002

12

clinical manifestation

TRACHEAL FOREIGN BODY

Choking, stridor inspiratoir, cough

Retraction of respiratory muscles
Cyanosis
3 classic sound :
- audible slap
- palpatory thud coughing or deep
inspiration
- asthmatoid wheezing on expiration
Murray, 2002
13

clinical manifestation

BRONCHIAL FOREIGN BODY

Cough
Unilateral wheezing
Decreased breath sound
Hemoptysis
Chest pain

Murray,2002; Munter,2005
14

IMAGING STUDIES

Radiography :
- PA & lateral soft tissue of the neck
- PA expiratory & inspiratory chest
- lateral chest
- lateral decubitus chest

CT Scan

MRI
Toliver,2004; Munter,2005
15

imaging

Limitations of techniques
- radiopaque FB easy to diagnose
- radiolucent FB :
secondary radiographic signs, such
as
obstructive emphysema
atelectasis
pneumonia
mediastinal shift
can help in diagnosing
16
Toliver,2004

MANAGEMENT OF LTB
FB
Pre hospital care
Emergency department care

17

Prehospital care:
If the patient is able to cough, cry or speak
or there is wheezing , stridor
there is still an airway
do not attempt to intervene
transport to the nearest facility where
definitive treatment can be provided
Rovin,2000; Munter,2005

18

management

- if severe airway compromise or

total obstruction occurs,
attemp chest thrust
back blows
Heimlich
depends on the age of the patient.
Munter,2005
19

Children :
< 1 year old :
- back blow (5)
- chest thrust (5)
in a head-down position
Repeat untill obstruction is relieved or
become unconscious.
> 1 year of old : Heimlich maneuver
Rovin,2000

20

Conscious patient

Heimlich maneuver
Repeat until :
1. FB is expelled
2. patient becomes unconscious

21

Unconscious patient :

Heimlich maneuver :
- 6-10 per cycle (adult)
5 per cycle (child)
Check for FB :
- adult : finger sweeping
- child :
do not perform a blind finger sweeping
remove FB only if visualized
CPR
22

Heimlich Maneuver

23

Heimlich

Quick upward thrust

24

Heimlich

25

Heimlich ..

26

Heimlich

27

Heimlich

28

Finger Sweep

Only on unconscious victim

Step 1 :
- open the victims mouth
- grasp the tongue & lower jaw between
the thumb & finger, lifting the jaw.
Step 2 :
- insert the index finger of the other hand
down along the inside of the cheek, deeply
into
the throat to the base of the tongue.
Step 3 :
- use the hooking action to dislogde the FB and
maneuver it into the mouth and removed. 29

finger sweep

30

finger sweep

31

finger sweep

32

Chest Thrusts

For victims :
- late stage of pregnancy
- obese
- abdominal wound
- Heimlich maneuver cannot be applied

Performed sternal compression

intrathoracic pressure increased
33

chest thrust ..

Administering to a conscious patient who is

stand
34

chest thrust ..

Hand placement for chest thrust

35

chest thrust ..

Sternum depressed 1.5 to 2 inches

36

chest thrust ..

37

Back blow

Blow between the persons

shoulder blades with the heel of
hand

38

Emergency department
care
- initial :
supportive therapy :
oxygen / cardiac monitor / intravenous line
- in stridorous patients :
nebulizer + epinephrine
temporarizing
- in unstable patients :
laryngoscope + Magill forceps
intubation + suction + Magill forcep
- extraction FB by bronchoscopy
Munter,2005
39

Management in Laryngeal
Obstruction

Heimlich maneuver
Cricothyrotomy
Tracheotomy
Removal of FB

40

Tracheal & Bronchial

Foreign Body

Remove the FB by bronchoscopy :

- full preparation
- under general anaesthesia
Emergency removal not indicated
unless : - airway obstruction +
- vegetable and likely to swell
up
41

management

Perform endoscopic evaluation on

patients who have :
- witnessed FB aspiration
- reliable history of aspiration
- radiographic FB +
- previously described classic signs &
symptoms of FB aspiration

Rovin,2000; Murray,2002; Tolliver,2004

42

management

- a strong history of suspected FB aspiration

even if the clinical findings are not as
conclusive or are not present.
- FB is negative in radiographic studies, but
the clinical suspicion still remains high.
Murray,2002
43

Key Factors in Successful

Management

Endoscopist team
Anesthesist team
Nurses and technician
Appropiate equipment

44

If 2 hours are spent in preparation, the

safe endoscopy procedure may take 2
minutes. But if only 2 minutes are taken
for preparation, the endoscopist may find
himself attempting make-shift ineffective
procedure for the next 2 hours.
Hollinger
45

Methods to Remove
Tracheobronchial FB

Rigid bronchoscopy with telescopic aid

Bronchoscopy with C-arm fluoroscopy
Tracheostomy and bronchoscopy via
stoma
Flexible bronchoscopy
Rigid and flexible bronchoscopy
Thoracotomy and bronchoscopy for
peripheral FB
46

Rigid or flexible
bronchoscopy ?
Depends on :
FBs location and type
Endoscopists experience
Availability of appropriate
instrument

47

Rigid Bronchoscopy
provide ventilation better airway
control
internal diameter > instrument >
- use rigid telescope better visibility
- wide variety of sizes and types of
retrieval forceps
object can be sheathed within the
bronchoscope partially or completely
perform with general anesthesia
48

Fiberoptic Bronchoscopy
Trained in rigid and flexible technique
The patients older than 10 years old
The FB is unimpacted
small
non obstructive
radiopaque
not sharp
distally
lodged
Initial diagnosis
The FOB and the other instruments
appropriate to the FB is available

49

Pearls of FBA

All that wheezes is not asthma

Practice with duplicate FB
Be ready and equipped
Dont make a closed case to be open
Dont turn a non-obstructing FB
obstructing
one
Dont miss the second FB

50

pearls

Dont exclude FBA in :

- the absence of any physical findings
- the presence of normal bilateral breath
sounds
- the normal findings on chest radiograph
Its OK if you cannot remove the FB
If can do no good, at least do no harm
51

C-arm Siemens Type Siere Mobile

2000

52

53

54

55

MARINA BAY SINGAPORE 2010

56

57

58

59

60

61

MONTE CARLO, 2010

62

63

64

65

Pitfalls in Endoscopic
Removal of FBA

Attempting to remove / manipulate a

FB located far beyond the tube-mouth
Swabbing to remove secretions, or to
apply local anesthetics, before study
of the presentation
Traction on the presenting part
without absolute certainty on the
safety of such traction
Too strong traction
66

pitfalls

Incautious approach to, and contact with

a FB before studying the presenting part.
Overriding a FB
Misuse of forceps, such as inclusion of
tissue in the grasp.
Making a preliminary examination for the
sole purpose of taking a look without
preparation for removal of the FB.
67

DR. SOETOMO HOSPITAL SURABAYA

2000 - 2006

Rigid bronchoscopy : 142 patients

- FB - :
8 patients
- FB + : 134 patients
131 succeeded : repeated rigid br. 3 px
2 failed flexible br.
1 condition worse, leading to
incomplete
removal
Flexible bronchoscopy : 2 patients
- after failed with rigid bronchoscopy
- succeeded

68

management

HISTORY OF THE REMOVAL OF FB

Until the late 1880s : bronchotomy

1897 : First endoscopic removal
Early 1900s : C. Jackson
- revolutionized the principles & techniques
- still followed today
1970s :
- the development of the rod-lens telescope
- improvement in anesthetic techniques
safer

Murray, 2002
69

imaging

Radiographic Findings of FB :
Normal findings
Radiopaque FB
Air trapping
Mediastinal shift
Atelectasis
Emphysema
Pneumonia
Lobar collapse
Rovin,2000; Munter,2005
70

ASAL PASIEN

Surabaya
: 49 pasien ( 22.37 %)
Luar Surabaya : 170 pasien ( 77,63 %)

71

21-08-2010
Pk 20.00 WITA

Px, 3 y.o
tersedak
peluit saat
loncat-2

Batuk
bertubi2

30 menit

Pulang kerumah
Batuk sampai biru
Di bawa ke RS Sari
Mulya

Tenang

15 menit

Terdengar
nafas
berbunyi
peluit

1 jam

RS
Kasongan
Alat (-)
6-7 jam

RS Sari Mulya
Dx : BA Bronkus
Kanan
Dirujuk ke RS DS

Berangkat
ke Surabaya
Pk 16.10 WITA

RS Ulin
Foto
torak

1 jam

5 menit

RS Sari Mulya
Alat radiologi
(-)

Surabaya

IRD
RSDS

Pk 16.10 WIB

Pk 19.00 WIB

Pk 11.00 WITA
72

21-08-2010
Pk 20.00 WITA

Px, 3 y.o
aspirated
whistle
when
jumping

Coughin
g

30 min

asimpt
omatic

Whistle-like
breath sound

1 hr

Alat (-)

15 min

6-7 hr

Sari Mulya Hospital

Dx : FB Bronchus
dextra
Dirujuk ke RS DS

Pulang kerumah
Batuk sampai biru
Di bawa ke RS Sari
Mulya

Kasongan
Hospital

Berangkat
ke Surabaya
Pk 16.10 WITA

RS Ulin
Thorax
photo

1 hr

5 min

RS Sari Mulya
Alat radiologi
(-)

Surabaya

IRD
RSDS

Pk 16.10 WIB

Pk 19.00 WIB

Pk 11.00 WITA
73

chest thrust ..

74

Back blow

75

Back blow ..

76