Late Clinical Features a. Laryngeal: partial or total airway obstruction, hoarseness, aphonia, hemoptysis b. Tracheal: airway obstruction, hemoptysis, wheezing, palpatory thud, auscultatory slap c. Bronchial: cough, ipsilateral wheezing, ipsilateral decreased breath sounds
Check valve effect No ExpirationNo Inspiration Emphysema Early Atelectasis
Clinical Diagnosis Conscious pt: 1. Hoarseness / aphonia 2. Respiratory distress Unconscious pt: 1. No chest movement 2. No air exchange at nose / mouth. 3. Cyanosis.
Radio-opaque F.B. larynx
Radio-opaque F.B. Bronchus
Radio-lucent F.B. Right Lung collapse & Left emphysema
Management of choking in an unconscious patient 1. Patient placed in supine position 2. Open airway + mouth to mouth ventilation 3. Correct airway obstruction
Opening the airway 1.Head-tilt: Extension of neck by backward pressure on forehead
Opening the airway 2. Head-tilt, chin-lift: Extension of neck by backward pressure on forehead + lift pts chin keeping mouth open.
Opening the airway 3. Head-tilt, neck-lift: Lift pts neck while pushing down on forehead. Prevents falling back of tongue.
Opening the airway 4. Modified jaw-thrust: For pt with neck / spinal injuries. Push patients jaw forward by applying pressure at angle of mandible. Avoid head tilt.
Correcting airway obstruction Back blows Abdominal thrusts Chest thrusts (for pregnancy, age < 8 yrs) All 3 raise subglottic pressure, to dislodge out FB Open pts mouth Blind finger sweeps in mouth
Back blows Place pt in lateral position, supporting pts chest against your knees. Use free hand to deliver five rapid blows to spinal Area b/w scapulae, to dislodge F.B.
Abdominal thrusts Straddle supine pt at his hip. Place your hand heel b/w pts umbilicus & ribcage, in midline. Hold that hand with your other hand & apply 5 rapid, inward + upward thrusts, to dislodge FB.
Chest thrusts Kneel beside supine pt at chest level. Place hand heel on centre of pts sternum. Lock hands. Apply 5 rapid downward thrusts. Only 2 fingers used for a small child.
Opening patients mouth Tongue-jaw lift technique: Hold pts tongue + lower jaw b/w your thumb & fingers. Lift pts tongue to move it away from pharyngeal wall.
Opening patients mouth Crossed-finger technique: Cross your thumb under your index finger. Place your thumb against pts lower lip & index finger against his upper teeth. Uncross your fingers to open pts mouth.
Blind finger sweeps Open pts mouth. Insert index finger of free hand into pts mouth, along pts cheek, till tongue base. Use it as a hook to roll out FB. Avoid pushing FB further back. Avoid blind sweeps in a child. Attempt to remove visible FB only.
Correcting airway obstruction in an unconscious pt 5 Back blows failure failure 5 Abdominal thrusts Or 5 Chest thrusts 5 Abdominal thrusts Or 5 Chest thrusts failure failure Open pts mouth + blind finger sweeps. Continue this sequence till FB is removed or pt is ready to be shifted to operation theatre.
Management of choking in a conscious pt If patient can speak, cough, or breathe: Do not interfere. Patient to be examined by an ENT specialist as soon as possible. If the patient cannot speak, cough, or breathe: Begin treatment for obstructed airway.
Correcting airway obstruction in a conscious pt > 1 yr old 5 Back blows failure 5 Abdominal thrusts (Heimlich maneuver) Or 5 Chest thrusts (for pregnancy, age < 8 yrs) Continue this sequence till FB is removed or pt becomes unconscious.
Back blows Place pt in sitting / standing position. Support pts chest while bending pt at the waist. Use your free hand to deliver 5 rapid blows to spinal area b/w two scapulae.
Stand behind sitting / standing pt & pass your arms around pts waist. Hold your fist against pts abdomen b/w umbilicus & ribcage. Lock hands & apply 5 rapid, inward + upward thrusts to dislodge FB.
Chest thrusts Stand behind standing pt & pass your arms around pts chest. Hold your fist against pts sternum in its centre. Lock hands & apply 5 rapid, back- ward thrusts to dislodge FB.
Correcting airway obstruction in an infant 5 Back blows failure 5 Chest thrusts Continue this sequence till FB is removed or pt is ready to be shifted to operation theatre.
Back blows in an infant Straddle infant face down, head lower than trunk, over your forearm, supported on your thigh. Deliver five rapid back blows, with heel of other hand b/w shoulder blades.
Chest thrusts in an infant Supporting pts head, keep infant supine b/w your hands, with head lower than trunk. Using 2 fingers, deliver 5 rapid backward thrusts on sternum.
Surgical Management For life threatening stridor Cricothyrotomy Emergency Tracheostomy For foreign body removal Direct Laryngoscopy Rigid Bronchoscopy Thoracotomy & Bronchotomy
Prevention of choking Adults: Cut food into small pieces Chew food slowly & thoroughly Avoid laughing / talking during eating Avoid excess alcohol with / before meals Infants & Children: Keep small objects away from children Avoid playing with food or toys in mouth
Swallowed Foreign Body
Diagnosis Plain X-ray (PA & Lateral): soft tissue neck, chest, abdomen for radio-opaque FB Fluoroscopy with Barium soaked cotton pledget for radiolucent FB Barium Swallow Flexible Oesophagoscopy
Coin in cricopharynx
Meat bolus in Cricopharynx
Toe ring in cricopharynx
Open safety pin
Tooth brush in stomach
Pharyngeal FB Common sites: tonsil, pyriform fossa, vallecula, base tongue Diagnosis confirmed by indirect laryngoscopy Usually removed in OPD but may require removal by Hypo-pharyngoscopy GA
Oesophageal & Gastric FB Common sites: cricopharynx, aortic indentation & cardiac end Usually removed by rigid oesophagoscopy GA Advancement into stomach is safe in difficult FB Oesophagotomy rarely required for impacted FB FB reaching stomach, usually passes out in stool Emetic & Cathartic agents are contraindicated
Indications for Immediate Intervention Associated respiratory obstruction Total oesophageal obstruction Disc battery (perforation occurs in 8-12 hrs) Sharp, impacted foreign body Gastro-intestinal FB > 5 cm in a child < 2 yr Gastro-intestinal FB with acute abdominal pain No progress of FB in serial X-ray after 24 hr Gastric FB with pyloric stenosis
Disc battery in stomach
Complications of neglected FB 1.Oesophageal ulceration & stricture 2.Oesophageal perforation mediastinitis 3.Peri-oesophageal cellulitis 4.Retro-pharyngeal abscess 5.Respiratory obstruction due to tracheal compression tracheal compression laryngeal oedema laryngeal oedema