The Laryngo-tracheo-bronchial foreign bodies suction
The Laryngo-tracheo-bronchial foreign bodies
Presented by Dr Nicodeme Lavaud, du Centre Chirurgical Des Facultes.
The treatment of the laryngo-tracheo-bronchial foreign body suction is a true challenge in surgery. We would like to present the case of a patient who was come in the emergency service for suffocation following the suction of a foreign body. We would like to pose, by this way the problematic of the severity that represent the laryngo-pharyngo-bronchic foreign bodies suction.
We have used a comparative study between the findings of our case and those of the contemporary studies published by internet. As a result: the suction of foreign bodies touches more often the men, sex-ratio 2.5:1. It occures more frequently between 0 to 2 years. The seat is more often the right bronchus. The fibroscopy is used for the extraction of the foreign bodies in most of the cases, if there is failure, the surgery is then practiced.
We should always think about these incidents and prepare ourselves to face those challenges in the hospitals.
Picture 1 : Child in the hospital
By his innocence that does not allow him to distinguish the right from the bad, the child often ingested foreing bodies, and without the help of advised adults, he can suction out them causing an obstruction of his respiratory tract. These cases are very widespread in the hospitals, and the parents often lament because of simple negligences. So would we present the inhalation of the tracheo-laryngo-bronchic foreign bodies. By sucking the foreign body, the poor child does not care about anything. However, the consequences can be severe, putting the whole community, including the surgical personel at bay. We will compare the data about a child that we have found in the emergency service of the hospital Justinien on 2011 with other contemporary data to contribute to a better understanding and treatment of thes cases.
The larynx is located between the pharynx and the trachea. It is constituted of cartilages. One of them has the shape of a ring on which is articulated forward the thyroid cartilage, and backward the arythenoide cartilages, from what leave the vocal cords to arrive to the angle of the thyroid cartilage. The subglottis space is the narrowest portion of the larynx it has a diameter of 2 cm and is located between the inferior face of the vocal cords and the trachea.
Picture 2 : the larynx Picture 3 : the vocal cords
Vascularisation of the larynx
The arteries are 3 in number on each side.
The superior laringeal artery, the median and the inferior laryngeal artery.
The superior and the inferior laryngeal arteries are branches of the superior thyroid artery. One vascularize to the upper floor of the larynx, the other, the lower floor of the larynx.
The posterior laryngeal artery come from the posterior branche of the inferior thyroïde artery.
The nerves come from the laryngeal nerves superior and inferior.
It is a part of the upper respiratory track that follows the larynx. It begins at the level of C5, and extends obliquely downward and backward to end at the Th4 level. The trachea measures 10 to 13 cm length. It consists in 18 to 22 rings of cartilages. His diameter is 2.3 centimeters. The trachea has a cervical portion and a thoracic portion which birfuque into 2 bronchi entering the lungs. They divide the mediastinum into two parts anterior and posterior.
Picture 4 : the respiratory tract
This is a conduct formed by the superposition of incomplete cartilage rings shaped horseshoe surrounded by the tracheal membrane reunited by the annular ligament. The interior of the trachea has a mucosal lining comprising the tracheal glands. Its posterior face is related to the esophagus by the Luschka ligament.
The tracheal bifurcation
It is realized by variable ways either by a particular cartilage Y shaped (cartilaginous carene), either by a large annular ligament (fibrous carene).
Vascularization of the trachea
Il includes the inferior thyroid artery, the subclavian, the internal thoracic, the suprem intercostal, the superior innominate and the median bronchic artery. They enter to the respiratory track near the jonction of the membranous and the cartilaginous portions. Each arterial branch desserts a 1 to 2 cm portions of the trachea. The vessels are interconnected along the lateral surface of the trachea by a major longitudinal anastomosis that sends segmental vessels to the smooth tissue between the cartilages.
The trachea gives two bronchis at D5 level. They are moving to the hilium of the corresponding lung where they give ramifications within the pulmonary parenchyma (bronchial tree). The length of the right bronchus is 2 cm, and 5 cm for the left bronchus.
The arteries of the extra pulmonary bronchus come from the bronchic arteries. The veins flow into the bronchic vein. The lymph nodes drains into the near tracheobronchial lymph nodes.
Picture 5 : The respiratory tract and the lung
At about 7 hours afternoon, a 8 year old little girl had arrived at the emergency service of the Justinien's hospital accompanied by her parents, then allowed for asphyxia and stirring following a suction of a foreign corps, a symptomatology which would evolve from 10 minutes of his admission.
The realized immediately review found a very agitated child with asphyxia with of respiratory struggle signs : indrawing, sweating at the extremities and, early cyanosis was also objectived. 10 minutes later the elderly residents had arrived and decided to enter the operating room with the girl. View the state of emergency, a radiography could not be practiced. Together with the anesthesiology department, an emergency tracheostomy have been practiced. Here what was the tracheostomy.
- the patient is supine with the neck in hyperextention.
- Horizontal skin incision of 3 centimeters at one centimeter below the crycoide cartilage.
- Separation on the center line, in a vertical plane of the prethyroidiens muscles.
- Opening of the trachea on the median line at the second tracheal ring.
- Attempt to insert a tracheal tube.
Unfortunately, she will not see the end of the intervention nor her parents.
According to a survey presented by the pan african medical journal dating the year of 2015, the laryngo-tracheo-bronchic foreign body suction occurs most often at 8.65 years old. The indian journal of otolaryngology and head and neck surgery (April 2002) have found that most of the cases, 64% occured between 0 and 2 years. Our findings are almost the same as those of the Panafrican Journal : the girl was 8 years old.
The sex ratio
According to the Panafrican Journal, the sex ratio is 2.5 men for 1 women. By our side, we have found only one girl, and we do worry, it is possible that the other cases have died before reaching the hospital. The narrowness of our sample does not allow us at all to compare our findings with some large-scale sturdies.
The delay between the aspiration of the foreign body and the consultation was 1 to 48 hours for 55% of the patients (Panafrican journal). According to the indian journal, the time taken between aspiration and removal of the foreign body was 0 to one day in 14 % of the cases. The greater portion of patients came 1 to 7 days after, 28%. Here, in our sturdy the delay was about 15 minutes after the suction, as it was an emergency.
The seat of the foreign body was laryngeal in 50% of the cases and bronchial in 45% of the cases according to the panafrican medical journal. the indian journal found the right bronchus in 56%, the left bronchus in 30%, the lower lobe of the lung in 4% , the sub glottis in 4% and the trachea in 6% of the cases.
Picture 6 : a foreign body in the respiratory tract
The foreign body was foodborne in 57,14% of the cases according to the panafrican. for the indian journal, it was plastic pen cap in 2%, coconut piece in 4%, groundnut in 74%, plastic whistle in 8% and seeds of seethapal dal in 6% of the cases. We still ignore the origin of the foreign body in our patient.
It was normal in 50% of cases and radio-opaque in 45% of cases, wile according to HIcham Kechna, they was radio-opaques in 27.7% of cases. For the indian journal, it shows an obstructive emphysema in 57% of cases and a consolidation in 20% of cases.
According to the panafrican medical journal 2015, at first a tracheotomy was realized to allow the extraction of the foreign body using the optic of an endoscopy in 47.6% of the cases.
According HIcham Kechna of the anesthesia department of the military hospital, Guelmim, maroc, en case of complete airways obstruction by isolation of the foreign body in the trachea, if it can not be extracted immediately, it must be pushed to beyond the carene to allow the patient’s oxygenation.
According to Dr Jahidi of the military hospital of instruction Mohammed V the therapeutic approach face to a respiratory distress in insulated conditions consists in:
- attempted extraction by finger of a tracheal foreign body.In case of failure
- The Heimlich maneuver should be attempted :
- The operator is positioned in the back of the victim and belt him with his arms (fist at the epigastric hollow), he exercises an abdominal compression upward and strong, almost brutal in order to obtain the removal of the foreign body by hyper pression. That gesture can be repeated 3 to 4 times with finger cleaning of the buccal cavity between each mouvement.
Whether it is an infant, he is elongated in ventral décubitus on the thighs of the operator. The pressure is exerted by strong slaps between the shoulder blades.
The emergency tracheobronchial clearing by a rigid pediatric bronchoscopy is sometimes the only solution to overcome a respiratory distress caused by an obstacle of the airways. The success rate varies between 61 to 97% according to the series. Being given that these potentially serious events (0.96%), particularly the desaturation, the laryngospasm etc. some authors propose the rigid bronchoscopy as secondary intention, after a flexible bronchoscopy under a local anesthesia referred to both exploratory and therapeutic. Recourse to surgery varie between 6 and 10.4% in the poor country. In our case the bronchoscopy was not availabl and there was not an oto-rhino-laryngologiste to help us.
According to the indian journal a fully experimented pediatric anesthetist is necessary for this procedure. The child should be connected to an ECG monitor and a pulseoximeter. He reports: "All of our cases where done under general anaesthesia with induction by pentathol, relaxation and apnoea with scoline, oxygenation with facemask. It is always better to identify the child's larynx first and pass the bronchoscope into trachea through a laryngoscope. The anaesthetist then stats inflating lungs with jet ventilation by the side of the bronchoscope. The total apnoea makes tracheo-bronchial tree completely open and so it is easier to visualise and catch the foreign body. The foreign bodies which stuck in sub glottis have to be removed at the earliest as they cause respiratory emergency. in one of our case we where forced to do tracheostomy. as the flange of plastic whistle could not be retrieved through glottis.It was then removed through the tracheostome".
Picture 7 : a bronchoscope Picture 8 : a bronchoscope
The mortality is 4.76%, by subglottic edema. In fact, even after the extraction of the foreign body, a subglottic edema can occur. the mortality was 0% on 50 patients in india.
Children May suck foreign bodies. It occurs most often at 8.5 years old according to the panafrican medical journal. The india Journal have found it between 0 and 2 years. These foreign bodies can cause choking of the airways. The laryngeal seat is the most common, 50% of the cases wile the right bronchus is the must common seat according to the indian Journal. That foreign body is most often foodborn (groundnut in 74%). The treatment depends on the experience of the physician, hence the need to get used to these extreme cases. In isolated situations we can try to remove it by the manoever of Heimlich. In hospital we can use the fibroscopy if the problem persists, the surgical intervention is then realized. J. Srppnatn and Vinay Mahendrakar for the indian Journal report that all his cases (50 cases) where done by bonchoscope with only one that need a tracheostomy.
Schwartz’s principles of surgery,10th
The laryngo-tracheo-bronchial foreign bodies suction is still a challenge, a true problem for patients and surgeons. We should evolve our capacity manage it.
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Date de dernière mise à jour : 11/07/2021