Foreign body aspiration

• Age:
1. Most victims are older infants and toddlers.
2. < 3 yr of age account for 73%
• Objects:
1. Liquids are the most common cause of choking in infants,
whereas small objects and food (e.g., grapes, nuts, hot dogs,
candies) are the most common source of foreign bodies in
the airways of toddlers and older children.
2. One third of aspirated objects are nuts, particularly peanuts.
3. Fragments of raw carrot, apple, dried beans, popcorn, plant
seeds are also common.
4. Small ornaments worn around neck- talisman, pendants etc
• Any child in the proper setting with the sudden onset of choking,
stridor, or wheezing has foreign body aspiration until proven
otherwise.
 CLINICAL MANIFESTATIONS
• Initial event: Stage I
1. Violent paroxysms of coughing, choking, gagging, and airway
obstruction occur immediately when the foreign body is
aspirated.
• Asymptomatic interval: stage II
1. The foreign body becomes lodged, reflexes fatigue, and the
immediate irritating symptoms subside.
2. This stage is most treacherous and accounts for a large
percentage of delayed diagnoses and overlooked foreign
bodies.
3. It is during this 2nd stage that the physician may minimize the
possibility of a foreign body accident, being reassured by the
absence of symptoms that no foreign body is present.
• Complications: Stage III
1. Obstruction, erosion, or infection
2. Complications:
1. Fever,
2. Cough,
3. Hemoptysis,
4. Pneumonia, and
5. Atelectasis.
 Symptoms
1. Respiratory distress
2. Stridor
3. Leaning chin forward and drooling.
4. Complete airway obstruction:
1. Sudden respiratory distress
2. Inability to speak or cough.
3. Cyanosis
5. Partial obstruction: violent paroxysms of
coughing, and wheezing.
 Laryngeal FB
1. Complete obstruction asphyxiates the child unless
promptly relieved with the Heimlich manoeuvre.
2. Objects that are partially obstructive are usually flat
and thin. They lodge between the vocal cords in the
saggital plane, causing symptoms of croup,
hoarseness, cough, stridor, and dyspnea.
3. Lateral neck radiograph can show enlarged epiglottis at
base of tongue or possibly a foreign body.
 Tracheal foreign bodies
1. Produce stridor and wheezing.

2. Posteroanterior and lateral soft tissue neck

radiographs (airway films) are abnormal
 Bronchial foreign body
1. During expiration the bronchial foreign body
obstructs the exit of air
2. Obstructive emphysema
3. persistent inflation of the obstructed lung
4. Shift of the mediastinum toward the opposite
side.
5. Decreased breath sounds or localized wheezing
Pendulum sign
 Management
Current guidelines for pediatric basic life support

• Mild:
1. No intervention is required.
2. The patient should be allowed to clear airway by
coughing
3. Watch for signs of impending severe airway
obstruction.
4. Blind finger sweeps should not be performed in
infants or children because the finger may actually
push the foreign body further into the airway
1. Airway obstruction is treated with a sequential
approach, starting with the head-tilt/chin-lift
maneuver to open and support the airway, followed
by inspection for a foreign body, and fingersweep
clearance or suctioning if one is visualized.
2. Blind suctioning or finger sweeps of the mouth are
not recommended.
3. A conscious child suspected of having a partial
foreign body obstruction should be permitted to
cough spontaneously until coughing is no longer
effective.
 Jaw Thrust
• The airway may be opened by jaw thrust, and
if the foreign body can be directly visualized, it
should be removed;
• If the patient resumes adequate spontaneous
ventilation, the patient's body is turned on its
side to the recovery position with the head to
the side
Opening the airway with the
head-tilt/chin-lift maneuver Jaw thrust
Finger sweep
1. Must be performed on
unconsciousvictims onl
2. With the victim’s face up, open
the victim’s mouth by grasping
both the tongue and lower jaw
3. Insert the index finger of the
other hand down along the
inside of the cheek
4. Use a hooking action to
dislodge the foreign body and
maneuver it to be removed.
• Back blow & Chest Thrust:
1. In the infant younger than 1 yr, a combination of five
back blows and five chest thrusts are administered.
2. The foreign body is removed if it is seen.
Back blows (top) and chest thrusts
Back blows (top) and chest thrusts
 Heimlich maneuver
• A conscious child older than 1 yr is
administered a series of five abdominal
thrusts (the Heimlich maneuver) with the
child standing or sitting.
• If unconscious, this is done with the child lying
down. After the abdominal thrusts, the airway
is examined for a foreign body, which should
be removed if visualized.
Heimlich maneuver
 Surgical
1. When the airway is obstructed and foreign
body could not be removed needle
cricothyrotomy is indicated
2. For foreign body bronchus, child should be
treated by bronchoscopic removal of foreign
body under anaesthesia.
 Croup

Dr.p.natarajan
 Acute Inflammatory Upper Airway
Obstruction
1. Croup,

2. Epiglottitis,

3. Laryngitis, and

4. Bacterial Tracheitis
 Anatomy
The larynx is composed of 4 major cartilages:

1. Epiglottic,

2. Arytenoid,

3. Thyroid, and

4. Cricoid cartilages: encircles the airway just below the

vocal cords and defines the narrowest portion of the
upper airway in children <10 yr of age.
 Terminology
1. Inflammation involving the vocal cords and structures inferior
to the cords:
1. Laryngitis,
2. Laryngotracheitis,
3. Laryngotracheobronchitis,
2. Structures superior to the cords: supraglottitis.
3. Croup:
1. Acute and infectious
2. Bark like or brassy cough and may be associated with
3. Hoarseness,
4. Inspiratory stridor,
5. Respiratory distress.
4. Stridor; harsh, high-pitched inspiratory sound,
 CROUP
(ACUTE LARYNGOTRACHEOBRONCHITIS)

1. Croup syndrome is another name for acute

laryngotracheo bronchitis,

2. Inflammation mainly of glottis and subglottic region

3. Produces brassy cough and hoarse voice;

4. Laryngitis may cause life threatening airway

obstruction.
 Croup
1. Croup typically affects the larynx, trachea, and
bronchi.
2. Larynx dominate the clinical picture over the
tracheal and bronchial signs.
3. Spasmodic croup may have an allergic
component and improves rapidly without
treatment,
4. Laryngotracheobronchitis is always associated
with a viral infection of the respiratory tract.
 Etiology
1. Viruses:
1. The parainfluenza viruses: 1, 2, and 3 - 75%
of cases;
2. Other viruses:
1. Influenza A and B,
2. Adenovirus,
3. Respiratory syncytial virus (RSV),
4. Measles.
 Bacteria
1. Haemophilus influenzae type b was the most
common; HiB vaccine reduced the incidence;
2. Streptococcus pyogenes, S. pneumoniae, and
Staphylococcus aureus, now represent a larger
proportion
3. Diphtheria can also produce croup syndrome
4. Mycoplasma pneumoniae rarely has been
isolated
 Spasmodic croup
1. 1-3 yr of age and is
2. Clinically similar to acute ALTB
3. Fever and family contact not present
4. The cause is viral in some cases,
5. Allergic and
6. Psychological factors may be important in
others
• Age:
 3 mo and 5 yr, with the peak in the second year of
life.
 Recurrences are frequent from 3-6 yr of age and
decrease with growth of the airway.
• Sex:
 higher in males,
• Seasonality:
 most commonly during the winter but may occur
throughout the year.
• Familial susceptibility:
 Approximately 15% of patients have a strong
family history of croup
 Croup: Clinical features

1. Begins with rhinorrhea, pharyngitis, mild

cough, and low-grade fever
2. Then the characteristic "barking" cough,
hoarseness, and inspiratory stridor follow.
3. The low-grade fever may persist, although
temperatures may reach 39-40°c ; some
children are afebrile.
4. Symptoms worse at night and often recur with
decreasing intensity for several days and resolve
completely within a week.
5. Agitation and crying greatly aggravate the symptoms
and signs.
6. The child may prefer to sit up in bed or be held
upright.
7. Older children usually are not seriously ill.
8. Other family members may have mild respiratory
illnesses.
9. Most patients with croup progress only as far as
stridor and slight dyspnea before they start to recover.
 Physical examination
1. Hoarse voice,
2. Coryza,
3. Normal to moderately inflamed pharynx,
4. Increased respiratory rate.
5. Severe type:
1. Airway obstruction progresses
2. Increasing respiratory rate;
3. Nasal flaring;
4. Suprasternal, infrasternal, and intercostal retractions;
5. Continuous stridor.
6. The child is hypoxic, cyanotic, pale, or obtunded
7. Needs immediate airway management.
 Investigations

1. Croup is a clinical diagnosis and does not

require a radiograph of the neck.

2. Radiographs of the neck may show the

typical subglottic narrowing or "steeple sign"
of croup on the posteroanterior view
 Differential Diagnosis
1. Diphtheritic croup
2. Aspiration of a foreign body
3. Retropharyngeal or peritonsillar abscess
4. Extrinsic compression of the airway (e.g.,
laryngeal web, vascular ring)
5. Intraluminal obstruction from masses (e.g.,
laryngeal papilloma, subglottic hemangioma).
6. Angioedema of the subglottic areas
7. Hypocalcemic tetany,
 Complications
1. Complications in 15% of patients
2. Pneumonia,
3. Cervical lymphadenitis,
4. Otitis media, or, rarely,
5. Meningitis or
6. Septic arthritis
7. Mediastinal emphysema and pneumothorax are the
most common complications of tracheotomy
 Treatment
1. Airway management.
2. Cool mist : provide cool mist through a tube held in front of
the patient by the parent: it
1. Moistens airway secretions to facilitate clearance,
2. soothes inflamed mucosa,
3. Provides comfort and reassurance to the child, lessening
any anxiety.
3. Nebulized epinephrine:
1. A dose of 0.25 to 0.75 ml of 2.25% racemic epinephrine
in 3 ml of normal saline can be nebulized as often as every
20 min.
1. Corticosteroids:
1. Decrease the edema in the laryngeal mucosa
through their anti-inflammatory action.
2. Dexamethasone used a single dose of 0.6 mg/kg IM
1. Intramuscular dexamethasone and nebulized
budesonide have an equivalent clinical effect,
and oral dosing of dexamethasone is as effective
as intramuscular administration.
2. Antibiotics:
1. Are not indicated in croup.
• helium-oxygen mixture (Heliox) have shown
similar clinical improvements
• Children with croup should be hospitalized for
any of the following:
1. progressive stridor,
2. severe stridor at rest,
3. respiratory distress,
4. hypoxia, cyanosis,
5. depressed mental status
 EPIGLOTTITIS
1. Epiglottitis is an infection of the epiglottis and
supraglottic structures
2. Etilogy:
1. In the past, Haemophilus influenzae type b was
common
2. Streptococcus pyogenes,
3. S. pneumoniae,
4. Staphylococcus aureus,
 Clinical features
1. 2-4 yr of age
2. This is a dramatic, potentially lethal condition
3. High fever, sore throat, dyspnea, and rapidly
progressing respiratory obstruction.
4. Within a matter of hours, the patient appears toxic,
swallowing is difficult, and breathing is laboured.
5. Drooling is usually present
6. Neck is hyperextended in an attempt to maintain the
airway.
7. The child may assume the tripod position
sitting upright and leaning forward with the
chin up and mouth open
8. rapidly increasing cyanosis and coma.
9. Stridor is a late finding and suggests near-
complete airway obstruction.
10.Complete obstruction of the airway and death
11.The barking cough typical of croup is rare.
12.Usually no other family members are ill with
acute respiratory symptoms.
 The diagnosis
1. Visualization of a large, "cherry-red" swollen
epiglottis by laryngoscopy
2. If in doubt, laryngoscopy should be
performed expeditiously in a controlled
environment such as an operating room
3. Classic radiographs of a child who has
epiglottitis show the "thumb sign"
 Management
1. Establishing an airway by nasotracheal intubation or,
less often, by tracheostomy is indicated
2. No clinical features have been recognized that
predict mortality.
3. Pulmonary edema may be associated with acute
airway obstruction.
4. In general, children with acute epiglottitis are
intubated for 2-3 days, because the response to
antibiotics is usually rapid.
 Complications
1. Most patients have concomitant bacteremia;
occasionally, other infections may be present, such as
2. pneumonia,
3. cervical adenopathy, or
4. otitis media.
5. Meningitis, arthritis, and other invasive infections with
H. influenzae type b are rarely found in conjunction
with epiglottitis.
 Drugs
1. Racemic epinephrine and corticosteroids are ineffective.

2. Cultures of blood, epiglottic surface, and, in selected cases,

cerebrospinal fluid, should be collected at the time of airway
stabilization.

3. Ceftriaxone, cefotaxime, or a combination of ampicillin and

sulbactam should be given parenterally

4. Epiglottitis resolves after a few days of antibiotics

5. Antibiotics should be continued for 7-10 days.

 Prevention

1. HiB vaccine is routinely given with DPT at

6,12,16 weeks and a booster at 18 months
2. Rifampin prophylaxis (20 mg/kg orally once a
day for 4 days; maximum dose, 600 mg) should
be given to all household members if there is
one contact younger than 48 mo of age who is
incompletely immunized or if there is an
immunocompromised child in the household.
 Prognosis
Untreated epiglottitis has a mortality rate of
6% in some series, but if the diagnosis is made
and appropriate treatment is initiated before
the patient is moribund, the prognosis is
excellent.