Approach In Caring For

Critical Pediatrics And Adult

Patients
Presenter : Dr. Yibeltal T/PGY1
Moderated : Dr. Girma/ENT surgeon
Contents
• Introduction
• Definition of critically ill patient
• Initial patient assessment and approach
• Critical patients in ENT
Introduction
• Critical care medicine specializes in caring for most seriously ill patients.
• These patients can be encountered in wards( medical, surgical),
emergency/regular OPD, outside hospitals although they are best treated in
ICU.
• Support for critical patients include provision of adequate nutrition, prevention
of infection, stress ulcers and gastritis and pulmonary embolism.
• Proper management of critically ill patients require:
• Early identification of the critically ill patient
• Identification of the immediate problem that can kill the patient
• Taking and performing quick measures to save the persons life.
• Some pathology requires high index of suspicion.
Definition Of Critically Ill Patient
• A patient with at high risk of
actual or potential life
threatening pathology.
• They are highly vulnerable,
unstable and complex.
• They require intense and vigilant
nursing care in addition to
medical or/and surgical care.
Initial Patient Assessment And Approach
• The conventional approach to patient problems involves taking a
careful history, performing a careful examination and obtaining
laboratory, radiological and other diagnostic results to lead to proof of
a specific diagnosis. NOT IN CRITICAL PATIENTS!!!!!!!
• The initial aspects of the management of critically ill patients has four
components: resuscitation, stabilization, monitoring, and disposition.
• The first responsibility is to determine which emergency patient is
most ill. TRIAGE!!!!!!!!
• The next step is to assign the patient to a physical location within the
department.
Initial Patient Ass’t….
• Three components are necessary for triage and identification of the life-threatened patient:
A chief complaint, complete vital signs and by visualizing and visualize/touch/auscultate.
• Prioritized plan in Emergency patients:
1)Rapid primary survey
2) Resuscitation ,often with RPS
3) Detailed secondary survey
4) Definitive care
• Immediate availability of nurses, doctors, anesthesiologists ,emergency room, ICU, theaters,
radiology, laboratory and blood bank is required.
Initial patient ass’t….
• Rapid primary survey
• Airway maintenance with C-spine control
• Breathing and ventilation
• Circulation (pulses, hemorrhage control)
• Disability (neurologic status)
• Exposure (complete) and Environment (temperature control)
• Resuscitation
• Detailed secondary survey
• Definitive care
 Rapid primary survey: Airway
• First priority
• Assume a cervical (C-spine) injury in every trauma patient ––> immobilize with collar and
sand bags.
• Can be caused by decreased LOC or problems in the airway lumen, wall or external to the
wall.
• Assess the ability to speak and breath, ASKING HIS/HER NAME.
• Watch for signs of obstruction like noisy breathing, RD, cyanosis, agitation, confusion and
etc..
• Think about ability to maintain patency in future.
• Can change rapidly, ALWAYS REASSESS
• The goal of treatment is to establish patent airway, permit adequate oxygenation and
ventilation.
Airway…
• Basic management vs definitive management.
• Basic management:
• Protects C-spine.
• Chin lift, jaw thrust to open the airway.
• Sweep and suction of mouth of foreign material.
• Airways (oropharyngeal and nasopharyngeal).
• Transtracheal jet ventilation
• Definitive management:
• Endotracheal intubation
• Surgical airway, unable to intubate.
Rapid primary survey: Breathing
• LOOK  mental status, color, chest movement, respiratory rate/effort.
• FEEL  flow of air, tracheal shift, crepitation, flail segment, sucking
chest wounds, subcutaneous emphysema.
• LISTEN stridor, other breath sounds, symmetry of air.
• Measurement of respiratory function: pulse rate, pulse oximetry, ABG
• Treatment modalities:
• Nasal prongs ––> simple face mask ––> oxygen reservoir ––> CPAP/BiPAP
• Venturi mask: used to precisely control O 2 delivery
• Bag-Valve mask and CPAP: to supplement ventilation
Rapid primary survey: Circulation
• The presence of a carotid pulse should be checked for 5-10 seconds.
• Determine for the presence of external bleeding.
• Look for other signs of circulatory shock like LOC, tachypnea, neck veins distention.
• Cyanosis, pallor, diaphoresis, cool extremities, slow capillary refill are indicative of
peripheral vasoconstriction.
• Blood pressure recordings and ECG assist in the ass’t.
• External bleeding can be controlled by direct pressure, pressure on pressure points
and elevation.
• 2 large bore IV lines should be established bilaterally.
• Obtain blood samples for biochemistry, full blood count/haematocrit and cross match
• Inotropes for cardiogenic shock and vasopressors for septic shock are administered.
Disability and Exposure

Disability Exposure
• Assess level of consciousness by • Undress patient completely
AVPU method (quick, rudimentary
assessment) • Essential to assess all areas for
• A- ALERT possible injury
• V - responds to VERBAL stimuli • Keep patient warm with a
• P- responds to PAINFUL stimuli blanket +/– radiant heaters;
• U- UNRESPONSIVE
avoid hypothermia
• size and reactivity of pupils.
• movement of upper and lower
extremities (UE/LE)
RESUSCITATION
• Restoration of ABC.
• Manage life-threatening problems as they are identified.
• Often done simultaneously with primary survey.
• Vital signs q 5-15 minutes
• ECG, BP and O 2 monitors
• Foley catheter and nasogastric (NG) tube if indicated.
• Order appropriate tests and investigations: may include CBC,
electrolytes BUN, Cr, glucose, amylase, INR/PTT, ß-HCG, toxicology
screen, cross + type
DETAILED SECONDARY SURVEY vs
DEFINITIVE CARE
Detailed secondary survey
• Done after RPS problems have been
corrected
• Designed to identify major injuries
or areas of concern
• Head to toe physical exam and X-rays
(C-spine, chest, pelvis - required in
blunt trauma).
• AMPLE history is asked.
Definitive care
1. continue therapy
2. continue patient evaluations
(special investigations)
3. specialty consultations including
O.R.
4. disposition: home, admission,
or another setting
• Decision/Action Points in
general impression:
• Any abnormal findings or life-
threatening chief complaint such
as major trauma/burns, seizures,
diabetes, asthma attack, airway
obstruction, etc. (urgent) –
proceed to Initial Assessment +
consider ALS.
• All findings normal (non-urgent) –
proceed to Initial Assessment.
• Decision/ Action Points in initial
assessment :
• Any abnormal finding (C, U, or P):
• open airway and provide o2,assist
ventilation, initiate CPR, suction, control
bleeding + other ALS management
• Check for the causes.
• Assist patient with prescribed
bronchodilator.
• All findings on assessment of child
normal (S):
• Continue assessment, detailed history
and P/E, treat the child.
Critical Patients In ENT

• Although majority of ENT cases are benign, there are several critical disorders that must
be immediately recognized and treated and can be because of:
• Infection
• Epiglottitis , croup, malignant otitis externa, Peritonsillar abscess, retropharyngeal abscess,…..
• Congenital
• Choanal atresia, a cyst in the larynx, membranes blocking trachea/ larynx, narrowing glottis…
• Trauma
• Facial trauma , skull base fracture trauma to the pharynx, larynx,…
• Endocrine
• Myxedema coma , thyroid storm
• Iatrogenic
• Post intubation granuloma, subglottic stenosis
Critical Patients In ENT…
• Head and neck oncology
• Oropharyngeal cancer, laryngeal cancer , nasopharyngeal cancer,….
• Benign conditions
• RRP,JNA,salivary gland tumours, laryngeal papillomatosis
• Post surgical
• Post tonsillectomy blockage, TIF, infection
• Anaphylaxis reactions
• Angioedema
• Foreign body
• Ear, upper airway
• Epistaxis
• Simultaneous
• suppurative labyrinthitis
Choanal Atresia

• The primary problem and concern in neonate with Choanal atresia,

specifically, is that they are obligate nasal breathers.
• Bilateral Choanal atresia the newborn often presents with cyanosis,
creating increased respiratory effort and notable chest retraction.
• Worsens when feeding and improves during crying.
• Bilateral atresia can be suspected when there is polyhydramnios on
prenatal U/S.
• Unilateral atresia present later in life.
• CT scan presence of excess bone/membrane in the area of choana.
Choanal Atresia….
• Treatment
• Stabilizing the patient is the most
crucial intervention in bilateral
Choanal atresia.
• McGovern nipple is a special
nipple used for oxygenation.
• More invasive methods like
endotracheal tube intubation and
tracheostomy can be used.
• There are several methods of
repair of the atresia.
Acute Epiglottitis
• Defined as inflammation of the epiglottis, most often due to infectious etiology.
• The most common cause bacterial cause is H Influenzae, BHS, staphylococcus
aureus and streptococcus pneumonia.
• Herpes simplex is the only virus identified on histologic specimen.
• Atypical organisms such as Aspergillus, Candida and Klebsiella can cause
epiglottitis in immunosuppressed patients.
• Non-infectious causes include thermal inhalation injury, inhalation of crack
cocaine( reports), neck trauma and caustic ingestion.
• There is decrease in incidence of the disease in the pediatric age group and now
common in adults.
Acute Epiglottitis ….
• Clinical presentation:
• Sore throat
• Odynophagia ( 90%) adults
• Hoarseness
• Dyspnea
• Drooling
• Stridor children
• Fever
• Tripod position

• Delay in presentation is common.

• HIGH INDEX OF SUSPESCION !!!!!!!!
Acute Epiglottitis ….
• The gold standard for diagnosis is direct visualization of the epiglottis
and the surrounding tissue via laryngoscopy.
• Fiber-optic nasopharyngeal laryngoscopy can be used to visualize the
posterior elements of hypopharynx including the epiglottis.
• Thumb sign classic radiographic finding due to the swelling of the
epiglottis in the lateral neck x-ray.
• ABG analysis, WBC count are non specific and has no diagnostic value
in acute epiglottitis.
Acute Epiglottitis ….
• Management:
• Centered on airway management and antibiotics.
• Up to 33% eventually require intubation. NO BLIND INTUBATION.
• Majority of adults respond to medical management.
• Third generation cephalosporin antibiotics are the current choice of
antibiotics.
• Patients should be hydrated.
• Given the potential for airway compromise , patients with epiglottitis require
admission to ICU.
• Epinephrine is shown not to influence the coarse of the disease.
• Glucocorticoids decrease the airway.
Croup
• The most common cause of stridor accounting for 90% of infectious airways
in children.
• Primarily affects children 6 months-3 years, M:F=2:1
• Patients typically present with barking cough, stridor, hoarseness.
• Biphasic stridor, tachypnea, retractions, cyanosis, and oxygen desaturations
are ominous signs, which signify impending airway compromise.
• The most common etiologic agent is parainfluenza type 1 & 2.
• Dx is primarily Hx and P/E.
• Frontal AP soft tissue X-ray shows narrowing of the subglottic area called
steeple sign.
Croup….
• Treatment of croup.
• Includes humidified mist, racemic
epinephrine, glucocorticoids.
• About 5% of admitted patients
develop respiratory failure that
may require airway intervention.
• For atypically presentations,
formal endoscopy may be
necessary to evaluate for bacterial
tracheitis or foreign body.
Ludwig’s Angina
• Bilateral infection of submandibular space.
• Most commonly arises from infected 2nd/3rd mandibular molar teeth.
• Is an aggressive, rapidly progressing cellulitis without LAP.
• Ludwig's angina is typically a polymicrobial infection involving the flora of the oral
cavity:
• Streptococcus viridans is the most isolated bacteria.
• Most abscess originating from the teeth also harbor anaerobes such as peptostreptococcus
species, actinomyces species.
• In immunosuppressed patients gram negative anaerobes also present.
• Staphylococcus infection also present in immunosuppressed individuals.
• Ludwig’s angina has been reported in patients with history of alcoholism, diabetes
mellitus, aplastic anemia, and immunodeficiency disorders.
Ludwig’s Angina…..
Ludwig’s Angina ….
• Patients will have history of fever,
chills , malaise , neck stiffness
,drooling ,dysphagia and muffled voice
• They also will lean forward to
maximize the airway diameter
• The physical findings include
symmetric woody induration , the
oropharynx is elevated and the mouth
is held open by lingual swelling.
• Patients are investigated by CBC,ESR
and CT scan.
Ludwig’s Angina….
• Treatment :
• Directed toward securing patent airway, providing systemic antibiotics, and surgical
decompression of the sublingual, submental and submandibular space.
• Stridor, drooling, cyanosis  artificial airway.
• Empiric antibiotics treatment in immunocompetent:
• Ampicillin sulbactam 3gm iv QID or penicillin G 2-4 MU QID + metronidazole 500 mg iv TID or
clindamycin 600mg IV QID
• immunocompromised:
• Cefipime + metronidazole or
• imipenem or meropenem
• vancomycin in MRSA
• Surgery : abscess drainage is indicated if no response to antibiotics, flactuance is
detected, collection observed on imaging,
Acute Retropharyngeal Abscess
• Retropharyngeal space lies behind the pharynx between the buccopharyngeal
membrane and prevertebral fascia.
• Commonly occurs in children below 3 yrs of age.
• Children  suppuration of the LNs due to infections in the adenoids, nasopharynx, posterior nasal
sinuses and nasal cavity.
• Adults penetrating injury to the posterior oropharynx or cervical esophagus.
• Patients present with hx of dysphagia, dyspnea , stridor and croupy cough.
• Change invoice quality: hot potato voice, gurgling sound
• Trismus can occur in about 20% of patient.
• They also have torticollis and bulge in the posterior pharyngeal wall.
• Physical examination is usually difficult and must be performed by experienced
physician in airway management.
Acute Retropharyngeal Abscess….
• Investigations:
• CBC: usually WBC is increased.
• Blood culture: rarely positive.
• Throat culture
• Imaging: lateral neck x-ray and CT
• AP and later CXR
• Treatment:
• Incision and drainage without
anesthesia.
• systemic antibiotic
• Tracheostomy : A large abscess may cause
mechanical obstruction to the airway or
lead to laryngeal oedema.
Malignant Otitis Externa
• A skull base osteomyelitis
• Mostly affects elderly diabetics and immunosuppressed patients.
• Diabetic patients are susceptible because of microangiopathic changes.
• Aspergillus may also be an etiologic organism and is thought to
originate from the middle ear or mastoid.
• It is an otitis externa that progresses to cellulitis, chondritis, osteitis and
ultimately osteomyelitis of the temporal bone.
• Can involve cranial nerves: V,VIVII, XI, XII
• The most frequently isolated causative organism is P. aeruginosa.
Malignant Otitis Externa ….
• Clinical features:
• Intense otalgia, otorrhea, aural fullness, pruritus and hearing loss.
• When the disease progresses granulation tissue in the EAC at the
osseocartilaginous junction.
• Edema, periaural lymphadenopathy, and trismus may be present.
• Cranial nerve palsies as the disease advance: facial nerve is the most
affected.
• Further progression may lead to sigmoid sinus thrombosis, meningitis, sepsis,
and death.
Malignant Otitis Externa….
Investigation
• ESR and CRP are elevated.
• CT scan and MRI  initial
evaluation to see the extent of the
disease.
• A technetium scan is the most
sensitive test for diagnosing bony
involvement but is not specific.
• Gallium scans follow up of the
disease.
Treatment
• Long-term parenteral antibiotics
are the treatment of choice.
• Aminoglycosides (e.g. tobramycin)
and antipseudomonal β-lactam
antibiotics may be used.
• Control of hyperglycemia and
immunosuppression.
• Surgical debridement may be
necessary to remove necrotic
tissue.
Epistaxis
• The severity can range from outpatient management to admission into
ICU.
• The treatment can range from as simple as nasal pressure to surgical
ligation in the OR.
• Divided into anterior and posterior epistaxis.
• Posterior epistaxis is more profuse, greater risk of airway compromise, aspiration
of blood, greater difficulty of controlling requires more invasive treatment.
• Can be caused by idiopathic, local or systemic causes.
• Hypertension is not an independent risk factor for epistaxis.
Epistaxis…
• Management of epistaxis :
• Determining the etiology and identifying the location is important.
• Anterior epistaxis is usually seen by anterior rhinoscopy.
• Oftentimes, posterior epistaxis is diagnosed by solely based on the fact that
posterior epistaxis is required.
• In severe cases, ATLS protocol goes into effect.
• Anterior skull base fracture
• Facial trauma.
Head And Neck Oncology Emergencies
• Squamous cell carcinoma is the most common malignancy in upper
aerodigestive tract.
• It is a complex area because:
• Highly vascularized
• Eating and breathing takes place.
• Patients present with acute airway and bleeding.
• Oropharyngeal cancer is the most common emergency presentation of
cancer.
• Laryngeal cancer patients may rarely present with dyspnea and stridor.
• These patients are managed by tracheostomy, intubation,C02 laser therapy or
laryngectomy.
Head And Neck Oncology Emergencies
……
• There are case reports where pleomorphic adenoma of minor salivary glands
of oral cavity present with acute airway obstruction.
• Usually managed by tracheostomy and excision of adenoma.
• There are also case reports where marked swelling of the submandibular
gland causes upper airway obstruction.
• Patients with prior radiotherapy to head and neck cancer can present with
Upper airway obstruction.
• Head and neck cancer can also be complicated by malnutrition, aspiration
pneumonia and psychiatric disorders associated with treatment.
• They can also present with side effects associated with treatment like
hypotension, bleeding and fever.
Respiratory papillomatosis
• The most common benign neoplasm of the
larynx in children.
• Mostly affects the supraglottic and sub-
glottic region.
• Tracheostomy tracheal and stomal
involvement.
• Children, between the age of 3 &5, usually
present with hoarseness or dysphonia,
stridor, or dyspnea.
• Diagnosis is made by fiber optic
laryngoscopy and biopsy.
• Surgery is by laser CO2 therapy or
microlaryngoscopy
Post operative critical patients in ENT
• Some of ENT surgeries are followed by grave consequences.
• The complications can be due to anesthesia, infection , bleeding ,
DVT/pulmonary embolism or local trauma due to the surgery.
• Post tonsillectomy patients may encounter post-op bleeding.
• Submandibular gland surgery can result in hematoma airway compromise.
• Is managed by wound exploration for hematoma evacuation and control bleeding.
• Hematoma is rare in sublingual gland surgery but if it occurs should be
explored immediately to prevent airway compromise.
• There are specific complications associated with laryngectomy, neck
surgery and tracheostomy.
Laryngectomy
• Superior thyroid and superior laryngeal arteries are the most
commonly affected arteries in laryngectomy.
• Higher rates of bleeding are associated with larger tumours and
tumours of supraglottic and pyriform sinus.
• Postoperative hemorrhage can be prevented with thorough
hemostasis intraoperatively with the use of surgical clips to ligate
larger vessels such as the superior laryngeal and lingual arteries.
• Laryngeal stenosis can occur partial laryngectomy.
• Can occur due to edema or cicatricial fibrosis.
• Management is with division of the stenosis and dilation
Laryngectomy…
• Patients can develop hypocalcemia due to hypoparathyroidism.
• Devascularized parathyroid glands should be implanted in the SCM if noted intraoperatively.
• Hypoparathyroidism develops immediately after surgery and calcium level should be monitored in early
postoperative period.
• Patients also should be observed for symptoms of hypocalcemia.
• Treatment is repletion of calcium and administration of vitamin D.
• Cardiac and pulmonary complications may complicate the postoperative course after
laryngectomy
• The most common cardia complication is heart failure and the most common respiratory
complication is pneumonia.
• Patients also can experience stroke, MI, pulmonary embolism and respiratory failure
requiring mechanical ventilation.
• Medical complications are treated as of the by medical protocol.
Tracheostomy
• Immediate post-operative care for patients with new tracheostomy
include ensuring that the tracheostomy tube is secured in place and it
is patent.
• The three most common tracheostomy emergencies are hemorrhage,
tube dislodgment and obstruction.
• A small bleeding is expected after initial procedure and every
tracheostomy change.
• Tube displacement can be deccanulation or dislodgment.
• Dislodgement of the tracheal tube during the first postoperative week
is considered a medical emergency.
Tracheostomy…
• The first step in caring for
tracheostomy patient in respiratory
distress is to remove and inspect
the inner cannula.
• The cannula can be obstructed with
secretion.
• Then catheterization of the
tracheostomy is attempted.
• TIF is a vascular complication
associated with tracheostomy and
carries a grave consequence.
Tracheoinnominate Fistula
• It is an abnormal connection between the innominate artery and trachea.
• A rare but life threatening complication of tracheostomy.
• Over inflation of the cuff in tracheostomy erodes the innominate artery.
• It can also be associated with prolonged intubation as a result of cuff
inflation.
• TIF should be top differential dx in patients with tracheostomy followed by
bleeding.
• Rigid bronchoscopy is the most effective diagnostic tool.
• Pathognomonic warning sign: sentinel bleeding and pulsation of the
tracheostomy tube that coincides with hear beat.
Tracheoinnominate Fistula…
• Clinical presentation includes:
• Hemoptysis
• Massive hemorrhage respiratory compromise leading to dyspnea and cyanosis.
• Hypovolemic shock
• Patients may also develop septicemia
• TIF can be prevented by limiting the time of intubation to less than 2 weeks
and properly preforming tracheostomy.
• Avoid repetitive head movement specially hyperextension.
• Immediate intervention include blood volume control, management of
hemorrhage, adequate oxygenation and hyperinflation of the tracheostomy
cuff.
Tracheoinnominate Fistula…
• If the above fails, the patient should be intubated and index finger
from within the trachestomy applied to control the bleeding.
• Rigid bronchoscopy is used during operation.
• After exposing the innominate artery during surgery, it is debrided
and the health tissue is closed with a monofilament suture.
• The affected tracheal part is excised and primary end to end
anastomosis of the trachea is done.
• If the above fails, the patient should be
intubated and index finger from within
the trachestomy applied to control the
bleeding.
• Rigid bronchoscopy is used during
operation.
• After exposing the innominate artery
during surgery, it is debrided and the
health tissue is closed with a
monofilament suture.
• The affected tracheal part is excised and
primary end to end anastomosis of the
trachea is done
Upper Airway Trauma
• It is blunt or penetrating traumas to the neck or face involving elements of the
upper airway.
• Can be caused by RTA, assaults, hanging or penetrating injuries.
• Airway injury is divided into maxillofacial, neck and laryngeal injury.
• The greatest concern is airway obstruction due to collapse of anatomical
structures, foreign bodies, hemorrhage or swelling.
• Fractures of the mandible can disrupt the attachments of the tongue to the
mandible, preventing effective basic airway manoeuvres.
• Penetrating and blunt neck trauma may involve almost every major vital
structure including respiratory, vascular, digestive, endocrine, and neurologic
organs
Upper Airway Trauma …..
• Early deaths from neck injury generally result from asphyxia or
hemorrhagic shock.
• If there is dysphagia, retropharyngeal air and pneumomediastinum
digestive tract injury should be suspected.
• Airway injury in blunt trauma may be very subtle initially, especially
laryngotracheal injuries.
• Cervical spine injuries must be excluded.
• There is often associated significant hemorrhage with these injuries.
Upper Airway Trauma …..
• Management of upper airway trauma (A)
• Cervical collar
• Use basic airway maneuvers
• Avoid nasal airway if basilar skull or nasal # is suspected.
• Supine position if there is involvement of large vessels injury.
• In mandibular fracture, a towel clip or large suture can be used to retract it.
• Don’t remove foreign bodies in the face and mouth until the patient is in
operating theatre.
• The trachea can be intubated directly through the neck in a penetrating
wound.
Upper Airway Trauma …..
• Management of upper airway trauma (B &C):
• If the RR is inadequate , assist ventilation with bag valve mask attached to oxygen.
• If Sa02 is < 95% is not requiring assisted ventilation, administer high flow oxygen
throw mask.
• Examine for associated pneumothorax or other chest injury.
• Measure PR, BP, and capillary refill.
• Attach to cardiac monitor and assess rhythm.
• Insert IV cannula and if shock present, give crystalloid rapidly.
• Take blood for FBC, biochemistry, crosshatch
• Reduce fractures immediately, especially if mid third of face is involved
• Pack nasopharynx if necessary and pack, suture or direct pressure of bleeds.
Upper Airway Trauma …..
• Specific treatment for laryngeal
trauma:
• Where there is no clinical
evidence of airway compromise,
but there is subcutaneous
emphysema due to blunt neck
trauma, administer humidified
oxygen and commence IV
antibiotics for possible salivary
contamination of the deep tissues
of the neck.
Foreign Bodies In Airway
• A foreign body aspirated into air passage lodge in larynx, trachea or bronchi.
• Children are more affected; >50% are less than 4 years.
• Patients may present with initial symptom of choking, gagging and sneezing
followed by symptomless interval because the respiratory mucosa adapts to
the presence of foreign body.
• Airway obstruction, inflammation or trauma induced by the foreign body
cause another episodes of symptom depending on the site.
• Larynx: sudden death, voice change, cough , wheezing, hemoptysis.
• Trachea: cough , hemoptysis ,audible slap, wheeze
• Bronchi: atelectasis, obstructive emphysema
Foreign Bodies In Airway ………
• The FB can be diagnosed by
history of FB ‘ingestion’ , hx of
coughing , wheezing and
diminished air entry on
auscultation.
• Lateral and PA soft tissue neck
and chest x-ray is very helpful.
• Chest CT and fluoroscopy/ video
fluoroscopy are also employed in
the dx.
Foreign Bodies In Airway ……
Management of laryngeal FB
• A large bolus of food obstructed
above V.C  pounding on the back,
turning the patient upside down,
and following Heimlich manoeuvre.
• Cricothyroidotomy or emergency
tracheostomy if Heimlich
manoeuvre fails.
• Emergency over direct
laryngoscope.
Management of tracheal & bronchial
FB
• Emergency removal is not
indicated unless there is airway
obstruction or vegetable in
nature.
• Removed by bronchoscopy with
full preparation and under
general anesthesia.
References
• Sataloff; comprehensive textbook of otolaryngology, head and neck
surgery , 1st edition
• Dhingra; diseases of ear, nose, throat and head and neck surgery , 6th
edition
• UpToDate 21.2
• Internet