FOREIGN BODIES IN LUNGS, TRACHEA AND BRONCHIAL TUBES

It is the acute obstruction of respiratory tracts as a result of aspiration of foreign bodies  of different nature(organic, inorganic, metallic)  in the respiratory tracts (larynx, trachea, bronchial tubes).  Depending on the location  foreign bodies are divided into balloting, valvular (valve) and obturacting. Mechanical obstructions   and laryngospasm  have the main role I pathogenesis.

Clinic. Polymorphic, depends on the level of localization of foreign body, its size and form, time of stay in respiratory tracts. At the hit of foreign body in a larynx on a complete health attack of strong cough arises up, dyspnea, asphyxia, hoarse of voice. The clinical sings change as a result of motion of body. A diagnosis is due to laryngoscopy. The foreign body of trachea predetermines an exhausting cough, characteristic noise of slamming as a result of its blow on trachea, dyspnea attack .In the case of invasive penetration of foreigh body pain in chest, blood phlegma occur. If there is aspiration of foreign body in main bronchus, symptoms are the same, as well as at the hit in a trachea. When it penetrates deeper, in the distal regions of respiratory tracts, a cough becomes weaker. Obturation atelectasis in the proper lobe with compensating emphysema of neighbouring lobe develops at the complete corking of bronchus. The incomplete corking valve stenosis and obturation emphysema occur. Collection of anamnesis is purposeful important in establishment of diagnosis. Roentgencontrastive foreign bodies, or indirect signs of aspiration of nonroentgencontrastive bodies (atelectasis, acute emphysema of segment, lobe or    lung), appear at roentgenologic research, the Holtskneht – Jacobson symptom is exposed: displacement of mediastenum at deep inhalation in a sick side and at deep exhalation – in healthy. Foreign body of trachea and bronchial tubes is diagnosed also by bronchoscopy.

Help on prehospital stage

1.                To try to delete the foreign body. To take a child for feet, to drop downward by a head (for a short time) and inflict a few blows on the back. The children of the first year of life are laid on abdomen and face on the forearm of doctor, here by forel and middle fingers a head and neck are fixed. A forearm together with a child is lowered downward on 60 ^O. By the rib of palm of right hand short blows are dealed between shoulder-blades. For  elders  children  the Heymlih method is used : on the epigastrial area of child, which lies on a side, a doctor lays  the palm of the left hand, by the fist of right hand deals 5-8 short blows under the corner of 45 ^O in direction of diaphragm, or child which suffered, is clasped from behind of back by  hands so that the right palm compresses in a fist was at level between umbilicus and sternum, and left palm – over it, four sharp blows are done in this position, sending them insite and upwards, causing an artificial cough.

2.                With an attempt to delete the review of mouth cavity foreign body by hands or pincers, at possibility with direct laryngoscopy.

3.                Immediate hospitalization to otolaryngology unit. During transporting there must be the promoted position, to quiet a child, oxygen therapy.

4.                At ineffective of previous measures and impossibility of rapid hospitalization, there is the risk of death from an asphyxia. So conicotomia or tracheostomy is executed. Method of conicotomia: head of patient is maximally  backwards, feel an interval between thyroid that cricoid cartilages and with scalpel or another cutting object cut a skin, and then conical ligamentum   in transversal position. In the opening hole tracheostomic, intubation or another tube, which is in hands, are placed in order to provide access of air in a trachea.

Method of tracheostomy: bolster under the shoulders (not under a neck!) of patient. A head is maximally background. The little turn of head causes the displacement of trachea and cut her over not on a middle line and the wound of esophagus. Local anaesthesia. Vertical cut of skin from a cricoid cartilage by length of 4-5 cm. If a neck is short transversal cut is used by length of 5-6 cm at level of 2-3 rings of trachea. After dissection skins and fascia execute the subsequent baring of trachea only by a dull way. Move away the isthmus of thyroid downward and do overhead tracheostomy. Before section a trachea is sewed by silk which serves as a holder. Interval between cartilages is cutting by scalpel   higher than a holder, canulla is entered in trachea.

Chronic foreign body producing bronchiectasis in a 2-year-old boy. He had a history of choking on "something" while playing outdoors. A productive cough, recurrent pneumonia, and finger clubbing developed over the next 9 months. Chest film (<IT+>A<IT->) shows right lower lobe infiltrate. Bronchogram (<IT+>B<IT->) shows nonfilling of anterior basilar segment (<IT+>arrow<IT->) of right lung. The resected segment (<IT+>C<IT->) contained a bronchiectatic cavity (<IT+>arrow<IT->) with an aspirated grasshead (<IT+>D<IT->). Recovery was complete after operation and included resolution of severe clubbing. (From Hilman BC (ed): Pediatric Respiratory Disease. Philadelphia, WB Saunders, 1993, p 519.)

 

Help on  hospital stage

1.                If foreign body is in a larynx - laryngoscopy must be done to its delete.

2.                At finding of foreign body in a trachea or bronchial tubes – quickly

                     tracheobronchoscopy with anesthesia.

3.                Antibiotics of wide spectrum of action.

                            ANOTHER PATHOLOGY THAT CAUSES BOS

                

                A large group of diseases that occur with the manifestations of BOS, are hereditary metabolic.

            Hereditary deficiency α₁-antitrypsin (α₁-protease inhibitor) is a relatively rare disorder, inherited by autosomal recessive type. The earliest complaint is shortness of breath that occurs without cough and sputum, which, however, may join later. Percussion, auscultation and radiological findings are typical of pulmonary emphysema: swelling of the chest, bandbox sound over the lungs, weak breathing, increased pneumatization of pulmonary pattern. At α₁-antitrypsin deficiency obstruction occurs due to loss of elasticity, and not as a result of bronchospasm. The diagnosis of α₁-antitrypsin deficiency is confirmed by decrease of its content in the blood (normal 20-30 IU / ml), phenotype, genetic examination of relatives of the patient.

              Clinical manifestations of BOS at congenital malformations of the heart and blood vessels have certain similarity with acute obstructive bronchitis. The main mechanism for the development of BOS is a compression or occlusion of bronchial obstruction. The main in diagnosis is clinical and instrumental examination of the cardiovascular system with obligatory echocardiography.

             Recently, problem of relevant spread of tuberculosis among children becomes actual, which may be masked as obstructive bronchitis. In such case will be a long-term symptoms of intoxication, a history of frequent respiratory infections.

At X-ray of the chest thqre will be marked narrowing of the lumen of the bronchi, areas of atelectasis, emphysema, the presence of fistula with separation of caseous mass. For the correct diagnosis the utmost importance has tuberculin diagnostics, as well as identification of the causative agent in the washing waters.

             Often, BOS may be detected in diseases of the central and peripheral nervous system. In children with birth trauma, CNS impairment, hypertension-hydrocephalic syndrome, with severe malformations of the brain may be disrupted coordination of swallowing and sucking, which may result in aspiration of food (mostly liquid) with the development of BOS. At myopathy (amyotrophy Verdniga-Hoffmann disease, Oppenheim's) dysphagia associated with paresis of the swallowing muscles occurs with subsequent development of aspiration bronchitis. Swallowing disorders in these diseases are wavelike nature: the periods of improvement are replaced by increasing aspiration, mainly in the background of ARVI. Increased respiration and a direct effect of viral infection on the neuro-muscular system may contribute to violations of swallowing, dyskinesia of bronchial tree with the development of pronounced bronhoconstriction.

Thus, the differential diagnosis of bronchial obstruction syndrome in children is an extremely important issue. The tactics to the patient, differential treatment measures, which in turn determines the outcome of the disease depends on the timely establishment of the causes of bronchial obstruction.

Referens:

A - Basic:

1.      Pediatrics. Textbook. / O. V. Tiazhka, T. V. Pochinok, A. N. Antoshkina et al. / edited by O. Tiazhka – Vinnytsia : Nova Knyha Publishers, 2011 – 584 pp. : il.ISBN 978-966-382-355-3

2.      Nelson Textbook of Pediatrics, 19th Edition Kliegman, Behrman. Published by Jenson & Stanton, 2011, 2608.  ISBN: 978-080-892-420-3.

3.      Illustrated Textbook of Paediatrics, 4th Edition.  Published by  Lissauer & Clayden, 2012, 552 p. ISBN: 978-072-343-566-2.

4.      Denial Bernstein. Pediatrics for medical Students. – Second edition, 2012. – 650 p.

ATTACK OF BRONCHIAL ASTHMA IN CHILDREN OF EARLY AGE

As a result of anatomo-physiologic features of breathing organs  in the children of early age  the pathophysiologic mechanisms of bronchoobstruction and  edema of mucus membrane of bronchial tubes and hypersecretion of bronchial glands come forward on the first plan. It is the reasone of  more gradual beginning and slow  development of disease, “moist” character of asthma, less efficiency of sympatomimetics.

Clinic. Trouble, crabbiness of child at the moderate phenomena of general intoxication and normal temperature of body. Cyanosis  of lips, nasolibs triangle, acrocyanosis. Dyspnoe, noisy, with the prolonged inspiration and   distance wheezes. Downing in of interribs intervals, supraclavicular areas, jugular pit. Attacks of underproductive, sometimes attack cough. A thorax is emphizematous, at percussion above lungs bandbox sound, at auscultation breathing is hard, with the prolonged inspiration and dissipated dry and different moist wheezes. Таchycardia. A liver is often enlarged. There can be eozinophylia in the general analysis of   blood, sometimes there is moderate neutrophyl leucytosis. On the X-ray examination of thorax organs pulmonary  picture is strengthening , areas of promoted pneumatisation without of infiltrative changes in lungs.

 

                            Further Inpatient Care

Admit patients for treatment of acute severe episodes if they are unresponsive to outpatient care (eg, they have worsening bronchospasm, hypoxia, evidence of respiratory failure).

Once the patient is admitted, further investigations (eg, PFTs, allergy testing, and investigations to rule out other associated conditions and complications) can be performed.

                                Further Outpatient Care

Regular follow-up visits (1-6-mo intervals) are essential to ensure control and appropriate therapeutic adjustments.

Outpatient visits should include the following:

Ø     Interval history of asthmatic complaints, including history of acute episodes

Ø     (eg, severity, measures and treatment taken, response to therapy)

Ø     History of nocturnal symptoms

Ø     History of symptoms with exercise and exercise tolerance

Ø     Review of medications, including use of rescue medications

Ø     Review of home-monitoring data (eg, symptom diary, peak flow meter

Ø     readings, daily treatments)

Ø     Patient evaluation should include the following:

Ø     Assessment for signs of bronchospasm and complications

Ø     Evaluation of associated conditions (eg, allergic rhinitis)

Ø     Pulmonary function testing (in appropriate age group)

Ø     Address issues of treatment adherence and avoidance of environmental

Ø     triggers and irritants.

Long-term asthma care pathways that incorporate the aforementioned factors can serve as roadmaps for ambulatory asthma care and help streamline outpatient care by different providers.

In the author's asthma clinic, a member of the asthma care team sits with each patient to review the written asthma care plan and to write and discuss in detail a rescue plan for acute episode, which includes instructions about identifying signs of acute episode, using rescue medications, monitoring, and contacting the asthma care team. These items are reviewed at each visit.

Inpatient & Outpatient Medications

ü     Bronchodilators (short- and long-acting)

ü     Controlling medications (nonsteroidal, steroidal, newer agents such

             as leukotriene modifiers)

ü     Medications for the treatment of associated conditions (antiallergy

               medications, nasal steroids for allergic rhinitis)

ü     Rescue medications for use in acute episodes (short burst of steroids)

                              Transfer

         Any patient with a high risk of asthma should be referred to a specialist. The following may suggest a high risk:

§                   History of sudden severe exacerbations

§                   History of prior intubation for asthma

§                   Admission to an ICU because of asthma

§                   Two or more hospitalizations for asthma in the past year

§                   Three or more emergency department visits for asthma in the past year

§                   Hospitalization or an emergency department visit for asthma within the

§                   past month

§                   Use of 2 or more canisters of inhaled short-acting beta₂-agonists per month

§                   Current use of systemic corticosteroids or recent withdrawal from

       systemic corticosteroids

The choice between a pediatric pulmonologist and an allergist may depend on local availability and practices. A patient with frequent ICU admissions, previous intubation, and a history of complicating factors or comorbidity (eg, cystic fibrosis) should be referred to a pediatric pulmonologist. When allergies are thought to significantly contribute to the morbidity, an allergist may be helpful.

Prevention

The goal of long-term therapy is to prevent acute exacerbations.

The patient should avoid exposure to environmental allergens and irritants that are identified during the evaluation.

Complications

§        Pneumothorax, status asthmaticus with respiratory failure

§        Fixed (nonreversible) airway obstruction

§        Death

Prognosis

Of infants who wheeze with URTIs, 60% are asymptomatic by age 6 years; however, children who have asthma (recurrent symptoms continuing at age 6 y) have airway reactivity later in childhood.

Some findings suggest a poor prognosis if asthma develops in children younger than 3 years, unless it occurs solely in association with viral infections.

Individuals who have asthma during childhood have significantly lower FEV1 and airway reactivity and more persistent bronchospastic symptoms than those with infection-associated wheezing.

Children with mild asthma who are asymptomatic between attacks are likely to improve and be symptom-free later in life.

Children with asthma appear to have less severe symptoms as they enter adolescence, but half of these children continue to have asthma.

Asthma has a tendency to remit during puberty, with a somewhat earlier remission in girls. However, compared with men, women have more BHR.

                    Patient Education

Patient and parent education should include instructions on how to use medications and devices (eg, spacers, nebulizers, MDIs). The patient's MDI technique should be assessed on every visit.

Discuss the management plan, which includes instructions about the use of medications, precautions with drug and/or device usage, monitoring symptoms and their severity (peak flow meter reading), and identifying potential adverse effects and necessary actions.

Write and discuss in detail a rescue plan for an acute episode. This plan should include instructions for identifying signs of an acute attack, using rescue medications, monitoring, and contacting the asthma care team.

Parents should understand that asthma is a chronic disorder with acute exacerbations; hence, continuity of management with active participation by the patient and/or parents and interaction with asthma care medical personnel is important.

Emphasize the importance of compliance with and adherence to treatment.

Incorporate the concept of expecting full control of symptoms, including nocturnal and exercise-induced symptoms, in the management plans and goals (for all but the most severely affected patients).

Avoid unnecessary restrictions in the lifestyle of the child or family. Expect the child to participate in recreational activities and sports and to attend school as usual.

                  ASPIRATION SYNDROME

 One of the most common causes of BOS in infants - a syndrome of habitual microaspiration of liquid food associated with dysphagia, often in combination with gastro-oesophageal reflux. Up to 30% of all cases of recurrent cough in infants are associated with aspiration syndrome. Determination of the cause may be difficult. Anamnestic data helps in the diagnosis of aspiration. Usually in these children there are the history and neurological symptoms such as attack coughing that develops in the child during feeding, the appearance of dry or moist rales in the lungs after a meal. The diagnosis is confirmed after examining a patient in the hospital.

Asthmatic State In Children

The asthmatic state is the attack of asthma, which lasts more than 6–10 hours and resistant to sympatomimetics and methylxantins. It is characterized by total bronchoobstruction on a background of refraction of b₂-adrenoreceptors with progress of hypoxia, hypercapnia, decompensative acidosis, dehydration and development of acute cardiac insufficiency of a right-heart type. In the process of development of the asthmatic state three stages are selected: relative indemnification, decompensation and hypoxemic comma.

Diagnostic criteria of asthmatic status

1. Protracted attack of bronchial asthma, which is not cured during 6 hears

    and anymore.

2. Resistens to sympatomimetics.

3. Violation of drainage function of bronchial tubes.

4. Development hypoxemia -  РаО₂  - 60 ml Hg, hypercarpnia - РаСО₂ ­ 60 ml Hg.

                                         Clinic.

 I stage of the asthmatic status (relative compensation). Forced sitting  position, leaning against hands, tachypnoe with the considerably prolonged inspiration, attack cough with much amount of viscid phlegm which is badly deleted. Skinis pale, cyanosys of lips, nasolips triangle, acro- or general cyanosys. A thorax is emphysematous, the excursion  is limited, above lungs percussion box sound. Plenty of the  distance wheezes in comparisone with little amount of  dry wheezes, the loosened breathing in lungs. The border of heart is not determined, are low, systolic murmur on an apex, tachycardia. A liver is enlarged, sickly. Arterial pressure is decreased.

                      Help on prehospital stage

1.    Do not use of symdatomimetics!

2.    To provide access of fresh air.

3.    To release from squeezing clothes.

4.    Oxygentherapy:  moistened air through a mask.

5.    2,4 % solution of Euphyllini in dose of a 5 mg/kg of  mass of intravenously streamly on a 15 –20 ml of isotonic  solution of sodium chloride.

6.    2 % solution of No-spani a 1 mg/кг mass on dose intramuscular.

7.    3 % solution of Prednisoloni 2-3 mg/kg of the masses (Hydrocortisonі 10-15 mg/kg) intramuscular or intravenously streamly.

8.    Urgent hospitalization.

Help on a hospital stage

1.    Do not use sympatomimetics!

2.    To provide access of fresh air.

3.    Oxygentherapy optimum 40 % by the moistened oxygen constantly.

4.    3 % solution of Prednisoloni in dose 2-3 mg/kg of  the mass intravenously streamly on a 5-10 ml of  isotonic  solution of sodium chloride.

5.    2 % solution of No-spani  1 mg/kg of  mass on dose intramuscular or intravenously streamly slowly.

6.    Solution of Corgliconi 0,06 % or Strophantini 0,05 % 0,1 ml per the year                        of life, but not more than 0,3-0,4 ml on a 5-10 ml isotonic  solution of sodium  chloride  intravenously streamly.

7.    Cocarboxylazae 50-100 mg, 5 % solution of sodium ascorbinati 2,0-5,0 ml, Panangini 0,5 ml per year of life of intravenously streamly in separate syringe .

8.    2,4 % solution of Euphyllini 7-10 mg/kg of  mass on a 200 ml of isotonic                    solution of sodium  chloride intravenously with a next continuous tranfusion on Euphyllinization by intravenously infusion of 2,4 % solution of Euphyllini at a speed of 0,7 mg/kg/hour on isotonic  solution of sodium  chloride, but not more than 24 mg/kg/day for the children upto 9 years and 20 mg/kg/day for children  senior than  9 years.

9.    Heparini 200-300 U/day on 4 intravenous stream injection every 6 hours.

10.          Reopoliglucini 150-200 ml intravenously in drops.

11.          In default of effect in 2 hours o repeate intravenous stream injection of                     Prednisolone 2-3 mg/kg of  the masses or Hydrocortisoni 10-15 mg/kg of  mass.

12.          Alkaline drink: mineral water, 1 % solution of soda, milk with a soda.                    Intravenous  injection of 4 % solution of sodium bicarbonatis only under the control of  acid – alkaline equilibrium indexes.

13.          Absence of effect after the repeated injection  of glucocorticoids testifies to transition of the asthmatic state in the ІІ stage.

Clinic of the ІІ stage of the asthmatic status (decompensations). Child in consciousness, excited or apathetical. General cyanosis of skin and mucus, a person is puffy, the veins of neck are swelling. Breathing is encreased, noisy with the prolonged inspiration and acute downing in of interribs intervals, supraclavicular and epigastrial areas, jugular pit with a limited excursion of thorax. Percussion: bandbox sound. Breathing is sharply loosened with single unsounding dry wheezes, in the lower areas of lungs breathing is not listened, syndrome of “mute lungs”. Таhycardia, pulse of the weak filling, unrhythmical. The tones of heart are not determined, tones are deaf. Arterial pressure is reduced. A liver is enlarged, sickly.

Help on prehospital stage

1.             To provide access of fresh air.

2.             Oxygentherapy:  moistened air through a mask.

3.             2,4 % solution of Euphyllini in dose of a 5 mg/kg of  mass intravenously

                    streamly on a 15-20 ml of  isotonic  solution of sodium  chloride.

4.             3 % solution of Prednisoloni in dose of a 3-5 mg/kg of  mass or

                   Hydrocortisoni 15-25 mg/kg of  mass intramuscular or intravenously

                   streamly.

5.             Urgent hospitalization.

Help on  hospital stage

1.             To provide access of fresh air.

2.             Oxygentherapy: optimum 40 % of the moistened oxygen constantly

                     through a mask.

3.             3 % solution of Prednisoloni in dose of  3-5 mg/kg of  mass or

                   Hydrocortisoni  15-25 mg/kg of  mass of intravenously streamly with the

                   repeated introduction after 1,5-2 hours in default of effect.

4.             2 % solution of No-spani 1 mg/kg of mass in dose intramuscular or

                    intravenously streamly slowly.

5.             Solution of Corgliconi 0,06 % or Strophantini 0,05 % in dose 0,1 ml per

                     the year of life, but not more than 0,3-0,4 ml intravenously streamly on a

                     5-10 ml of  isotonic solution of sodium  chloride.

6.             Cocarboxylazae 50-100 mg, panangini 0,5 ml per year of life, 5 %

                    solution of  sodium  ascorbinati 2,0-5,0 ml intravenously streamly in

                    separate syringes.

7.             2,4 % solution of Euphyllini 7-10 mg/kg of mass on a 200 ml of isotonic

                    solution of sodium  chloride of intravenously in drops. If Euphyllini was

                   already entered at treatment of I stage of the asthmatic status, continue

                   Euphyllinization at a speed of 0,7 mg/kg/hour on isotonic solution of

                   sodium chloride 50 ml/ hour.

8.             Heparini 200-300 Units/kg/days, divided in 4 injections, every 6 hours

                      intravenously streamly.

9.             In default of effect after the repeated introduction of glucocorticoids

                    urgent intubation with bronchoscopy sanation and after that- artificial

                    ventilation.

10.        On artificial ventilation Euphyllinization must be continued, repeat

                    introductions of Prednisoloni every 1,5-2 hours in  dose of  6-10 mg/kg

                   of  mass.

11.        Mucolitic drugs endotrachially with the following lavagge of bronchial

                     tubes with bronchoscopy.

12.        Intravenously 4 % solution of sodium bycarbonatis only under the

                      control of indexes acid – alkaline equilibrium.

13.        Haemosorbtion, plazmopheresis.

It is not recommended to enter:

1.Antihistaminic drugs – Suprastini,Tavegili, Claritini.

2.Sedative drugs – Seduxeni, Sodium oxytirati , Aminasini.

3.Drugs with ephedrini – Solutani, Broncholitini.

4.Unselective b_2- -adrenomimetics - Astmopent, Alupent, Izadrin.

5.Prolonged b_2- -adrenomimetics – Salmeterol, Seretid.