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Foreign bodies of the trachea and bronchi
Most often, foreign bodies of the respiratory tract are found in young children. This is because children, learning the world around them, take various objects into their mouths, and their protective reflexes are not sufficiently developed.
The frequency of predominant localization of foreign bodies in the respiratory tract is as follows: in the larynx - 13%, in the trachea - 22%, in the bronchi - 65% (Rokitsky M.R., 1978). Other authors cite approximately the same figures.
Facilitating moments for the penetration of foreign bodies into the respiratory tract are crying, laughing, talking with food, sudden excitement, accompanied by a deep breath while a food or foreign object (such as a pin or needle is a dangerous and common habit!) In the mouth, intoxication , as well as various neurological diseases (bulbar paralysis).
As soon as a foreign body passes the glottis, a reflex spasm occurs. The vocal folds close tightly, preventing the foreign body from being thrown back, despite a strong cough.
The overwhelming number of foreign bodies (70 - 30%), whose dimensions are less than the diameter of the trachea, fall on the right bronchus, which is almost a direct continuation of the larynx (Suprunov 3.K., 1960).
The clinical picture depends on the nature of the foreign body and the degree of its fixation in the lumen of the respiratory tract. Large foreign bodies (a piece of meat) caught during a conversation while eating in the respiratory tract can, first of all, obstruct the glottis of the larynx, or, passing through it, close the lumen of the bifurcation and cause asphyxiation, quickly lead to a tragic outcome.
Foreign bodies of plant origin (legumes, sunflower seeds), prone to swelling, can cause complete obstruction of the bronchus and atelectasis of the switched off segment of the lung, which leads to early infection and the development of pneumonia. Ears of cereals tend to penetrate into the pulmonary parenchyma, causing serious suppurative processes (Mitin Yu.V., 1994).
In the clinical course of the disease caused by a foreign body of the bronchus, three periods can be distinguished: the period of acute respiratory disorders, the secretive period and the period of complications.
The period of respiratory disorders begins from the moment a foreign body enters the respiratory tract and is accompanied by violent manifestations. It is characterized by paroxysmal, often repeated very painful cough for the victim, often turning into vomiting, which can simulate a clinic of a foreign body of the esophagus.
The secretive period begins with the field of movement of the foreign body through the respiratory tract with its subsequent fixation, expressed to one degree or another. Moreover, the farther from the main bronchi the foreign body is located, the less its clinical manifestations are expressed (Mitin Yu.V., 1994). This period is characterized by the disappearance of external manifestations of a foreign body. Breathing stabilizes, rare coughing fits can be regarded as symptoms of a cold.
The clinic of foreign bodies of the bronchi is determined by the general reactivity of the body, the length of stay of the foreign body in the bronchus and the variant of its obstruction. There are three types of bronchial obstruction: through, valve and complete.
In the first, most favorable form of obstruction, the foreign body does not completely close the lumen of the bronchus and does not cause a significant violation of gas exchange. The inflammatory process in the lung does not develop or is not clearly expressed.
The most common and unpleasant type of obstruction of the bronchus is valve. It occurs in cases where a foreign body almost corresponds to the diameter of the bronchus. During inspiration, with the expansion of the bronchus, air enters the lung. When you exhale, the lumen of the bronchus is reduced, which leads to its complete obstruction. As a result, distal to the foreign body, playing in this case the role of a valve valve, which lets in but does not let out air, there is an excessive accumulation of air and emphysema develops.
Complete obstruction of the bronchus turns off the blocked segment of the lung from the breath and leads to its atelectasis.
Atelectasis of the whole lung can occur reflexively, sometimes it is bilateral, which leads to very serious consequences.
A long stay of a foreign body causes the formation of bronchiectasis and suppurative process of the lung, which determines the further clinical picture of the period of complications.
The diagnosis of a foreign body of the trachea and bronchi is based on anamnestic data and clinical manifestations characteristic of a particular type of obstruction.
In typical cases, the diagnosis of a foreign body of the respiratory tract, especially the trachea, is not difficult. An important objective symptom is a cough, especially disturbing the patient at night. Sometimes coughing fits are accompanied by cyanosis and vomiting, resembling whooping cough. The appearance of a paroxysmal cough is characteristic with a change in body position, which is associated with the movement of a foreign object in the lumen of the respiratory tract and irritation of the mucous membrane. This movement of a foreign body and cough sometimes leads to its spontaneous removal.
A case is described when a patient with a foreign body of a bronchus making a trip to the hospital, shaking a railway carriage caused a cough, during which the foreign body on its own departed.
In our practice, we observed a patient with a hypersthenic physique with a short full neck, who, with a deep breath, got a cherry bone into the airways. During an additional x-ray examination, which was carried out after bronchoscopy, which did not bring success, she suddenly went away with a cough.
However, such happy examples of self-separation of a foreign body of the respiratory tract belong to casuistry.
An objective symptom of a foreign body of the trachea is its ballot, auscultation trapped like cotton. This is due to the impact of a foreign body thrown up during coughing on the lower surface of the vocal folds, which, in response to touching them, frantically contract, preventing it from exiting the trachea (Suprunov V.K., 1960).
With a complete obstruction of the bronchus over a portion of the lung turned off from the breath, weakened breathing and dullness of percussion sound are determined.
In the case of valve obstruction, the physical signs of emphysema are established. Incomplete obstruction of the bronchus does not give distinct percussion and auscultatory symptoms of a foreign body. Sometimes in these cases listening to stridor breathing is possible.
X-ray examination (fluoroscopy and radiography) is performed in all cases of suspicion of a foreign body.
It must be borne in mind that foreign bodies can be radiopaque in no more than 20% of cases (Mitin Yu.V., 1994). Without dwelling on all the details of the X-ray manifestation of the foreign body of the bronchi, its main signs should be noted, with which clinicians should be familiar. So, with incomplete through blockage of the bronchus, a pressure difference is created in both halves of the chest. As a result, when inhaling, the mediastinal organs - the heart and large vessels, move to the affected side, and when exhaling, they again occupy the middle position (Goltsknecht-Jacobson symptom). In the case of valve obstruction of the bronchus, the transparency of the affected segment of the lung increases, the mediastinal organs are shifted to the healthy side. Excursion of the diaphragm of the affected side is noticeably limited. With complete obstruction of the bronchus, as a result of the developed atelectasis, a homogeneous shadow radiologically determined, merging with the shadows of the mediastinum and the dome of the diaphragm.
The given clinical and radiological symptoms of foreign bodies of the trachea and bronchi, allows with a greater degree of probability to establish the correct diagnosis. In cases where the clinical manifestations are not clear enough and the diagnosis remains doubtful, the only reliable method is tracheobronchoscopy.
Thus, tracheobronchoscopy should be performed for diagnostic purposes in the presence of doubtful clinical signs of a foreign body and in all cases of its presence in the airways for removal.
Currently, foreign bodies of the trachea and bronchi are removed mainly through the natural pathways (upper tracheobronchoscopy) using a respiratory bronchoscope under general anesthesia and with the use of muscle relaxants. The widespread use in clinical practice of a respiratory bronchoscope, as well as fiber fiberscopes, allowed, in most cases, to abandon lower tracheobronchoscopy.
The following own clinical observation can serve as an illustration of the difficulty of establishing a diagnosis of a foreign body of the respiratory tract (bronchi) and the difficult circumstances that sometimes develop when it is removed.
A full man of 37 years during a business trip, eating a first course, accompanied by an active discussion of production matters, choked on meat bone. There was severe coughing and vomiting. In the future, there was a relative improvement, the patient was free to eat, voice and breathing were not disturbed. However, he was worried about recurring coughing fits and vague chest discomforts. Upon returning from a business trip, he was repeatedly examined in various medical institutions of the city, however, there was no suspicion of a foreign body of the respiratory tract and the absence of a foreign body of the esophagus was established. Clinical base of the Military Medical Academy. The doctor on duty, drawing attention to frequent coughing attacks, an anamnesis of the disease and suspecting a foreign body of the respiratory tract, hospitalized the patient. The characteristic appearance of coughing attacks during a change in body position (when getting out of bed) was noteworthy. There was no hemoptysis. Physical examination by the hospital’s therapists, given the patient’s completeness, did not establish sufficiently distinct clinical symptoms. When radiography was performed in the left half of the chest below the level of bifurcation a low-contrast shadow was determined, which could be mistaken for a foreign body. To clarify the diagnosis and remove a possible foreign body, the upper bronchoscopy using respiratory bronchoscope Friedel. A suspicious narrowing of the distal part of the left main bronchus filled with granulations was found. The foreign body was not visualized. Nevertheless, with forceps, it was possible to find a solid formation that wedged tightly into the wall of the bronchus. After repeated attempts, he managed to displace. It turned out to be a dense meat bone, resembling, in shape, a cocked hat with sharp edges. Removal of a foreign body that did not enter the lumen of the bronchoscope was performed simultaneously with its removal from the respiratory tract. When passing through the glottis, the bone caught on the vocal folds and slipped out of the forceps. Quickly inserted into the throat with the index finger managed to transfer the foreign body into the nasopharynx. After tracheal intubation and restoration of the normal course of anesthesia, in a calm environment, the foreign body was finally removed.
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Foreign bodies of the trachea and bronchi
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