OBJECTIVE: To summarize and discuss the effective management methods and techniques of pediatric tracheal and bronchial foreign bodies.
METHODS: To review and summarize the management of 1204 cases of tracheal and bronchial foreign bodies in surgeries completed by the authors from January 1990 to December 2004. The age of the children was as young as 9 months and as old as 14 years. The result was that all the foreign bodies were successfully removed surgically except for one case in which a metal whistle that had remained for 6 years was finally removed by open chest. Conclusion Tracheal and bronchial foreign body
The method and technique of tracheal and bronchial foreign body removal are very important and critical factors for successful treatment of pediatric tracheal and bronchial foreign bodies.
Tracheal and bronchial foreign body is an acute problem in pediatric otolaryngology. Removal of foreign body by surgery is the only final and effective measure. How to avoid complications and remove the foreign body quickly during surgery depends on many factors, but the method and technique of tracheal and bronchial foreign body removal are very important and critical factors. To summarize the more than one thousand cases of tracheal and bronchial foreign body removal completed by the author from January 1990 to December 2004, we would like to discuss our experience and feelings about the surgery.
Clinical data: 1204 cases of pediatric tracheal and bronchial foreign body surgeries completed by the authors from January 1990 to December 2004. The sites of foreign body obstruction: 528 cases in the left bronchus, 618 cases in the right bronchus, 43 cases in the trachea, and 15 cases in the bilateral bronchus. The types of foreign bodies included: 1135 cases of plant-based foreign bodies (peanut kernels, peanut shells, sunflower seeds, watermelon seeds, pumpkin seeds, corn, beans, date kernels,); 69 cases of special types of foreign bodies (plastic pen caps, whistles, automatic pencil heads, bamboo flutes, large-headed pins, iron nails, stones, milk teeth, pins, roller balls,, chicken bones, fish bones, plastic toys, screws, valve core caps). The ages ranged from 9 months to 14 years. The shortest time of foreign body choking was 4 hours and the longest was 6 years. Except for one case in which a metal whistle that had remained for 6 years was finally removed by open-heart surgery, all the foreign bodies were successfully removed by surgery. There were no intraoperative or postoperative tracheotomy cases.
Surgical steps
1.Preparation of instruments and apparatus.
(1) Routinely prepare two sets of cold light sources, one connected to the direct laryngoscope and the other to the bronchoscope.
(2) Select the appropriate direct laryngoscope and bronchoscope according to the age of the child. Choose a small direct laryngoscope and a 3.0F bronchoscope for 5 months to 1 year old; choose a medium direct laryngoscope and a 3.5F bronchoscope for 1 to 2 years old; choose a large direct laryngoscope and a 4.0F bronchoscope for 2 to 4 years old.
(3) Prepare foreign body forceps according to the child’s foreign body history and X-ray film, such as foreign body of peanut rice, prepare crocodile mouth forceps, antitension forceps, biopsy forceps, etc., as well as suction head, trigeminal lens, mirror plugs, etc. that go with this.
(4) Check whether the emergency equipment such as monitor, oxygen, suction device is intact before surgery.
(5) High-frequency ventilation connections are ready.
(6) Tracheotomy kit and various types of tracheal cannulae are ready.
2.Surgical methods and techniques
(1) Exposure of the voice box
The child is routinely placed in the supine position with the head 10-15 cm above the operating table, the assistant sits on the right side of the operating table, so that the child’s head is resting on the left knee, the left hand fixes the forehead, the right hand holds the child’s chin, so that the child’s neck is extended, the shoulders should be fixed and pressed down and flattened, which is important for the operator to be able to gently pick up the epiglottis as soon as possible to expose the vocal canal. First, put a piece of gauze on the upper incisor, put the direct laryngoscope into the mouth with the left hand, lift the tongue root, expose the epiglottis, then push the direct laryngoscope to the surface of the epiglottis, lift the epiglottis upward to expose the vocal incisors, the key action is to lift the shoulder strength while the bowl rotates inward, do not take the upper teeth as the fulcrum to cock the epiglottis upward, which can not fully expose the epiglottis and easily damage the upper teeth or gums. Expose the vocal canal while observing the vocal canal and subvocal canal.
(2) Surgical method of tracheal foreign body
For children with a “tapping sound” or a foreign body clearly located in the trachea, or children with significant respiratory distress or respiratory failure, the voice box should be exposed with direct laryngoscopy under no anesthesia. Extend the crocodile-mouth foreign body forceps under the voice box and immediately rotate the jaws by 900 so that the posterior lobe of the forceps is pressed against the posterior wall of the trachea and the upper lobe is open. As soon as the head of the forceps is extended under the vocal cords, the patient immediately has a reflex cough, and the foreign body can have a slight impact feeling when it rushes into the mouth of the forceps, which immediately closes the mouth of the forceps, and if the mouth of the forceps does not close tightly, it means that the foreign body is clamped, and the forceps are rotated 900 to remove it. If the first time not taken out can be swabbed again, open the jaws under the vocal cords to stimulate the child to cough, in order to activity foreign body is flushed into the jaws, remove foreign body. If the swabbing is unsuccessful three times, the posterior lobe of the forceps can be placed against the posterior wall of the trachea and the upper and lower lobes of the forceps can be opened and closed while reaching downward to find the foreign body. If the clamp clips tissue such as mucosa or bronchial opening in the groping, the clamp can not move up and down but move up and down with breathing, then it should be abandoned immediately and never pulled out forcibly. If the jaws cannot remove the foreign body in the up and down open part, then the position should be changed, rotate 900 and open in the left and right horizontal position to remove the foreign body that may be in the upright position in the trachea. If it still cannot be swabbed successfully, the bronchoscope should be introduced immediately.
(3) Surgical method of bronchial foreign body
After the left hand holds the direct laryngoscope to expose the vocal canal, do not move, the right hand clamps the bronchoscope horizontally (the bevel of the mirror mouth is vertical) to the vocal canal, immediately change the view of the vocal canal from the mouth of the bronchoscope, push the bronchoscope into the trachea about 2cm when inspiratory, withdraw the direct laryngoscope, wrap the bronchoscope with the gauze padded by the upper teeth, connect high-frequency ventilation, the left hand supports the fixed bronchoscope not to move to the left and right, and the right hand pushes inward. The principle of advancement is “no hole is too small”. Advance along the trachea under direct vision, and instruct the assistant to adjust the head position during the advancement to keep the mirror parallel to the trachea. The method of adjusting the head position is “head high”, which means the whole head moves upward, “head low” means the whole head moves downward, “head tilt” means the head position remains unchanged, and the right hand pushes the lower jaw backward to make the head Tilt the head back. “Head down” means the head position remains unchanged, and the left hand is lifted upward to bring the lower jaw closer to the sternum. After reaching the tracheal ridge, the preoperative diagnosis of no foreign body or suspected foreign body is entered first. The right hand gently turns the bronchoscope, entering the right side to the left and the left side to the right. The assistant turns the head synchronously according to the direction of oxygen supply tube rotation on the bronchoscope, and pushes into the bronchus after the bronchial opening is exposed. During the bronchial advancement, the assistant is instructed to change the head position to reach the bronchial rongeur and reveal the bronchial opening of each lobe, then withdraw to the bronchial rongeur and re-enter the other side. If a foreign body is found on the first side, do not swab it, but continue to examine the other side, if there is no foreign body on the other side, go back to the first side and swab the foreign body, if there is a foreign body on the posterior side, swab the posterior side first, remove it, and then take the foreign body on the anterior side. The method of swabbing foreign body is to bring the bronchoscope close to the foreign body, aspirate the secretion around the foreign body, put the foreign body clamp into contact with the foreign body from the bronchoscope, (not to push the foreign body inward), and decide the opening direction of the clamp by the shape of the foreign body and the gap between the foreign body and the bronchial wall. Withdraw the bronchoscope about 1cm, foreign body clamp does not move, naturally open the mouth of the clamp, so that a lobe of the clamp mouth and foreign body and one side of the bronchial wall gap on the side of the large stick, lightly push about 0.5 ~ 1cm, clamping. If the foreign body is not clamped immediately withdraw the foreign body clamp, aspirate the secretion, re-approach the mirror lip to the foreign body, observe the position of the foreign body and bronchial wall, bleeding, and then retry to take. Do not advance while clamping (this is easy to shatter the foreign body, and the second is to push the foreign body into the deep, or even into the lobe trachea orifice). If the foreign body has been clamped, the clamping force varies depending on the type of foreign body, which requires experience and continuous exploration, keep the force unchanged after clamping, withdraw the foreign body clamp, bronchoscope does not move, lightly touch the lip of the bronchoscope, can not pull out the foreign body clamp, at this time the right hand to keep the foreign body clamp and bronchoscope relative position does not move, use the left hand to withdraw the bronchoscope backward, the withdrawal process, the assistant will gradually rotate the head position from the position During the withdrawal process, the assistant gradually adjusts the head position from rotational position to positive position to ensure that the bronchoscope and foreign body clamp are withdrawn together. The bronchoscope should be withdrawn vertically when exiting the vocal fold, as close to the vocal fold as possible (so that the lip of the mirror is vertical to the vocal fold to protect the foreign body from being blocked by the vocal fold and dislodged under the vocal fold). Immediately after withdrawing the bronchoscope, the surgeon checks the foreign body for integrity to determine whether it is removed intact. During the withdrawal of the bronchoscope, the second assistant has prepared the direct laryngoscope, and if a second lower bronchoscope is needed, the bronchoscope is immediately reintroduced for examination and swabbing as described above.
If the foreign body is dislodged in the process of exit, one is blocked by the vocal hatch and dislodged under the vocal hatch; one is blocked by the tongue root and dislodged in the oral cavity, which is mostly caused by the bronchoscope not changing the angle of the oral cavity in time after exiting the vocal hatch. At this time should immediately pick up the tongue root with direct laryngoscope, need to quickly while sucking secretions with suction, while checking whether there is a foreign body in the oral cavity, such as no, do not delay, immediately expose the vocal fold, observe the vocal fold and subglottic situation, there is a foreign body directly with alligator forceps to remove the foreign body, and then into the bronchoscope to check to determine whether there is a foreign body on both sides of the deposit, if there is a foreign body, re-try to take.
(4) Surgical method of foreign body in lobe bronchus
There are two methods to remove the foreign body from the lobe bronchus: one is to adjust the bronchoscope to the lobe bronchus mouth, if the foreign body is in the lobe bronchus mouth, or partly outside the bronchus mouth, the foreign body forceps directly try to take, if the foreign body has entered the lobe bronchus, the fine tip foreign body forceps should close the mouth, first enter the lobe bronchus mouth, then gently open and push inward, do not force or reckless, incorrect method or too much force is very likely to cause tracheal rupture. For the lobe bronchial mouth or the foreign body within the clamp needs more rich experience of bronchial foreign body removal. The second is to introduce the foreign body into the foreign body storage site with fiberoptic bronchoscope and remove the foreign body with fiberoptic bronchoscope foreign body clamp.
(5) Removal methods for special foreign bodies
① Columnar or conical foreign body with hole in the middle, such as plastic pen cap, automatic pencil tip, mouth flute, etc. As the foreign body is large, it is usually kept in the trachea or bronchus, and some of the middle holes can have airflow, or one end is blind or the middle hole is blocked, forming a distal negative pressure, and this foreign body is generally close to the trachea or bronchial wall. Surgical method should be bronchoscope lip contact foreign body lateral shift, so that the mirror lip against the side of the trachea or bronchial wall, the larger foreign body clamp half open (so that a lobe clamp head from the middle hole into), there is a gap since the gap inserted, no gap a little force into the foreign body clamp up to 0.5cm, force clamping, gently turn, clamping the side wall of the foreign body pulled outward, sometimes due to negative pressure, swelling and other reasons of resistance. Can be more forceful outward pulling, pulling will suddenly feel the resistance disappeared, along with the bronchoscope together with the exit, out of the vocal fold to adjust the position of the foreign body, do not damage the vocal fold due to foreign body (because the foreign body clamping, generally will not be the vocal fold block off, but the position is not correct, the damage to the vocal fold caused by forceful force).
② For round or solid irregular non-vegetative foreign body, such as roller ball. The application of three-jawed forceps try to take, due to the shortcomings of the three-jawed forceps themselves, try to take can not force to advance, it is very easy to cause serious complications such as damage to one of the jaws or penetrate the wall of the trachea. Try to take three times if unsuccessful, should be bronchoscope lip against one side of the bronchial wall, with a crochet needle (crochet needle bending part depending on the location of the foreign body to stay) horizontal insertion, after crossing the foreign body, rotate 90 °, the foreign body hooked outward, and then try to take with the three-clawed forceps. Take this foreign body to have patience, can not be rushed.
③ other special foreign bodies such as denture, nails, stones, bone fragments, etc., the integrated use of the above methods, are not difficult to remove.
(6) For the foreign body that has been completely wrapped by granulation due to long-term retention, it is recommended to remove the foreign body by opening the chest.
Surgery-related issues
1.Posture requirements of doctors and nurses
The nurse holding the head is seated on the right side of the operating bed, and the height of the left foot is enough for the knee to be the support point of the hand; the soles of the feet cannot be mostly suspended, that is, to ensure that the height can be flexibly adjusted during the operation and not to make the head position unstable due to fatigue caused by the long operation time, and we have made a multi-layer step stool. The surgeon should take a sitting position for the operation.
2.Intraoperative operation cooperation
While changing the head position according to the operator’s request, another important duty of the head nurse is to observe the change of the color of the child’s lips, especially in acute anesthesia-free surgery, and to notify the operator immediately of any changes in the condition.
3.Intraoperative medication problem
As the foreign body in most cases is mostly plant-based foreign body, such as: fava beans, peanut rice, melon seeds, etc. These substances contain free fatty acid and oleic acid, which are easy to swell and erode after absorbing water; the mucous membrane around the foreign body is also easy to swell, and repeated attraction and clamping during the operation will easily aggravate tracheal and bronchial edema. Therefore, intraoperative intravenous dexamethasone is routinely injected to achieve anti-inflammatory and eliminate laryngeal, tracheal and bronchial edema.
4.Application of high-frequency ventilation
High-frequency jet ventilation can not only regulate oxygen flow but also provide a certain oxygen supply pressure, which is intermittent oxygen supply. As long as the appropriate working parameters are maintained, the intraoperative oxygen saturation can still be normal, as confirmed by surgical monitoring. The application of high-frequency ventilation has an important role to play in ensuring the smooth performance of surgery.