Foreign body in trachea – various foreign objects that got into the windpipe as a result of aspiration or injury. The clinic of a foreign body in trachea is characterized by a painful cough, acrocyanosis, attacks of suffocation, vomiting, a symptom of balloting. Diagnosis of a foreign body in trachea is based on the data of anamnesis, external examination, auscultation and percussion, laryngoscopy, tracheobronchoscopy, X-ray examination. Medical care consists in the urgent extraction of foreign bodies in trachea by endoscopic or surgical means.
ICD 10
T17.4 Foreign body in the trachea
Meaning
Foreign bodies of the respiratory tract are observed mainly in childhood. Thus, over 93% of all cases of aspiration of objects into the tracheobronchial tree occur in children under the age of 5 years. According to the frequency of entry into various parts of the airway, foreign bodies in trachea occupy an intermediate place (18%) between foreign bodies in bronchus (70%) and foreign bodies in larynx (12%). A foreign body in trachea is a serious danger due to the possibility of asphyxia and death of the patient. Prevention and therapeutic tactics for foreign bodies of the larynx, trachea and bronchi are topical issues of modern otolaryngology and pulmonology.
The trachea or windpipe is a hollow cartilaginous tube connecting the larynx and the main bronchi. The trachea is located at the level of the VI cervical – IV-V thoracic vertebrae, in an adult it has a length of 11-13 cm. With its upper end, the windpipe is connected to the cricoid cartilage of the larynx; in the lower part, the trachea is divided into the main bronchi (right and left). The place of separation of the trachea into the main bronchi is called tracheal bifurcation. On average, the diameter of the trachea in an adult is 1.5—1.8 cm, while it is not the same throughout the breathing tube and decreases in the tracheal bifurcation zone. Therefore, foreign bodies in trachea are quite often localized in the bifurcation area.
Causes of foreign body in trachea
Foreign bodies enter the windpipe from the mouth or from the outside, through the wound canal of the neck or chest.
In the vast majority of cases, there is an aspiration mechanism of penetration of foreign bodies into the trachea. Most often this is due to the vicious habit of holding various small objects in the oral cavity, which, by carelessness or childish pranks, slip into the windpipe. The ingress of foreign bodies into the trachea usually occurs with a deep breath, hasty eating, laughing, talking, fright, coughing, while playing. In some cases, aspiration of foreign bodies into the trachea is facilitated by the misalignment of the function of the epiglottis, which covers and opens the entrance to the larynx. The uncoordinated lifting of the epiglottis during swallowing opens the entrance to the larynx, and foreign bodies are carried away by a jet of air into the respiratory tract. As a result of the subsequent reflex closing of the vocal folds and spasm of the vocal muscles, the foreign body cannot leave the windpipe even with a strong cough.
Conditions that increase the risk of aspiration of foreign bodies into the trachea are defects in dentition, the use of poorly fixed dentures, diseases that occur with sudden coughing attacks (bronchitis, whooping cough, etc.). Ingestion of foreign bodies into the trachea can be observed in patients with neurological disorders accompanied by a decrease in innervation of the oral cavity, larynx and pharynx (stroke bulbar paralysis, myasthenia gravis, traumatic brain injuries), as well as persons suffering from epilepsy, under the influence of anesthesia, intoxicated, suddenly unconscious.
It is possible that foreign bodies may enter the trachea during dental manipulations, especially if local conduction anesthesia is used. Potentially dangerous manipulations include removal of crowns, tooth extraction, removal of casts for prosthetics, etc. Cases of dental instruments getting into the trachea are described: extractors, cutters, fragments of hooks. In patients with tracheostomy, devices for cleaning the tracheostomy cannula may enter the trachea. The migration mechanism of foreign bodies entering the trachea is possible, for example, from the pharynx (leeches, ascarids), esophagus (sewing needles, etc.) or bronchi (bronchitis).
Symptoms of foreign body in trachea
The clinic of a foreign body in trachea is determined by the totality of the previously considered pathological mechanisms. Immediately after aspiration of a foreign body, patients experience suffocation. Following this, as a protective mechanism, a paroxysmal cough occurs, resembling that of whooping cough. Coughing attacks are accompanied by lacrimation, separation of saliva and nasal mucus, vomiting, cyanosis of the face. With the displacement of a foreign body into the larynx and its infringement in the area of the vocal folds, asphyxia may develop.
After the acute phase, there is some improvement in the condition. Cough worries periodically, intensifying with a change in body position, physical effort. There is difficulty breathing, pain behind the sternum, separation of mucosal sputum sometimes with traces of blood or fragments of a foreign body.
With balloting foreign bodies in trachea, a popping sound is clearly heard, and when palpating the anterior surface of the neck, jerky movements are felt. You can also remotely hear various sound phenomena (whistling, buzzing, wheezing) that occur when an air jet passes between the walls of the trachea and a foreign body. Alternating overlap of the right and left main bronchus with an unfixed foreign body leads to significant respiratory disorders and the development of bilateral pneumonia.
With fixed foreign bodies in trachea, the condition of patients can be extremely severe. Tachypnea, inspiratory or expiratory dyspnea, pronounced acrocyanosis, retraction of compliant areas of the chest are noted. The patient is restless, tends to take a position that facilitates breathing.
The introduction of fixed objects into the trachea can lead to bedsores, ulcers, followed by the proliferation of granulation tissue and the development of tracheal stenosis. Foreign bodies in trachea must be distinguished from acute tracheitis, severe pneumonia and asthmatic bronchitis.
Diagnostics
Foreign bodies in trachea are recognized by physical, endoscopic and X-ray examination. Otolaryngologists, pulmonologists, radiologists, endoscopists are involved in the examination of patients. During clinical examination, sonorous, somewhat labored breathing is detected, sound phenomena of stridor and balloting of a foreign body are heard above the trachea area; dry wheezing is heard in the lungs.
With the help of laryngoscopy, it is possible to obtain direct and indirect confirmation of the fact of aspiration: it is possible to see a foreign body or traces of damage to the mucous membrane of the trachea. Foreign bodies located at the bifurcation level can be detected during tracheobronchoscopy, lung x-ray, bronchography.
Treatment for foreign body in trachea
Therapeutic tactics for a foreign body in trachea is reduced to its urgent extraction. When choosing a method for removing a foreign body from the trachea, its location, shape, size, consistency, degree of displacement, age and individual characteristics of the patient are taken into account.
The preferred method is endoscopic extraction of foreign bodies from the tracheal lumen. Sometimes foreign objects can be removed by direct laryngoscopy. In other cases, upper tracheobronchoscopy is resorted to under general anesthesia, tracheal aspiration.
Indications for the prompt removal of a foreign body from the trachea are its deep occurrence, wedging into the wall of the trachea, pronounced violation of external respiration. In this case, a tracheotomy is performed and a foreign object is removed by lower bronchoscopy. Following the removal of a foreign body from the trachea, the tracheotomy opening is sewn tightly with a primary suture (if the object was removed shortly after ingestion) or left for temporary insertion of a tracheostomy tube. In case of rupture of the trachea or other complicated variants, it is necessary to resort to open surgical intervention.
After removal of foreign bodies in trachea, antimicrobial therapy is performed to prevent purulent-inflammatory complications. Measures to prevent foreign bodies from entering the trachea do not differ from those for foreign bodies of the respiratory tract of a different localization.
Literature
- An alternative method of management of pediatric airway foreign bodies in the absence of rigid bronchoscopy. Tamiru T, Gray PE, Pollock JD. Int J Pediatr Otorhinolaryngol. 2013 Apr;77(4):480-2. link
- Unusual large foreign bodies in the lower respiratory passages and cervical soft tissues. Akhmatnurova NV. Vestn Otorinolaringol. 2009;(2):60-1. link
- Extraction of a large tracheal foreign body through a tracheotomy. Golz A, Fradis M, Netzer A, Joachims HZ, Westerman ST, Gilbert LM. Am J Otolaryngol. 1997 Sep-Oct;18(5):335-7. link
- Diagnosis and management of upper aerodigestive tract foreign bodies. Digoy GP. Otolaryngol Clin North Am. 2008 Jun;41(3):485-96, vii-viii. link
- Sharp foreign bodies in the tracheobronchial tree. Murthy PS, Ingle VS, George E, Ramakrishna S, Shah FA. Am J Otolaryngol. 2001 Mar-Apr;22(2):154-6. link
