36. Foreign body aspiration. Clinic. First aid.

Very often, a foreign body enters the respiratory tract by inhalation (aspiration). This usually happens to young children who use small objects while playing or inhale food while feeding. A variety of small objects can get into children's airways. Foreign body in the upper respiratory tract in children may threaten their lives, so it is necessary to urgently consult a specialist. ENT doctors very often remove all kinds of small objects, parts of toys and parts of food from the nose, lungs, bronchi, larynx and trachea of ​​children.

When a foreign body enters the bronchus or smaller airways, children experience coughing, weakening of respiratory sounds, and wheezing for the first time. This classic triad is observed in only 33% of children who aspirate a foreign body. The longer foreign objects remain in place, the more likely the presence of a triad of symptoms is, but even with significantly late diagnosis it develops in 50% of children. Aspiration of a foreign body in children is common, the objects are varied, but among them they predominate food products: nuts (peanuts), apples, carrots, seeds, popcorn. In children who have inhaled a foreign body, signs of severe stenosis of the upper respiratory tract are observed: attacks of suffocation with prolonged inhalation, with periodically strong cough and cyanosis of the face up to lightning asphyxia, weakening of respiratory sounds, stridor, wheezing, sensation of a foreign body, wheezing. If there is a moving body in the trachea, during screaming and coughing, you can sometimes hear a popping sound.

Foreign body aspiration.

General information.

The entry of foreign objects into the respiratory organs is called foreign body aspiration. This is a dangerous condition that can lead to serious trauma to the larynx, airway obstruction and asphyxia. Aspiration of small bodies often occurs into the right, wider bronchus.

Most often, aspiration of foreign bodies, organic and inorganic, occurs in young children, but remains possible for people of any age and gender.

Causes of the disease.

The first and main cause of pathology is leaving children 2-7 years old without adult supervision. A curious child puts small objects into his mouth, accidentally inhales, and the foreign body ends up in the respiratory organs.

There are frequent cases of aspiration of food particles during eating, both in children and in adults. A dangerous habit is the habit of holding small objects (screws, buttons) in your teeth while working, rolling toothpicks in your mouth, etc.

Symptoms of the disease.

Aspiration of a foreign body is manifested by difficulty in the respiratory process, a sharp unexpected attack of coughing (if a foreign object gets into the trachea, the cough resembles the symptoms of whooping cough), blueness of the skin, in severe cases - asphyxia with loss of consciousness, in extremely severe cases - death from suffocation when completely blocked by foreign bodies body of the respiratory tract.

If an aspirated foreign body remains in the respiratory system, this is characterized by attacks of suffocation with paroxysmal cough, persistent manifestations of stenosis, pain in the larynx, sometimes radiating to the ear area. Exacerbations of the condition are replaced by calmer periods. In almost all cases, hoarseness is noted, the patient feels the presence of a foreign body in the larynx. More specific signs depend on the location of the foreign object and its movements. If foreign bodies are in the bronchi, trachea or larynx for a long time, inflammatory processes with suppuration develop.

Possible complications.

Due to the presence of aspirated bodies in the respiratory organs, chronic forms of bronchitis and pneumonia may occur, lung abscess and purulent pleurisy may develop.

Medical assistance.

The task of doctors is to promptly remove the aspirated foreign body; Treatment tactics are developed after determining the location of the object that has entered the respiratory organs and its characteristics. If the situation allows, the removal of foreign bodies should be carried out in a specialized (otolaryngological) department of the hospital.

Clinic.

The following symptoms are typical for patients who have aspirated foreign bodies. A healthy child suddenly develops a sharp paroxysmal cough, asphyxia, sometimes with loss of consciousness and cyanosis of the facial skin. Characterized by stenotic breathing with retraction of the yielding areas of the chest, frequently recurring bouts of coughing, and hoarseness of the voice. The intensity of the cough depends on the shape, size, nature and location of the foreign body. When a foreign body is fixed, the cough is usually less intense.

For foreign bodies in the trachea bronchial tree stenosis can be fulminant, acute, subacute and chronic. Fulminant stenosis occurs when a foreign body is wedged into the glottis. Acute stenosis caused by a foreign body in the larynx or trachea. Acute tracheal stenosis is most often caused by a large foreign body localized in the area of ​​tracheal bifurcation and closing the lumen of the bronchi. Subacute stenosis is observed when the bronchus is partially blocked, for example by beans, chronic - when a foreign body is wedged into the bronchus with partial blockage of its lumen.

The condition of children with a foreign body in the larynx is often severe. When aspirating a small sharp foreign body (sewing needle, fish bone) at the first moment it enters the larynx, sometimes no breathing problems are observed; the phenomena of stenosis in such cases occur much later as a result of the development of reactive edema of the laryngeal mucosa, leading to asphyxia. When aspirating foreign bodies of a pointed or angular shape, which with a sharp end can wedge into the thickness of the mucous membrane of the larynx and disrupt its integrity, pain in the throat and behind the sternum is possible, aggravated by coughing and sudden movements. An admixture of blood appears in the sputum.

Important symptoms indicating a foreign body in the larynx are shortness of breath and voice dysfunction. The latter can be short-term or long-term. Persistent hoarseness, as well as aphonia, indicate the localization of a foreign body in the glottis or subglottic space; a rough voice and slight hoarseness indicate injury to the vocal folds during the passage of a foreign body.

The most common symptom of a foreign body in the larynx is pronounced attacks of whooping cough, which sometimes lasts a long time, with pauses of varying lengths. Older children may experience foreign body sensation and pain when swallowing. On auscultation, harsh breathing and rough wire-like rales are heard in both lungs, more so in the upper sections.

Chest X-ray usually reveals increased transparency of the lung tissue without focal and infiltrative changes.

Foreign bodies of the trachea are common; they (for example, watermelon seeds) easily move in the tracheobronchial tree and cause paroxysmal whooping cough. Breathing disturbances are not as pronounced as when foreign bodies are localized in the larynx, and periodically intensify due to the balloting (movement) of the foreign body at the moment of its contact with the lower surface of the true vocal folds. The cough may be intermittent and worsen at night and when the child is restless. Sometimes coughing attacks are pronounced, accompanied by facial cyanosis and vomiting, reminiscent of whooping cough, which often causes diagnostic errors, especially when the moment of foreign body aspiration is “overlooked.”

Balloting of a foreign body is a characteristic sign of unfixed foreign bodies located in the trachea, and is objectively manifested by the symptom of flapping. When the child is restless, crying, laughing or coughing, a flapping sound is clearly heard - the result of a foreign body launching and hitting the walls of the trachea, larynx and vocal folds during movement during inhalation and exhalation. Coughing up a foreign body is hampered by the valve mechanism of the tracheobronchial tree, which consists in expanding the trachea during inhalation and narrowing it during exhalation, as well as the fact that when coughing, a foreign body is thrown to the glottis and, in contact with the lower surface of the vocal folds, causes closure of the glottis and spasm of the larynx . The following deep breath again carries the foreign body into the lower parts of the trachea.

The mucous membrane in the area of ​​the tracheal bifurcation is characterized by increased sensitivity to external irritations compared to the mucous membrane throughout the rest of the respiratory tract. Therefore, when a foreign body is localized in the bifurcation area, the cough is especially pronounced and lasts a long time. When a foreign body significantly blocks the lumen of the trachea or bronchus and exhaled air passes through the gap formed between the surface of the object and the wall of the trachea or bronchus, a whistle similar to that in bronchial asthma can be heard.

With foreign bodies in the bronchi, a distinction is made between through, valve and complete blockage. In cases of through blockage, the foreign body does not completely close the lumen of the bronchus. Breathing is not impaired. The inflammatory process in the lung tissue is moderate.

Valve blockage is characterized by the fact that the foreign body is in loose contact with the walls of the bronchus and, when inhaling, air penetrates into the lung. When you exhale, it does not come out due to contraction of the bronchial muscles. Thus, air is trapped in the lung, causing emphysema. Due to complete blockage of the bronchus by a foreign body, obstructive atelectasis develops in the lung.

When a foreign body passes through the bronchus, breathing becomes free, coughing occurs less frequently and has a shorter duration, and the child calms down. The localization of a foreign body in the bronchus depends on its size. Large foreign bodies are retained in the main bronchi, small ones penetrate into the lobar and segmental bronchi. In this case, it is usually not possible to establish any characteristic subjective signs. On the side of the obstructed bronchus, more forced breathing is heard, as if overcoming an obstacle; in the area of ​​localization of the foreign body, shortening of the percussion sound, weakening of breathing and vocal tremor are noted. But sometimes dry and even wet rales are heard. If a foreign body remains in the bronchus for a long time, sputum production is observed; its quantity and quality depend on secondary changes in the lung and tracheobronchial tree.

X-ray examination reveals signs of impaired bronchial conduction - a symptom of displacement of the mediastinal organs towards the obstructed bronchus, atelectasis of a segment or lobe of the lung in accordance with the level of localization of the foreign body, emphysematous changes in the lungs with ventricular bronchial stenosis.

With atelectasis, as with emphysema, symptoms of respiratory failure may occur.

If there is complete obstruction of one of the main bronchi, then the corresponding lung is switched off from the act of breathing. As a rule, atelectasis of the corresponding lung is accompanied by cardiovascular failure. Atelectasis of a segment of one lung can occur along with emphysema in the other lung with a displacement of the mediastinal organs to the painful side. Emphysema is accompanied by shortness of breath and pathological disorders of the cardiovascular system.

Later, along with atelectasis, bronchitis or pneumonia develops. However, with complete or valvular closure of the bronchi and disruption of their drainage function, chronic pneumonia can develop, in which inflammatory process at the site of fixation of the foreign body.

A foreign body in the respiratory tract is recognized not only on the basis of a carefully collected history, objective data, and knowledge of the main clinical manifestations of aspiration of foreign bodies, but also with the help of X-ray examination (tomography, bronchography, etc.). For final diagnosis, endoscopic methods (bronchoscopy, direct laryngoscopy) are also used.

To detect a foreign body in the bronchus, aspiration of purulent contents should be performed using an electric suction, and swelling of the bronchial mucosa should be reduced with a 0.1% solution of adrenaline. Foreign bodies of the tracheobronchial tree should be differentiated from laryngotracheobronchitis, pneumonia, acute bronchitis, congenital lobar emphysema, foreign body of the esophagus, acute respiratory disease, etc. As a result of a long stay of a foreign body in the respiratory tract, complications arise, more often in young children. This is often due to a narrowing of the airway lumen, as well as a decrease in the resistance of the lung tissue. In addition, organic foreign bodies, such as peas, often cause bronchopneumonia. Such bronchopneumonia takes a long time and is difficult to treat. One of the very rare and severe complications of foreign bodies in the respiratory tract is a lung abscess. Complications include diseases such as abscess pneumonia, tracheobronchitis, pulmonary atelectasis, pneumothorax, bronchiectasis, bleeding, etc.

First aid.

First aid is a set of benefits that allows you to restore and maintain the basic vital functions of the patient’s body before providing qualified medical care.

Tasks of first aid:

If possible, eliminate pathological effects.

Effective temporary artificial replacement and control of the functions of vital organs and systems of the body (for example, artificial ventilation, chest compressions).

Fast transportation (provision) of qualified medical care.

However, the success of first aid depends not only on knowledge and skills in providing assistance, but also on the deontological component.

The term “deontology” 9 from the Greek. Deonthos - due), that is, the doctrine of proper behavior, actions, course of action, is associated with the name of the English priest Bentham (XVIII), who puts religious and moral content into this concept. In relation to medical activities, the term “medical deontology” very soon began to mean a set of ethical rules, norms, principles that guide a health worker, a set of relevant professional, moral, ethical and legal principles and rules that make up the concept of medical duty.

Assisting an infant with foreign body aspiration:

Place your baby on your arm or hip with his head down

Hit the child's back 5 times with the heel of your hand.

If the obstruction remains, turn the baby over and press 5 times with a push-like movement of two fingers on the baby's chest in the midline, at a point a finger's width below the level of the nipples (see picture).

If the obstruction remains, check for a foreign body in the mouth

Assisting a child over 1 year of age with foreign body aspiration:

Patting the back to remove a foreign body from the child's airway Pat the child on the back with the heel of your hand 5 times while the child is sitting, kneeling, or lying down.

If the obstacle remains, stand behind the child and wrap your arms around his torso; clench one hand into a fist just below the baby's sternum; place your other hand on your fist and sharply press your stomach in an upward direction; repeat this procedure (Heimlich maneuver) 5 times.

If the obstruction remains, check for a foreign body in the mouth.

If necessary, repeat the entire procedure sequentially, starting with patting on the back.

Foreign bodies in the respiratory tract are a terrible and very dangerous pathology.

Many children became disabled, many underwent difficult manipulations and operations due to the oversight and inattention of their parents. There were also deaths.

Dear parents! Remember an important rule: children under 3-4 years old should not be given small toys and foods (nuts, peas, etc.) that can be inhaled. Believe me, your child will live well without them. And in this way he will avoid many troubles.

Mechanical asphyxia– this is a complete or partial blockage of the respiratory tract, leading to disruption in vital organs due to oxygen starvation. Asphyxia can lead to death if the cause of its occurrence is not eliminated in time. Frequent victims of asphyxia may be infants, elderly people, patients with epilepsy, persons in alcohol intoxication.

Asphyxia is an emergency condition and requires urgent measures to eliminate it. Knowing some general rules, such as examining the oral cavity for the presence of a foreign body, tilting the head to the side to avoid tongue retraction, artificial respiration“mouth to mouth” can save a person’s life.


Interesting facts

• The most sensitive organ during oxygen starvation is the brain.
• The average time of death with asphyxia is 4–6 minutes.
• Game with asphyxiation - children's way obtaining euphoria as a result of various methods of briefly introducing the body into a state of oxygen starvation.
• During asphyxia, involuntary urination and defecation are possible.
• Most common symptom asphyxia - convulsive painful cough.
• Asphyxia is diagnosed in 10% of newborn children.

What are the mechanisms of asphyxia?

To understand the mechanisms of development of asphyxia, it is necessary to consider in detail the human respiratory system.

Breathing is physiological process necessary for normal human life. During breathing, when you inhale, oxygen enters the body, and when you exhale, carbon dioxide is released. This process is called gas exchange. The respiratory system provides all organs and tissues with oxygen, which is necessary for the functioning of absolutely all cells of the body.

Structure of the respiratory tract:

• upper respiratory tract;
• lower respiratory tract.

Upper respiratory tract

The upper respiratory tract includes nasal cavity, oral cavity, as well as the nasal and oral parts of the pharynx. Passing through the nose and nasopharynx, the air is warmed, moistened, and cleansed of dust particles and microorganisms. The temperature of the inhaled air increases due to its contact with the capillaries ( the smallest vessels ) in the nasal cavity. The mucous membrane helps to humidify the inhaled air. The cough and sneeze reflex helps prevent various irritating compounds from entering the lungs. Some substances located on the surface of the nasopharyngeal mucosa, such as lysozyme, have antibacterial effect and are capable of neutralizing pathogenic microorganisms.

Thus, passing through the nasal cavity, the air is purified and prepared for further entry into the lower respiratory tract.

From the nasal and oral cavities, air enters the pharynx. The pharynx is simultaneously part of the digestive and respiratory systems, being a connecting link. It is from here that food can enter not into the esophagus, but into the respiratory tract and, as a result, become the cause of asphyxia.

Lower respiratory tract

The lower respiratory tract is the final section of the respiratory system. It is here, or more precisely in the lungs, that the process of gas exchange occurs.

The lower respiratory tract includes:

• Larynx. The larynx is an extension of the pharynx. Below, the larynx borders the trachea. The hard skeleton of the larynx is the cartilaginous frame. There are paired and unpaired cartilages, which are connected to each other by ligaments and membranes. The thyroid cartilage is the largest cartilage of the larynx. It consists of two plates articulated under different angles. So, in men this angle is 90 degrees and is clearly visible on the neck, while in women this angle is 120 degrees and it is extremely difficult to notice the thyroid cartilage. Important role plays the epiglottic cartilage. It is a kind of valve that prevents food from entering the lower respiratory tract from the pharynx. The larynx also includes the vocal apparatus. The formation of sounds occurs due to changes in the shape of the glottis, as well as when the vocal cords are stretched.
• Trachea. The trachea, or windpipe, consists of arched tracheal cartilages. The number of cartilages is 16 - 20 pieces. The length of the trachea varies from 9 to 15 cm. The mucous membrane of the trachea contains many glands that produce secretions that can destroy harmful microorganisms. The trachea divides and passes below into the two main bronchi.
• Bronchi. The bronchi are a continuation of the trachea. The right main bronchus is larger than the left, thicker and more vertical. Just like the trachea, the bronchi consist of arcuate cartilage. The place where the main bronchi enter the lungs is called the hilum of the lungs. After this, the bronchi branch repeatedly into smaller ones. The smallest of them are called bronchioles. The entire network of bronchi of various sizes is called the bronchial tree.
• Lungs. The lungs are a paired respiratory organ. Each lung consists of lobes, with right lung there are 3 lobes, and in the left - 2. Each lung is penetrated by a branched network of the bronchial tree. Each bronchiole ends ( smallest bronchus) transition to the alveoli ( hemispherical sac surrounded by blood vessels). It is here that the process of gas exchange occurs - oxygen from the inhaled air penetrates the circulatory system, and carbon dioxide, one of the final products of metabolism, is released with exhalation.

Asphyxia process

The process of asphyxia consists of several successive phases. Each phase has its own duration and specific characteristics. In the last phase of asphyxia, a complete cessation of breathing is observed.

There are 5 phases in the process of asphyxia:

• Pre-asphyxial phase. This phase is characterized by a short cessation of breathing for 10–15 seconds. Erratic activity is common.
• Dyspnea phase. At the beginning of this phase, breathing becomes more frequent and the depth of breathing increases. After a minute, exhalation movements come to the fore. At the end of this phase, convulsions, involuntary bowel movements and urination occur.
• Brief cessation of breathing. During this period, there is no breathing, as well as pain sensitivity. The duration of the phase does not exceed one minute. During a period of short-term respiratory arrest, you can only determine the work of the heart by feeling the pulse.
• Terminal breathing. Trying to take one last deep breath of air. The victim opens his mouth wide and tries to catch air. In this phase, all reflexes weaken. If by the end of the phase foreign object does not leave the airways, then complete cessation of breathing occurs.
• The phase of complete cessation of breathing. The phase is characterized by complete failure respiratory center maintain the act of breathing. Persistent paralysis of the respiratory center develops.

Reflex cough
When a foreign object enters the respiratory system, a cough occurs reflexively. The first stage of the cough reflex involves taking a shallow breath. If a foreign object only partially closes the lumen of the respiratory tract, then a large share most likely it will be pushed out during a forced cough. If there is a complete blockage, then a shallow breath can aggravate the course of asphyxia.

Oxygen starvation
As a result of complete closure of the airway, mechanical asphyxia leads to respiratory arrest. As a result, oxygen starvation occurs in the body. The blood, which is enriched with oxygen in the alveoli at the level of the lungs, contains extremely small reserves of oxygen due to the cessation of breathing. Oxygen is essential for most enzymatic reactions in the body. In its absence, metabolic products accumulate in cells, which can damage the cell wall. In case of hypoxia ( oxygen starvation), the energy reserves of the cell are also sharply reduced. Without energy, a cell is unable to perform its functions for a long time. Different tissues respond differently to oxygen deprivation. Thus, the brain is the most sensitive, and bone marrow– least sensitive to hypoxia.

Disorders of the cardiovascular system
After a few minutes, hypoxemia ( reduced content oxygen in the blood) leads to significant disturbances in the cardiovascular system. The heart rate decreases and blood pressure drops sharply. There are disorders in heart rate. This causes an overflow venous blood, rich in carbon dioxide, of all organs and tissues. There is a bluish complexion – cyanosis. The cyanotic hue occurs due to the accumulation in the tissues of a large amount of protein that transports carbon dioxide. In the case of serious vascular diseases, cardiac arrest can occur at any phase of the asphyxial state.

Damage to the nervous system
The next link in the mechanism of asphyxia is damage to the central nervous system ( central nervous system). Consciousness is lost at the beginning of the second minute. If the flow of oxygen-rich blood does not resume within 4 to 6 minutes, then nerve cells begin to die. For normal functioning, the brain must consume approximately 20 - 25% of the total oxygen received during breathing. Hypoxia will lead to death in case of extensive damage to the nerve cells of the brain. In this case, there is a rapid oppression of all vital important functions body. This is why changes in the central nervous system are so destructive. If asphyxia develops gradually, the following manifestations are possible: impaired hearing, vision, and spatial perception.

Involuntary acts of urination and defecation often occur with mechanical asphyxia. Due to oxygen starvation, the excitability of the soft muscles of the intestinal wall and bladder increases, and the sphincters ( orbicularis muscles that act as valves) relax.

Highlight the following types mechanical asphyxia:

• Dislocation. Occurs as a result of closure of the airway lumen by displaced damaged organs ( tongue, mandible, epiglottis, submandibular bone).
• Strangulation. Occurs as a result of strangulation with hands or a noose. This type of asphyxia is characterized by extremely strong compression of the trachea, nerves and vessels of the neck.
• Compression. Compression of the chest by various heavy objects. In this case, due to the weight of the object squeezing the chest and abdomen, it is impossible to perform breathing movements.
• Aspiration. Penetration into the respiratory system by inhalation of various foreign bodies. Common causes of aspiration are vomit, blood, and stomach contents. As a rule, this process occurs when a person is unconscious.
• Obstructive. There are two types of obstructive asphyxia. First type – asphyxia of the lumen of the respiratory tract, when foreign objects can enter the respiratory tract ( food, dentures, small objects). Second type - asphyxia from covering the mouth and nose with various soft objects.

Obstructive asphyxia is a particular and most common type of mechanical asphyxia.

Highlight following types obstructive asphyxia:

• closing the mouth and nose;
• closing the airway.

Closing the mouth and nose

Closing of the mouth and nose is possible due to an accident. So, if a person falls face first onto a soft object during an epileptic seizure, this can lead to death. Another example of an accident is if, while breastfeeding, the mother unknowingly closes the baby's nasal cavity with her mammary gland. With this type of asphyxia, the following signs can be detected: flattening of the nose, a pale part of the face that was adjacent to a soft object, a bluish tint to the face.

Closure of the airway

Closure of the airway lumen is observed when a foreign body enters it. Also, the cause of this type of asphyxia can be various diseases. A foreign body can close the airway during fear, screaming, laughing or coughing.

Obstruction by small objects usually occurs in small children. Therefore, you need to carefully ensure that the child does not have access to them. Elderly people are characterized by asphyxia caused by the entry of a denture into the lumen of the respiratory tract. Also, the absence of teeth and, as a result, poorly chewed food can lead to obstructive asphyxia. Alcohol intoxication is also one of the most common causes of asphyxia.

The course of asphyxia may be affected by the following: individual characteristics body:

• Floor. To determine the reserve capabilities of the respiratory system, the concept of vital capacity ( vital capacity). vital capacity includes the following indicators: tidal lung volume, inspiratory reserve volume and expiratory reserve volume. It has been proven that women have vital capacity 20–25% less than men. It follows from this that the male body better tolerates the state of oxygen starvation.
• Age. The vital capacity parameter is not a constant value. This indicator varies throughout life. It reaches its maximum by the age of 18, and after 40 years it gradually begins to decline.
• Susceptibility to oxygen starvation. Regular exercise helps increase lung capacity. Such sports include swimming, athletics, boxing, cycling, mountaineering, and rowing. In some cases, the vital capacity of athletes exceeds the average of untrained people by 30% or more.
• Presence of concomitant diseases. Some diseases can lead to a decrease in the number of functioning alveoli ( bronchiectasis, pulmonary atelectasis, pneumosclerosis). Another group of diseases can limit breathing movements, affecting the respiratory muscles or nerves of the respiratory system ( traumatic rupture of the phrenic nerve, trauma to the dome of the diaphragm, intercostal neuralgia).

Causes of asphyxia

The causes of asphyxia can be varied and, as a rule, depend on age, psycho-emotional state, the presence of respiratory diseases, diseases digestive system or associated with the entry of small objects into the respiratory tract.

Causes of asphyxia:

• diseases of the nervous system;
• diseases of the respiratory system;
• diseases of the digestive system;
• aspiration of food or vomit in children;
• weakened infants;
• psycho-emotional states;
• alcohol intoxication;
• talking while eating;
• haste in eating;
• lack of teeth;
• dentures;
• entry of small objects into the respiratory tract.

Nervous system diseases

Some diseases of the nervous system can affect the airway. One of the causes of asphyxia may be epilepsy. Epilepsy is a chronic human neurological disease characterized by sudden occurrence convulsive seizures. During these seizures, a person may lose consciousness for several minutes. If a person falls on his back, his tongue may roll back. This condition can lead to partial or complete closure of the airways and, as a consequence, to asphyxia.

Another type of nervous system disease leading to asphyxia is damage to the respiratory center. The respiratory center is understood as a limited area medulla oblongata, responsible for the formation of the respiratory impulse. This impulse coordinates all respiratory movements. As a result of traumatic brain injury or swelling of the brain, damage to the nerve cells of the respiratory center may occur, which can lead to apnea ( termination breathing movements ). If paralysis of the respiratory center occurs during a meal, this inevitably leads to asphyxia.

Neuritis can lead to difficulty swallowing and possible blockage of the airways. vagus nerve. This pathology is characterized by hoarseness and impaired swallowing. Due to unilateral damage to the vagus nerve, vocal cord paresis may occur ( weakening of voluntary movements). Also, the soft palate cannot be maintained in its original position, and it descends. With bilateral damage, the act of swallowing is sharply disrupted, and the pharyngeal reflex is absent ( swallowing, coughing or gag reflexes when irritated, the pharynx is impossible).

Respiratory system diseases

There are a number of diseases of the respiratory system that lead to blockage of the airways and cause asphyxia. Conventionally, these diseases can be divided into infectious and oncological.

The following diseases can cause asphyxia:

• Abscess of the epiglottis. This pathology leads to swelling of the epiglottic cartilage, an increase in its size and a decrease in its mobility. During food intake, the epiglottis is not able to perform its functions as a valve that closes the lumen of the larynx during the act of swallowing. This inevitably leads to food entering the respiratory tract.
• Quinsy. Phlegmonous tonsillitis or acute paratonsillitis is a purulent-inflammatory disease of the tonsils. It occurs as a complication of lacunar tonsillitis. This pathology leads to swelling of the soft palate and the formation of a cavity containing pus. Depending on the location of the purulent cavity, blockage of the respiratory tract is possible.
• Diphtheria. Diphtheria is an infectious disease that usually affects the oral part of the pharynx. In this case, the occurrence of croup, a condition in which the airways are blocked by diphtheria film, poses a particular danger. The airway can also be blocked if there is extensive swelling of the pharynx.
• Tumor of the larynx. A malignant tumor of the larynx leads to the destruction of surrounding tissues. The degree of destruction determines the size of food that can penetrate from the pharynx into the larynx. Also, the tumor itself can cause asphyxia if it partially or completely blocks the lumen of the larynx.
• Tracheal tumor. Depending on the shape, the tumor can protrude into the lumen of the trachea itself. In this case, stenosis is observed ( narrowing) lumen of the larynx. This will significantly complicate breathing and subsequently lead to mechanical asphyxia.

Digestive system diseases

Diseases of the digestive system can lead to food entering the respiratory tract. Asphyxia can also be caused by aspiration of stomach contents. Swallowing disorders can be a consequence of burns of the mouth and pharynx, as well as in the presence of defects in the anatomy of the oral cavity.

The following diseases can cause asphyxia:

• Cancer upper section esophagus. A tumor of the esophagus, growing, can exert significant pressure on adjacent organs - the larynx and trachea. Increasing in size, it can partially or completely compress the respiratory organs and, thereby, lead to mechanical asphyxia.
• Gastroesophageal reflux. This pathology is characterized by the entry of stomach contents into the esophagus. In some cases, the contents of the stomach can penetrate into the oral cavity, and when inhaled, enter the respiratory tract ( aspiration process).
• Tongue abscess. An abscess is a purulent-inflammatory disease with the formation of a cavity containing pus. The following picture is typical for a tongue abscess: the tongue is enlarged in volume, inactive and does not fit in the mouth. The voice is hoarse, breathing is difficult, there is profuse salivation. For tongue abscess purulent cavity may be located in the root zone and prevent air from entering the larynx. Also, increased size of the tongue can cause asphyxia.

Aspiration of food or vomit in children

Aspiration is the process of various foreign materials entering the respiratory system through inhalation. As a rule, vomit, blood, and stomach contents can be aspirated.

Aspiration is quite common among newborns. It can occur if the mammary gland fits tightly into the baby's nasal passages and makes breathing difficult. The child, trying to breathe, inhales the contents of his mouth. Another reason may be the baby's incorrect position during feeding. If the baby's head is tilted back, the epiglottis is not able to completely block the lumen of the larynx from milk entering it.

Aspiration of regurgitated masses during vomiting is also possible. The cause may be malformations of the digestive tract ( esophageal atresia, tracheoesophageal fistula).

Birth trauma, toxicosis during pregnancy ( complication of pregnancy, manifested by edema, increased blood pressure and protein loss in urine), various malformations of the esophagus significantly increase the chance of asphyxia due to aspiration.

Weakened infants

In weakened or premature newborns, the swallowing reflex is usually impaired. This occurs due to damage to the central nervous system. Various infectious diseases that the mother of the child suffers during pregnancy, toxicosis or intracranial birth trauma can disrupt the swallowing process. Aspiration of breast milk or vomit can cause mechanical asphyxia.

Psycho-emotional states

During food intake, various psycho-emotional states can affect the swallowing act. Sudden laughter, screaming, fright or crying can lead to the throwing of a bolus of food from the pharynx into the upper respiratory tract. This is explained by the fact that during psycho-emotional manifestations, air must be exhaled from the larynx to create certain sound vibrations. In this case, food from the oral part of the pharynx can be accidentally sucked into the larynx during the next inhalation.

Alcohol intoxication

The state of alcoholic intoxication is common cause asphyxia in the adult population. During sleep, aspiration of vomit may occur as a result of impaired gag reflex. Due to inhibition of the functions of the central nervous system, a person is unable to perceive the contents of the oral cavity. As a result, vomit can enter the respiratory tract and cause mechanical asphyxia. Another reason may be the separation of swallowing and respiratory processes. This condition is typical for severe alcohol intoxication. In this case, food and liquid can easily penetrate the respiratory system.

Talking while eating

Food particles can be inhaled when talking while eating. Most often, food ends up in the larynx. In this case, a person coughs reflexively. During a cough, pieces of food can usually be easily released into the upper respiratory tract without causing harm to health. If a foreign object was able to fall lower - into the trachea or bronchi, then the cough will not have an effect and partial or complete asphyxia will occur.

Haste while eating

Hasty consumption of food not only leads to diseases of the gastrointestinal tract, but can also cause mechanical asphyxia. With insufficient chewing of food, large, poorly processed pieces of food can close the lumen of the oropharynx. If the oral cavity contains large number poorly chewed pieces of food, you may have problems swallowing. If the bolus of food does not release the oropharynx within a few seconds, inhalation will be impossible. Air simply will not be able to penetrate this food bolus and, as a result, a person may choke. The protective mechanism in this case is the cough reflex. If the food bolus is too large and coughing does not lead to its release from the oral cavity, then blockage of the airways is possible.

Missing teeth

Teeth serve several functions. Firstly, they mechanically process food to a uniform consistency. Grinded food is more easily processed further in the gastrointestinal tract. Secondly, teeth are involved in the process of speech formation. Thirdly, during the process of chewing food, a complex chain of mechanisms arises aimed at activating the work of the stomach and duodenum.

Missing teeth can cause asphyxia. When food enters the oral cavity, it is not crushed enough. Poorly chewed food can get stuck in the mouth and become a foreign object. The large and small molars are responsible for grinding food. The absence of several of them can cause mechanical asphyxia.

Dentures

Dental prosthetics is an extremely popular procedure in dentistry. These services are most often used by older people. Average term The lifespan of dentures varies between 3 and 4 years. After this period, dentures may wear out or become loose. In some cases, they may be partially or completely destroyed. If a denture gets into the respiratory tract, it will irreversibly lead to asphyxia.

Inhalation of small objects

Foreign objects can become needles, pins or pins if they are used for quick access to cleaning the oral cavity. Children are characterized by asphyxia, in which coins, balls, buttons and other small objects enter the respiratory tract. Also, small fragments of toys can get into the respiratory tract. Some foods can also cause closure of the airways. These include, for example, seeds, peas, beans, nuts, candies, and tough meat.

Symptoms of asphyxia

During asphyxia, a person tries to clear the airways of a foreign object. There are a number of signs that will help you understand that we're talking about specifically about asphyxia.

Symptom	Manifestation	Photo
Cough	If a foreign object enters the larynx, a person will reflexively begin to cough. At the same time, the cough is convulsive, painful, and does not bring relief.
Excitation	A person instinctively grabs his throat, coughs, screams and tries to call for help. Small children are characterized by strangled crying, frightened eyes, wheezing and wheezing ( stridor). Less often, the crying is strangled and muffled.
Forced pose	Tilt of the head and torso forward allows you to increase the depth of inhalation.
Blue complexion	As a result of oxygen starvation, a large amount of blood containing carbon dioxide is concentrated in the tissues. A protein that is bound to carbon dioxide and gives skin bluish tint.
Loss of consciousness	The blood flowing to the brain does not contain enough oxygen. With hypoxia, the nerve cells in the brain cannot function normally, which leads to fainting.
Stopping breathing	Breathing stops within a few minutes. If the cause of asphyxia is not eliminated and the foreign body is not removed from the lumen of the respiratory tract, then after 4–6 minutes the person will die.
Adynamia	Reduced physical activity up to its complete cessation. Adynamia occurs due to loss of consciousness.
Involuntary urination and defecation	Oxygen starvation leads to increased excitability of the soft muscles of the walls of the intestines and bladder, while the sphincters relax.

First aid for mechanical asphyxia

Mechanical asphyxia is an emergency condition. The life of the victim depends on the correctness of first aid actions. Therefore, every person is obliged to know and be able to provide emergency care.

Providing first aid in case of mechanical asphyxia:

• self-help;
• providing first aid to an adult;
• providing first aid to a child.

Self help

Self-help can only be provided if consciousness is maintained. There are several methods that will help in case of asphyxia.

Types of self-help for asphyxia:

• Perform 4 – 5 strong cough movements. If a foreign body enters the lumen of the respiratory tract, it is necessary to make 4–5 forced cough movements, while avoiding deep breaths. If a foreign object has cleared the airway, a deep breath can again lead to asphyxia or even worsen it. If a foreign object is located in the pharynx or larynx, then this method may prove to be effective.
• Apply 3 to 4 pressures in the upper abdomen. The method is as follows: place the fist of the right hand in the epigastric region ( upper part abdomen, which is bounded above by the xiphoid process of the sternum, and on the right and left by the costal arches), with the open palm of your left hand, press your fist and with a quick sharp movement towards yourself and up, make 3 – 4 pushes. In this case, the fist, making a movement to the side internal organs, increases intra-abdominal pressure and chest cavity. Thus, air from the respiratory system rushes out and is able to push out the foreign body.
• Lean top part belly into the back of a chair or armchair. As in the second method, the method increases intra-abdominal and intrathoracic pressure.

Providing first aid to an adult

Providing first aid to an adult is necessary if he is intoxicated, his body is weakened, in a number of certain diseases, or if he cannot help himself.

The first thing to do in such cases is to call an ambulance. Next, you should use special first aid techniques for asphyxia.

Methods of providing first aid to an adult with asphyxia:

• Heimlich maneuver. It is necessary to stand from behind and clasp your arms around the victim’s torso just below the ribs. Place one hand in the epigastric region, clenching it into a fist. Place the palm of the second hand perpendicular to the first hand. With a quick jerking motion, press your fist into your stomach. In this case, all the force is concentrated at the point of contact of the abdomen with thumb hand clenched into a fist. The Heimlich maneuver should be repeated 4 to 5 times until breathing normalizes. This method is the most effective and will most likely help push the foreign object out of the respiratory system.
• Perform 4–5 palm strikes on the back. Approach the victim from behind, using the open side of your palm to deliver 4 to 5 blows of medium force on the back between the shoulder blades. The blows must be directed along a tangential trajectory.
• A method for providing assistance if a person cannot be approached from behind or is unconscious. It is necessary to change the person's position and turn him on his back. Next, position yourself on the victim’s hips and place the open base of one hand in the epigastric region. With your second hand, press on the first and move deeper and upward. It is worth noting that the victim’s head should not be turned. This manipulation should be repeated 4 – 5 times.

If these first aid methods do not work, and the victim is unconscious and not breathing, then artificial respiration must be urgently performed. There are two methods for performing this manipulation: “mouth to mouth” and “mouth to nose”. As a rule, the first option is used, but in some cases, when it is not possible to breathe into the mouth, you can resort to mouth-to-nose artificial respiration.

Methods for providing artificial respiration:

• "Mouth to mouth." You must use any rag material ( handkerchief, gauze, piece of shirt) as a gasket. This will avoid contact with saliva or blood. Next, you need to take a position to the right of the victim and sit on your knees. Inspect the oral cavity for the presence of a foreign body. To do this, use the index and middle fingers of the left hand. If it was not possible to find a foreign object, go to next steps. Cover the victim's mouth with a cloth. They tilt the victim's head back with their left hand, and with their right hand they pinch his nose. Make 10 - 15 air injections per minute or one exhalation every 4 - 6 seconds. It should be in close contact with the victim's mouth, otherwise all the inhaled air will not reach the victim's lungs. If the manipulation is performed correctly, you will notice movements of the chest.
• "Mouth to nose." The procedure is similar to the previous one, but has some differences. Exhale into the nose, which is previously covered with material. The number of blows remains the same - 10 - 15 exhalations per minute. It is worth noting that with each exhalation you need to close the victim’s mouth, and in the intervals between blowing air, open your mouth slightly ( this action simulates the passive exhalation of the victim).

If the victim experiences weak breathing, the process of blowing air into the lungs should be synchronized with the victim’s independent inhalation.

Providing first aid to a child

Providing first aid to a child is extremely challenging task. If the child cannot breathe or speak, coughs convulsively, or his complexion becomes bluish, he should be called immediately. ambulance. Next, free him from restraining clothing ( blanket, diaper) and begin performing special first aid techniques for asphyxia.

Methods of providing first aid to a child with asphyxia:

• Heimlich maneuver for children under 1 year. Place the child on your arm so that the face rests on the palm. It is good to fix the baby's head with your fingers. The legs should be different sides from the forearm. It is necessary to slightly tilt the child's body down. Perform 5–6 tangential pats on the child’s back. Patting is done with the palm of the hand in the area between the shoulder blades.
• Heimlich maneuver for children over 1 year of age. You should place the child on his back and sit on his knees at his feet. Place the index and middle fingers of both hands in the epigastric region. Apply moderate pressure in this area until the foreign body clears the airways. The technique must be performed on the floor or any other hard surface.

If these first aid methods do not help, and the child is not breathing and remains unconscious, artificial respiration must be performed.

For children under 1 year of age, artificial respiration is performed using the “mouth-to-mouth and nose” method, and for children over 1 year of age, artificial respiration is performed using the “mouth-to-mouth” method. To begin, place the baby on his back. The surface on which the child should lie must be hard ( floor, board, table, ground). It is worth checking the oral cavity for the presence of foreign objects or vomit. Next, if a foreign object was not found, place a cushion from available materials under the head and begin blowing air into the child’s lungs. It is necessary to use rag material as a gasket. It should be remembered that exhalation is carried out only with the air that is in the mouth. The volume of a child's lungs is many times less than that of an adult. Forced inhalation can simply rupture the alveoli in the lungs. The number of exhalations for children under one year old should be 30 per 1 minute or one exhalation every 2 seconds, and for children over one year old - 20 per 1 minute. The correctness of this manipulation can be easily verified by the movement of the child’s chest while air is blown in. It is necessary to use this method until the ambulance team arrives or until the child’s breathing is restored.

Do I need to call an ambulance?

Mechanical asphyxia is emergency. Asphyxial status directly threatens the life of the victim and can cause rapid death. Therefore, if signs of asphyxia are recognized in a person, it is necessary to immediately call an ambulance, and then begin to take measures to eliminate asphyxia.

It must be remembered that only an ambulance team can provide high-quality and qualified assistance. If necessary, all necessary resuscitation measures will be performed - chest compressions, artificial respiration, oxygen therapy. Also, emergency doctors can resort to urgently- cricoconicotomy ( opening the laryngeal wall at the level of the cricoid cartilage and conical ligament). This procedure will allow you to insert a special tube into the hole made, and through it, resume the act of breathing.

Prevention of mechanical asphyxia

Prevention of mechanical asphyxia is aimed at reducing and eliminating factors that can lead to closure of the airway.

(applicable to children under one year of age):

• Prevention of aspiration during feeding. It should be remembered that during feeding the baby's head should be elevated. After feeding, it is necessary to ensure that the baby is in an upright position.
• Use of a feeding tube in case of feeding problems. It is not uncommon for a baby to have trouble breathing when bottle feeding. If holding your breath during feeding occurs frequently, then using a special feeding tube may be a way out.
• Purpose special treatment children prone to asphyxia. In case of repeated repetition of mechanical asphyxia, the following treatment regimen is recommended: injections of cordiamine, etimizol and caffeine. This regimen can only be used after consultation with your doctor.

To prevent mechanical asphyxia, you must follow the following recommendations:(applicable to children over one year of age):

• Restricting the child's access to solid foods. Any solid product in the kitchen can cause asphyxia. You need to try to prevent foods such as seeds, beans, nuts, peas, candies, and hard meat from falling into the child’s hands. You should avoid such foods for up to four years.
• Selecting and purchasing safe toys. The purchase of toys should be based on the age of the child. Each toy should be carefully inspected for any removable hard parts. You should not purchase construction sets for children under 3–4 years old.
• Making the right food choices. Nutrition for a child must strictly correspond to his age. Well-chopped and processed food is a necessity for children under three years of age.
• Keep small items in a safe place. It is worth keeping various office supplies such as pins, buttons, erasers, caps in a safe place.
• Teaching children to chew food thoroughly. Solid food should be chewed at least 30–40 times, and food with a soft consistency ( porridge, puree) – 10 – 20 times.

To prevent mechanical asphyxia, you must follow the following recommendations:(applicable to adults):

• Limit alcohol consumption. Drinking alcohol in large quantities can lead to disruption of chewing and swallowing and, as a result, increase the risk of mechanical asphyxia.
• Refusal to talk while eating. During a conversation, an involuntary combination of swallowing and breathing is possible.
• Be careful when eating fish products. Fish bones often get into the lumen of the respiratory tract, causing partial closure of the lumen of the respiratory tract. Also, the sharp part of a fish bone can penetrate the mucous membrane of one of the organs of the upper respiratory tract and lead to inflammation and swelling.
• Use pins, needles and hairpins for their intended purpose. For quick access, hairpins and pins can be placed in the mouth. During a conversation, these small objects can freely penetrate the respiratory tract and cause asphyxia.

1

A comprehensive study was carried out on 215 children of various ages who aspirated foreign bodies into the respiratory tract. Anamnestic, clinical, radiological and endoscopic criteria for diagnosing this pathology were studied, and the frequency of clinical complications of aspiration was studied. Follow-up observation of these children shows a significant frequency of persistent changes in the lungs after removal of foreign bodies.

foreign bodies

respiratory tract

1. Complications due to foreign bodies in the lower respiratory tract in childhood/ V.G. Zenger, A.E. Mashkov, D.M. Mustafaev et al. // Russian otorhinolaryngology. - 2008. - No. 3. - P. 46-51.

2. Foreign body simulating bronchial asthma / Yu.L. Mizernitsky et al. // Complex diagnostic cases in the practice of a pediatrician; edited by HELL. Tsaregorodtseva, V.V. Length. - M., 2010. - P. 292-297.

3. Rokitsky M.R. Surgical diseases lungs in children. - L., 1988. - P. 151-167.

4. Shamsiev A.M., Bazarov B.B., Baibekov I.M. Pathomorphological changes in the bronchi and lungs due to foreign bodies in children // Pediatric surgery. - 2009. - No. 6. - pp. 35-36.

5. Crawford NW. Foreign body aspiration in a child detected through emergency department radiology reporting: a case report // Eur J Emerg Med. - 2007. - No. 14(4). -P. 219-221.

6. Roberts J, Bartlett AH, Giannoni CM et al. Airway foreign bodies and brain abscesses: report of two cases and review of the literature // Int J Pediatr Otorhinolaryngol. - 2008. - No. 72(2). - R. 265-269.

Foreign bodies of the tracheobronchial tree are a common emergency pathology that threatens the child’s life and requires immediate assistance. The presence of severe complications during aspiration of foreign bodies into the respiratory tract, the possibility of death, diagnostic difficulties with an uncertain clinical picture, as well as the possibility of chronic damage bronchopulmonary system make the problem of foreign bodies in the respiratory tract extremely relevant, especially in matters of early diagnosis and full treatment of children with foreign bodies.

We examined and treated 215 children with foreign bodies in the respiratory tract, which amounted to 4.5-6.9% of all children under 3 years of age treated in the chest department, and 0.2-0.5% of all children under 16 years of age. treated in the pulmonology department of the Regional Children's Hospital for the period from 2000 to 2006.

To remove foreign bodies, fibrotracheobronchoscopy (FTBS) was used, which has great diagnostic capabilities and is a low-traumatic manipulation. It was especially indicated for the initial search for foreign bodies of the tracheobronchial tree, when they are located in the distal parts of the bronchi and in the absence of clear anamnestic data on their aspiration. FTBS was performed with Olympus endoscopes, through the biopsy channel of which conventional biopsy forceps were passed. Then, if necessary, rigid tracheobronchoscopy was performed under general fluorothan endotracheal anesthesia. For this purpose, a rigid Storz bronchoscope of various sizes and a laryngoscopic set were used. After removing the foreign body, the tracheobronchial tree was sanitized with various solutions (0.5% dioxidine solution, 0.01% miramistin solution, 5% epsilon-aminocaproic acid solution). In cases of severe bronchial hyperreactivity, medications were simultaneously administered intravenously to reduce bronchospasm (aminophylline, metipred).

To study the degree of activity of the local inflammatory process and the state of the bronchial epithelium, a cytological study of bronchial washings obtained during bronchofibroscopy was carried out by aspiration using a vacuum suction of warm instilled into the bronchi saline solution. To obtain an objective picture of the condition of the bronchial mucosa and characterize the local inflammatory process, the method of cytological examination of broncho-alveolar lavages was used by examining and photographing stained smears using an Axiolab video microscope (Carl Zeiss, Germany), equipped with an AVT-HORN video camera and a Pentium III computer. To characterize inflammatory changes in the bronchial mucosa, a technique was used that included assessing the intensity of endobronchial inflammatory changes in patients according to J. Lemoine. To take into account the severity of bronchoscopic changes, the following signs of endobronchitis were identified: swelling of the bronchial mucosa, its hyperemia, quantity and nature bronchial secretions, the severity of the vascular pattern of the bronchial wall. The intensity of each sign was assessed on a three-point scale.

To study the state of the respiratory system in the long-term period after removal of foreign bodies (after 1 month - 10 years), some of the patients were re-admitted to the hospital, where they underwent a full clinical, radiological, endoscopic and computer examination. To assess the risk of developing bronchopulmonary complications after aspiration of foreign bodies, special statistical methods were used evidence-based medicine with the calculation of the absolute and relative risk of complications, the increase in the absolute and relative risk of complications and the index of potential harm of aspiration.

The main group consisted of children of the first 5 years of life (86.0%), of which the largest group was the group of children 2-3 years of life (61.4%). There was a significant predominance of children who aspirated organic foreign bodies into the respiratory tract (85.1%) compared to children with inorganic foreign bodies.

The most common organic foreign bodies in the respiratory tract were sunflower and other seeds and various types nuts, which account for more than half of aspiration cases (58.1%). Of the inorganic foreign bodies, the most common were metal and plastic parts from toys (9.8%), which were most often encountered by children. The main location of aspirated foreign bodies was the bronchi (92.5% of cases), much less often they are retained in the trachea (3.3%). Foreign bodies were found in the bronchi of the right lung more often (49.3% of cases) than in the bronchi of the left lung, which can be explained by the anatomical and physiological features of the structure of the tracheobronchial tree. The duration of presence of aspirated foreign bodies in the respiratory tract was different: within 1 day before removal - 37.7% of cases, and during the first week - 33.9% of cases. In the remaining children (28.4%), the foreign body was removed from the trachea and bronchi later than the first week for various reasons, and in 13.5% of children - later than 1 month after aspiration. Aspiration of a foreign body into the respiratory tract in the vast majority of cases occurred while the child was in full health during meals or play and was accompanied by a characteristic clinical picture, the main manifestations of which were paroxysmal cough (100.0%) of varying intensity, difficulty wheezing (65.1%) , shortness of breath (51.6%) and cyanosis (22.5%) of the skin and mucous membranes. In addition, some children experienced a short-term attack of apnea (4.6%), single reflex vomiting (5.1%), restlessness (8.4%) or lethargy (1.4%), choking and refusal to eat (1 .9%) and moaning (1.1%). As a result of the traumatic passage of a foreign body through the respiratory tract and fixation in them, some children experienced pain in the chest or side (4.2%), sore throat (1.9%) and hoarseness (1.9%). A typical history of foreign body aspiration into the respiratory tract was identified in 99.1% of children. In other cases, it was not possible to identify the moment of aspiration. This was due to the fact that at the time of aspiration the children were left without parental supervision or hid what happened for fear of punishment.

An objective study of children who aspirated foreign bodies into the respiratory tract revealed various clinical symptoms. The most common percussion signs of foreign body aspiration were a pronounced box-like tone of the lung sound in the area of ​​the foreign body (15.8%), which occurs with valve blockage of the bronchus, or a box-like tone of the lung sound on both sides of the lungs (15.3%) or a shortening of the lung sound on side of the lesion (12.6%), occurring with partial through or complete blockage of the bronchi. The overwhelming majority of children also had oral wheezing, audible at a distance (60.5%), dry and moist coarse bubbling wheezing on both sides (45.6%), or wheezing on the affected side (24.6%). In 2.3% of children, a “clicking” symptom was noted on auscultation, indicating the presence of a ballistic foreign body in the respiratory tract. Only 3.2% of children did not have pronounced percussion and auscultation changes in the lungs due to aspiration.

Almost every child (93.5%) with radiopaque foreign bodies of the trachea and bronchi had indirect signs bronchial obstruction. The most common radiological sign of impaired bronchial obstruction during aspiration of a foreign body into the respiratory tract was increased pneumatization of the lung tissue (42.8%) on the side where the foreign body was located. In a number of cases (10.2%), even displacement of the mediastinal organs was detected healthy side. Analysis of the data showed that the shorter the duration of aspiration of foreign bodies, the more often emphysematous swelling in the lungs is detected (in the first 3 days - in 60.9% of children). A decrease in pneumatization of the lung tissue (atelectasis of a lobe, segment, lung) was detected in 20.0% of children, and a displacement of the mediastinal organs towards a foreign body was noted in 8.8% of children. The majority of children with radiopaque foreign bodies had enhancement and deformation of the pulmonary pattern on both sides (52.1%) or uneven pneumatization of the lung tissue (17.7%). In the study group, only 6.5% of children had radiopaque foreign bodies in the form of metal or plastic parts with metal parts from toys.

The endoscopic picture of changes in the tracheobronchial tree in children with foreign bodies depended on the age of the child, the nature of the aspirated foreign body, as well as the duration of its presence in the respiratory tract. Only in 6.0% of cases were no changes detected in the mucous membrane of the respiratory tract during aspiration, which was noted when foreign bodies were in the respiratory tract for short periods of time (within 24 hours) or in older children. In all other children (94.0% of cases) with foreign bodies, a varied endoscopic picture was revealed: in 39.1% of cases, catarrhal-mucous endobronchitis was detected, in 46.5% of cases - catarrhal-purulent endobronchitis

catarrhal fibrinous endobronchitis. Purulent endobronchitis occurred already on the 1st day after aspiration of a foreign body in 11.7% of cases, mainly with organic foreign bodies (82.6% of cases). With a further increase in the duration of the presence of a foreign body in the tracheobronchial tree, the incidence of purulent endobronchitis increased significantly, and with the organic nature of the foreign body, the purulent nature of the inflammation was noted immeasurably more often. Thus, when the foreign body was present for 1 day, the following nature of mucosal damage was revealed: catarrhal-mucosal (17.2%), catarrhal-purulent (10.7%) and even catarrhal-fibrinous (2.3%). And when aspirated foreign bodies were present for 3 days, catarrhal-mucosal endobronchitis was detected in 24.2%, catarrhal-purulent in 18.6% and catarrhal-fibrinous in 4.6% of cases. The phenomena of tracheitis were observed in more than half of the children (52.1%) with foreign bodies of the tracheobronchial tree, with prolapse of the membranous part of the trachea (9.8%) and displacement of the carina (8.8%). In the 1st week from the moment of foreign body aspiration, tracheitis was observed in 36.7% of cases. As the duration of presence of a foreign body in the respiratory tract increased, the frequency of detection of tracheitis decreased significantly.

Bedsores occurred at the site of fixation of foreign bodies (4.6 %), and the development of granulation tissue(17.7%), and when trying to remove an impacted foreign body (16.3%), severe bleeding of the bronchial mucosa was noted. Bedsores were more common with organic foreign bodies, when the foreign body was present for more than 3 days, and in children in the first three years of life. The development of granulations was noted for any duration of presence of a foreign body in the respiratory tract. Thus, in several children (7.9%) the development of granulation tissue around the foreign body was noted, even when it was present for 24 hours. With an increase in the duration of presence of a foreign body in the respiratory tract, the frequency of development of granulation tissue increased significantly: with a duration of stay from 2 to 7 days, granulations occurred in 34.2% of cases, and with a duration of more than a week, the frequency of development of granulation tissue sharply increased to 65.8 % of cases.

The frequency of development of granulation tissue depended little on the nature of the foreign body: with organic foreign bodies, granulation occurred in 17.0% of cases, and with inorganic foreign bodies - in 21.2% of cases. However, with organic foreign bodies, granulation appeared already from the 1st day after aspiration, and with inorganic foreign bodies, after 7 days of the foreign body being in the respiratory tract. Ballistic foreign bodies were noted in 3.2% of cases with the simultaneous occurrence of the “clicking” symptom (2.3%). In several children (5.1%), bronchoscopy revealed abnormalities of the tracheobronchial tree in the form of impaired branching of the upper and lower lobe bronchi. This contributed to the prolongation of repair processes after removal of foreign bodies from the respiratory tract. Also, bronchoscopy revealed bronchial stenosis (1.9%) when the foreign body was in the bronchi for more than a month, as well as bronchiectasis (0.5%) when the foreign body was in the bronchi for more than 2 years. The identified changes were confirmed on a bronchogram and computed tomography.

The incidence of clinical complications of aspiration also varied. In almost all children (91.6%), aspiration of foreign bodies was complicated by bronchitis and pneumonia. Only in 18 children (8.4%) with a short period of foreign body presence (1-28 hours) there were no clinical, radiological, or endoscopic complications in the airways during aspiration of foreign bodies. The vast majority of these children were over 3-4 years of age. The most common clinical complication of foreign body aspiration was bronchitis (83.7%): acute simple (36.5%) and obstructive bronchitis (47.2%). If the duration of aspiration of a foreign body into the respiratory tract exceeded 7 days, then the incidence of bronchitis decreased slightly. It should be noted that the incidence of bronchitis in children with aspiration of foreign bodies is higher, the younger the child. Thus, in children of the first 2 years of life, bronchitis complicated aspiration in 62.1% of cases, and in children over 2 years of age - in 37.9% of cases. The development of bronchitis was noted during aspiration of any foreign bodies, but with aspiration of organic foreign bodies, the incidence of bronchitis was higher (86.0%), compared with aspiration of inorganic foreign bodies (69.2%).

In addition, aspiration of foreign bodies was complicated by pneumonia (13.7%). In children of the first 2 years of life, pneumonia complicated aspiration (66.7%) much more often than in older children (33.3%). With an increase in the duration of presence of a foreign body in the respiratory tract, the frequency of pneumonia increased from 6.9% of cases in the first 3 days to 26.7% of cases in 1 week after aspiration, to 32.6% of cases in the first 2 weeks after aspiration and 32.1 % of cases with aspiration duration of more than 1 month. A clear dependence of the incidence of pneumonia on the nature of the aspirated foreign body was revealed: with organic foreign bodies, the incidence of pneumonia is 2-3 times higher than with inorganic foreign bodies. Moreover, pneumonia occurred more often when pieces of chewed organic foreign bodies entered the segmental bronchi (50.0% of cases). Consequently, the younger the child, the longer the duration of stay of the foreign body in the tracheobronchial tree, the significantly higher the likelihood of developing pneumonia, especially if the foreign body is of an organic nature.

In 2.5% of cases, post-traumatic laryngitis occurred in children after aspiration of a foreign body, and all these cases were observed in children with organic foreign bodies (watermelon and pumpkin seeds, beans, fish bone) 1-2 weeks after aspiration in young children.

Sanitation and diagnostic tracheobronchoscopy was performed on the 1st day of admission to the hospital in 89.8% of cases, on the 2nd day - in 6.5% of cases. For the remaining children (3.7%), it was carried out at a later date due to the severe severity of the condition, long periods of foreign bodies being in the respiratory tract with a satisfactory general condition or in the absence of indications of aspiration. The vast majority of sick children (74.9%) underwent one sanitation and diagnostic bronchoscopy, the remaining children underwent 2 (20.5%) or more bronchoscopy (4.6%) due to severe clinical symptoms and endoscopic picture. Only 3.2% of children had spontaneous passage of a foreign body during severe cough, and in half of them only part of the chewed foreign body came off, which was confirmed by bronchoscopy.

Follow-up observation of children who suffered aspiration of foreign bodies into the respiratory tract, 2 months - 10 years after its removal, revealed that this group of patients is very heterogeneous. In this group of 39 children, organic foreign bodies were identified in the anamnesis in 35 children (89.7% of cases), and their long-term presence in the respiratory tract (more than 3 days before removal) was noted in 61.5% of cases. All of them were discharged upon initial admission from hospital to satisfactory condition, but were not subsequently registered with a pediatrician at the dispensary. Almost all children had a chronic or recurrent pathology of the respiratory tract in their follow-up. Only 2 children showed no pathological changes in the tracheobronchial tree. These were children with inorganic foreign bodies and aspiration duration of less than 24 hours.

So, the results of the study revealed a significant percentage of pulmonary complications due to aspiration of foreign bodies into the respiratory tract, leading value in the formation of which are the duration of aspiration, the age of the patients and the nature of the aspirated foreign body. Despite the removal of foreign bodies from the respiratory tract and complex treatment, the general clinical condition of children and the condition of their tracheobronchial tree do not return to normal at the time of discharge from the hospital. The significant frequency of persistent changes in the lungs after removal of foreign bodies dictates the need to monitor these children with a local pediatrician and (or) pulmonologist for at least 5 years to prevent the development of chronic bronchopulmonary processes and disability of the child.

Reviewers:

• Polevichenko E.V., Doctor of Medical Sciences, Professor, Head. Department of Childhood Diseases No. 1, Rostov State Medical University, Rostov-on-Don;
• Chepurnaya M.M., Doctor of Medical Sciences, Professor of the Department of Childhood Diseases of the Faculty of Pedagogical Training of the Rostov State Medical University, Chief Children's Allergist of the Ministry of Health of the Rostov Region, Head. Pulmonology Department of the State Healthcare Institution OBD, Rostov-on-Don.

The work was received by the editor on April 28, 2011.

Bibliographic link

Kozyreva N.O. ON THE PROBLEM OF ASPIRATION OF FOREIGN BODIES INTO THE RESPIRATORY TRACT IN CHILDREN // Basic Research. – 2011. – No. 9-3. – P. 411-415;
URL: http://fundamental-research.ru/ru/article/view?id=28523 (access date: 03/01/2019). We bring to your attention magazines published by the publishing house "Academy of Natural Sciences"

Clinic

More than 3,000 people die each year due to foreign body aspiration, with about 50% being children under 4 years of age. Foreign body aspiration (FBA) is the most common cause of death in children under 6 years of age due to accidents at home. This usually happens to children aged 1 to 4 years, but 6-month-old babies have also been affected. Peanuts and sunflower seeds are most often identified as IT, but aspiration of almost any object of a certain size and type (metal or plastic balls, a lump of food or grass) is possible. At the age of up to one year, such IT often turns out to be eggshells that enter the trachea when feeding the child.

With aspiration of FBs, various symptoms are observed depending on the location of the FB and the degree of obstruction: wheezing, persistent pneumonia, stridor, cough and apnea. Repeated stridor and (or) wheezing may indicate a thrombosis that periodically changes its position in the airway: stridor occurs when the gastrointestinal tract is proximal, and wheezing occurs when it is more distal. Stridor due to IT suggests its localization in the larynx, trachea, or main bronchus. The usual localization of IT is the main bronchus (often on the right); This results in cough, unilateral wheezing or stridor and classic radiographic findings. Laryngeal and tracheal FBs are less common, but they are not rare: they account for 10-15% of all FBs. A patient with persistent stridor and croup who does not improve within 5 to 7 days may have a tracheal FB.

In classic cases, symptoms arise suddenly (the child chokes, coughs, and has the urge to vomit), but usually alleviates as the FB passes into the smaller airways. This in turn can lead to pneumonia, atelectasis or wheezing. Localization of IT in the stem bronchus is characterized by a three-phase course of symptoms: acute onset, latent asymptomatic period, and late appearance wheezing or stridor. In almost 7% of cases, IT aspiration may go unnoticed by the child’s parents; or they simply forget about it. There is often no history of aspiration; or anamnestic data are collected only retrospectively. So the doctor should have a high degree of vigilance regarding IT.

Foreign bodies in the upper esophagus can cause stridor. In addition, they can cause dysphagia or delay in weight gain, especially in the case of prolonged stay of radiolucent FB in the esophagus (for example, an aluminum cap, etc.). But even in the absence of dysphagia, the presence of a foreign body in the esophagus in a patient with stridor should be suspected.

Diagnostics

If the FB is radio-opaque, it can be easily detected by radiography. However, most FBs in the airways are radiolucent, so their presence is diagnosed based on changes in the shape and size of the airways or their dynamics. Foreign bodies in the larynx can be identified by air contrast on lateral films of the neck. The same applies to tracheal FBs, although their identification may require special equipment (for example, xerography or laminography). Xerograms may also be useful in identifying small non-radiopaque FBs in the lower respiratory tract.

The presence of a foreign body in the main bronchus causes a kind of valvular air retention in the affected lung, since during exhalation the bronchus contracts around the IT and obstructive emphysema occurs. This leads to hyperinflation of the lung with bronchial obstruction and displaces the mediastinum during exhalation in the direction opposite to the obstruction. This shift can be observed on inspiratory and expiratory radiographs in the anteroposterior projection or during fluoroscopy. If necessary, during exhalation you can press on the patient’s epigastrium, which will ensure maximum exhalation and make it easier to receive nice photo. In a very small or uncooperative child, it is sometimes impossible to obtain good radiographs during inspiration and expiration.

Mediastinal shift can also be seen on bilateral chest x-rays with the patient in the supine position. Typically, the lower half of the chest is less distended with a raised half of the diaphragm and “splinted ribs.” The opposite is observed on the side of IT localization, where the lung is constantly in a state of hyperinflation and its volume does not decrease even when the affected side is “down”. Such images can be taken even in small and non-contact patients.

It is very important that for the appearance these changes it takes some time. Obtaining a single negative radiograph does not exclude the presence of IT. In difficult cases, a CT scan may be necessary for diagnosis. And yet most important rule is to maintain a high degree of alertness regarding the possible presence of IT. Preoperative diagnosis of FB in the respiratory tract is made in only 60% of patients. In cases where suspicion of IT remains despite the lack of radiological confirmation, bronchoscopy should probably be resorted to.

Foreign bodies in the esophagus are usually radiopaque and are easily detected on radiographs. Flat FBs in the esophagus (such as coins) are almost always oriented in the circumferential plane, so that they appear “forward facing” on anteroposterior films. Tracheal FBs are almost always oriented in the sagittal plane due to the lack of cartilage in back wall trachea. However, these “rules” have exceptions. Anteroposterior and lateral films will certainly reveal radiopaque FBs. To diagnose radiolucent FBs in the esophagus, the use of barium, xerography, or tomography may be required.

Therapeutic measures

Treatment of patients with FB in the respiratory tract consists of laryngoscopic or bronchoscopic removal of FB in the operating room under anesthesia. This can be a difficult procedure, especially in very small patients with almost “tiny” airways. Sometimes it is very difficult to remove the entire foreign body using bronchoscopic forceps; in such cases a Fogarty catheter or basket may be required urinary stones. Similarly, esophageal FBs can be removed using endoscopic forceps with (or without) a Foley catheter. However, a Foley catheter is used only if the foreign body has a smooth surface, without sharp edges, and is in the esophagus for a sufficiently long time (at least 2 weeks); in addition, the patient must not have a previous esophageal disease. Immediate bronchoscopy is almost never required. Usually you can wait and find individual approach, especially in a patient with a full stomach.

Due to swelling of the airways, which is caused by the presence of the IT itself and the necessary instrumental intervention, as well as the presence chemical pneumonia in case of aspiration of food (especially peanuts), the patient will require respiratory treatment within 24-72 hours after IT removal. Antibiotics, corticosteroids, oxygen, fine aerosols, and physical therapy may be necessary. After bronchoscopic removal of a foreign body, the patient does not experience a sharp improvement in condition, as in patients with epiglottid after intubation.

The penetration of foreign bodies and liquids into the respiratory tract as a result of their absorption by the flow of inhaled air is aspiration. Mortality reaches 70%, and among the fatal complications of anesthesia in obstetrics, aspiration syndrome ranks first.

Aspiration syndromes

Aspiration of a foreign body into the airway may be asymptomatic or fatal. When children with a reduced level of consciousness aspirate stomach contents through vomiting, severe pneumonia or acute respiratory distress syndrome may result.

Most frequent syndromes include:

• Foreign body aspiration
• Aspiration associated with gastroesophageal reflux
• Drowning.

Aspiration into the tracheobronchial tree is more common than recognized. Most patients are children under 4 years of age. Fatalities are also more often observed in this age group. Younger children mostly aspirate food, small toys, or other small items.

Airway obstruction in children

The symptoms of foreign bodies in the respiratory tract are varied. This may be either an acutely developed, threatened condition, such as airway obstruction, or a condition accompanied by a chronic cough.

Clinical signs of foreign body obstruction:

• ineffective cough, increased difficulty breathing with the involvement of auxiliary muscles, participation in breathing of the wings of the nose, inspiratory shortness of breath,
• wheezing when exhaling,
• stridor,
• cyanosis of the skin and mucous membranes.

Very important differential diagnosis during aspiration syndrome between airway obstruction caused by a foreign body, infection or allergic process.

According to the mechanism of airway obstruction, foreign bodies are divided into:

1. Non-obstructive lumen - air passes freely past the foreign body during inhalation and exhalation,
2. Completely obstructing the lumen - no air passes through at all,
3. Obstructing the lumen like a “valve” - when you inhale, air passes past the foreign body into the lung, and when you exhale, it closes the lumen, thereby preventing air from leaving the lung.

By fixation:

• Fixed - foreign bodies sit firmly in the lumen of the bronchus and practically do not move during breathing,
• Ballistic foreign bodies - they are not fixed in the lumen and during breathing can move from one part of the respiratory system to another.

How to determine foreign body aspiration?

Foreign bodies in the respiratory tract can be found in the nasal passages, larynx, trachea, bronchi, in the tissue of the lung itself, in pleural cavity. By localization, the most dangerous place to live is the larynx and trachea, since foreign bodies in this area can completely block the access of air to the lungs. If emergency assistance is not provided for aspiration syndrome, death can occur within 1-2 minutes. Ballistic foreign bodies of the trachea are also dangerous because when they strike from below vocal cords persistent laryngospasm occurs, leading in itself to almost complete closure of the lumen of the larynx.

Foreign bodies in the main and lobar bronchi also very dangerous. When the lumen of the bronchus is obstructed like a “valve,” intrathoracic tension syndrome may develop, leading to very dangerous breathing and circulatory disorders.

Foreign bodies of small bronchi They may not show themselves at all at first. They do not cause pronounced respiratory disorders, and do not affect the child’s well-being in any way. But, after some time (from several days to several years) it may develop purulent process leading to the formation of bronchiectasis or the development of pulmonary hemorrhage. In the clinical picture of such foreign bodies, 3 stages can be distinguished:

• aspiration of a foreign body into the respiratory tract followed by a coughing attack,
• asymptomatic period,
• period of complications.

Despite the variety of clinical symptoms, it is necessary to identify the most characteristic features for specific localization of foreign bodies in the respiratory tract.

A foreign body in the bronchus has a pathogenetically dual effect. On the one hand, as a mechanical factor, it partially or completely blocks the lumen of the bronchus, causing hypoventilation of this section of the bronchus, impaired drainage function, and in some cases atelectasis. On the other hand, as an inflammatory factor, it acts locally on the bronchial wall, causing an inflammatory reaction.

The intensity of inflammation depends both on the object itself and on the reactivity of the body - general and local.

Objects with an uneven surface create more favorable conditions for inflammation: mucus and fibrin easily settle and remain on them. Dense objects with a smooth surface (metal, glass, plastic) are less likely to provoke inflammation.

Qualitative composition of a foreign body

Besides external features, the quality of the composition is also important. A foreign body always causes an inflammatory reaction in the tissues of the body. Its intensity depends on physical and chemical properties of this substance.

Various metals, plastics, and glass cause moderate inflammation of tissues, and organic substances cause a more violent inflammatory process that occurs much faster.

Of particular importance in the development of the inflammatory process during aspiration syndrome is attached to a foreign protein in the composition of an organic object. This protein causes allergization of the body and causes significant activity of the local inflammatory process.

Consequences

Diseases that develop after a foreign body enters the respiratory tract:

Laryngitis

After aspiration of a foreign body into the respiratory tract has occurred, the child may develop laryngitis, which in some of them develops after the object is removed from the larynx.

The phenomena of laryngeal stenosis can develop from the first days of the disease. In the clinical picture, the voice of almost all patients is clear, although some have slight hoarseness. From the first day there is a rude, loud, barking cough and inspiratory stridor, and in severe cases, inspiratory dyspnea. Body temperature rises to 38-39°C. The duration of the febrile period varies depending on the severity of the disease and the addition of complications (descending tracheobronchitis, pneumonia). On average, this period lasts 5-6 days. When the phenomena of laryngitis and laryngostenosis do not weaken or even intensify, repeated laryngoscopy is indicated, which makes it possible to verify the radical removal of the object and visually exclude the remaining particle of the aspirated object, because the progression of laryngitis is often caused by the abandonment of a part or an entire object.

Tracheobronchitis

The consequences of foreign body aspiration in the form of acute tracheobronchitis are common. Primary, due to irritation by a foreign body, the mucous membrane of the trachea and bronchi swells, and secretion increases. Hyperemia of the mucous membrane develops, sometimes with pinpoint hemorrhages. Secondary infection intensifies all of the above pathological processes. With tracheobronchitis, in the vast majority of cases, there is a history of direct indications of aspiration of a foreign body into the respiratory tract. However, in a number of patients, the cause of tracheobronchitis is considered to be an influenza infection, and only the detection of an object during endoscopy or its independent coughing makes it possible to establish correct diagnosis. Occasionally, tracheobronchitis is observed after removal of a foreign body. The cause of tracheitis can also be laryngitis, in which the inflammatory process moves from the larynx to the trachea.

Tracheitis

In most children, tracheitis develops 2-3 days after aspiration of a foreign body into the respiratory tract and is expressed primarily by a cough, initially dry. Sputum does not disappear in the first days, then it appears in small quantities, mucous in nature. Over time, the sputum becomes purulent; young children do not spit it out, but swallow it. Usually the body temperature does not rise or its rise does not last long. Significant deterioration general condition the patient is not noted. However, patients become lethargic, have poor appetite, and older children sometimes complain of chest pain.

Bronchial obstruction with aspiration syndrome

It leads to the development of hypoventilation and atelectasis of the corresponding zone. Atelectasis forms quickly with aspiration of round or oblong objects that have a circle in cross-section. This quickly leads to hermetic blockage of the bronchus. Air does not enter the lung tissue, but the air contained in the alveoli is absorbed. The lung becomes airless.