FOREIGN

BODY
OBSTRUCTION
OVERVIEW

- Partial or complete blockage of the

breathing tubes to the lungs due a foreign
body
- According to the National Safety Council’s statistics (NCS), foreign-body
obstruction is the fourth leading cause of unintentional death, resulting in
5,051 documented deaths in 2015.

- Due to the prevalence and rapidity of unconsciousness and death associated

with choking, all persons, including those outside of the health field, should
have a basic understanding of how to care for a choking victim

- Simple maneuvers taught to lay-people, such as the Heimlich

maneuver, have been proven to save lives.
 ETIOLOGY

Young children are

susceptible because:

-Lack molars for grinding

foods
-They tend to be running or
playing at time of aspiration
-Puts objects in their mouth
frequently
-Glottal closure and the
expiration reflex
EPIDEMIOLOGY

- choking episodes is difficult to measure

- food is the most common precipitant,
with 59.5% of cases
- by non-food items, such as coins,
marbles, balloons, and paper, with 31.4%
. In 9.1% of cases, the cause was unknown

The estimated rates of fatal choking for

adults aged 18 to 64 are at 0.1 per 100000
and 0.7 per 100000 for those over 65 years
of age
Among children:
Choking rates were highest
among infants less than one year,
and over 75% of choking incidents
occurred in children under 3

Among Adults:
Conditions associated with a
higher risk of choking include
Alzheimer disease, parkinsonism,
prior stroke, intellectual or
developmental disability, poor
dentition, intoxication, dysphagia
along with psychotropic
medications, and advanced age
 CAUSES

- Meat ALWAYS
- Dentures REMEMBER!!!
-Elderly with Dysphagia
- Drug or alcohol - Cut food into small pieces
intoxication - Chew slowly
- Neurological - Avoid running, laughing
impairment (stoke) during chewing or
- Mental impairment swallowing
- Keep away foreign bodies
like coins, bids, and nuts.
FOREIGN BODY IN THE NOSE

Symptoms:
-Difficulty breathing through the affected nostril
- Feeling of something in the nose
- Bloody nasal discharge
- Irritability particularly in infants
- Irritation or pain the nose.
 FOREIGN BODY IN THE LARYNX

- Laryngeal foreign bodies usually cause complete or partial airway obstruction

Laryngeal Symptoms:

-Croup
- Stridor
- Cough
- Hoarseness
- Dyspnea
- Painful in swallowing
- Aphonia
FOREIGN BODY IN THE TRACHEOBRONCHIAL TREE

Signs:
-Episodes of coughing

Site:
-Depends on size and shape of foreign body
- the most common site is the right main
bronchus because of its straighter angle of origin
from the trachea

If foreign body is retained for longer period

of time, the following occur depending on the
time of FB and duration: Accumulation of
secretions, bronchitis with edema, swelling and
granulations, bleeding and bloodstained
secretions, inspiratory and expiratory vulvular
stenosis, and partial obstruction of lower airway
or emphysema.
 FOREIGN BODY IN THE EAR

If an object becomes lodged in the ears:

- Don’t probe the ear with a tool such as a
cotton swab or matchstick
- Remove the object if POSSIBLE
- Try using gravity.
- Try using oil for an insect.
- Try washing the object out

If any of this fail and or the person is still

having pain, SEEK MEDICAL ASSISTANCE
IMMEDIATELY.
 HISTORY AND PHYSICAL

-begin with an assessment of the ABCs (airway,

breathing, and circulation)
- The clinician should focus on skin color, level of
consciousness, and work of breathing, noting chest
wall retractions, nasal flaring, and the use of
accessory muscles
- The classical physical exam features include stridor
and hoarseness for laryngotracheal foreign bodies
and unilateral wheezing and decreased breath sounds
for foreign bodies in the bronchi
- In the absence of these physical exam findings,
providers should pay particular attention to risk
factors such as age or disability and chest x-ray
findings of atelectasis, lung hyperinflation, or
pneumonia.
 FBAO ALGORITHM
Assess severity

Mild Severe
Airway Obstruction Airway Obstruction
(effective cough) (Ineffective cough)

Encourage cough Conscious

Continue to check 5 back blows Unconscious
for deterioration to 5 abdominal “Start CPR
Ineffective cough thrusts
or until obstruction
relieved
FIRST AID MANAGEMENT
HEIMLICH’S
MANEUVER
BACK BLOWS
ABDOMINAL THRUSTS
 PROGNOSIS

-The prognosis of FBAO depends on the

degree of obstruction and duration of
hypoxia
- Patients with partial FBAO that can clear
the airway have little to no complications
and can be managed based on any existing
risk factors for future aspiration events
- In a complete FBAO, loss of
consciousness occurs in seconds to
minutes
- For patients requiring CPR, outcomes are
particularly grim as mortality reaches 90%
for out of hospital cardiac arrests, and of
those who survive to hospital admission,
mortality reaches 60%-70%
 COMPLICATIONS
- The most feared complication of
FBAO is hypoxia resulting in
respiratory arrest, anoxic brain
injury, and death
- Long term complications of
undiagnosed airway foreign bodies
are atelectasis, pneumonia, or
bronchiectasis, occasionally
requiring lobectomy or
segmentectomy.
- Complications of the Heimlich
maneuver include injury to the
abdominal or thoracic viscera and
regurgitation of stomach contents
INHALATION INJURY
DEFINITION

Inhalation injury refers to pulmonary injury resulting from inhalation

of smoke or chemical products of combustion. Inhalation injury
results in direct cellular damage, alterations in regional blood
circulation and perfusion, obstruction of the airways, and the release
of pro-inflammatory cytokine and toxin release.
NOTE!

• Inhalation injury happens to be one of the most challenging injuries for burn care
providers. This is because it is one of the classic determinants of mortality that
occurs after severe burn injury. The other determinants are age, the extent of
injury, as well as delay in resuscitation

• Inhalation injury results in direct cellular damage, alterations in regional blood circulation and
perfusion, obstruction of the airways, and the release of pro-inflammatory cytokines and
toxin release. Inhalation injuries also cause reduced functionality of mucociliary clearance and
weakening of alveolar macrophages. With this, the patient is placed at a high risk of bacterial
infection, especially pneumonia, which is one of burn patients' top causes of death.
Anatomical Classification
• UPPER AIRWAY
• LOWER AIRWAY
• SYSTEMIC TOXICITY
Symptoms of inhalation injuries can depend on what you breathed in.
But they often include:

• Coughing and phlegm

• A scratchy throat
• Irritated sinuses
• Shortness of breath
• Chest pain or tightness
• Headaches
• Stinging eyes
• A runny nose
• Hoarse Voice
• If you have a chronic heart or lung problem, an inhalation injury can make it worse.
 Heat Injury to the
Upper Airway
Injury results in the structures of the
airway above the carina. This is due to
the combination of efficient heat
dissipation in the upper airway, the low
heat capacity of air, and reflex closure of
the larynx.
The result of the injury to these airway
structures includes extensive swelling of
the tongue, epiglottis, and aryepiglottic
folds and accompanying obstruction. It
takes a period of hours for airway
swelling to develop as fluid resuscitation
is taking place.
Chemical Injury to the
Lower Airways
• Lower airway injury occurs as a
result of the chemicals in smoke.
Due to the low heat capacity of air
and the efficient bronchial
circulation regulating the
temperature of the airway gases,
most gases are at body temperature
when the pass through the glottis.
• Sulfur dioxide
• laminated furniture may contain glues
that may release cyanide gas during
combustion
Systemic Toxicity due to Carbon Monoxide
or Cyanide Exposure
• Carbon monoxide hampers the delivery of oxygen to various tissues
in the body, which can lead to serious damage and even death.
• Carbon monoxide is a colorless, odorless, tasteless gas produced
by burning gasoline, wood, propane, charcoal or other fuel.
Improperly ventilated appliances and engines, particularly in a
tightly sealed or enclosed space, may allow carbon monoxide to
accumulate to dangerous levels.
The most common symptoms
of carbon monoxide poisoning are
headaches, dizziness, and nausea.

• Other symptoms include:

• Headache
• Fatigue
•Palpitations
•Shortness of breath
• Confusion
•Agitation
• Abdominal pain
•Drowsiness
• Nausea and vomiting
•Hallucinations
• Weakness •Visual disturbances
•Seizure
On the other hand, inhaled hydrogen
cyanide, which is a product of the
combustion of multiple household
materials also inhibits the cytochrome
oxidase system. This then foster a
synergy with carbon monoxide to
cause tissue hypoxia with acidosis
and a reduction in the consumption of
oxygen by the brain tissues
Diagnosis

Initially, the diagnosis of inhalation injury was

based on the following indirect observations:
• Facial burns
• Singed nasal vibrissae
• A history indicating a burn injury that occurred in
an enclosed space
• Carbonaceous secretions
• Hypoxia, rales, rhonchi and wheezes are not often present on admission.
But when they occur, they are seen in patients with the most severe
injury and this may mean an extremely poor prognosis
• Patients may have changes of diffuse or focal infiltrates or
pulmonary edema between five to ten days after injury
• . Therefore, the admission film is usually not used for diagnostic
purposes, but is useful for making baseline evaluations.[
Chest X-ray of
patient on
admission has also
been shown to be a
poor indicator of
inhalation injury.
TOOLS FOR DX
• Bronchoscopy
• Pulmonary Function test
• Xenon lung Scan
fiberoptic
bronchoscopy

•The observations may

include the presence of
soot, mucosal necrosis,
char, edema of the
respiratory airways, and
inflammation
Xenon scanning 

Safe and quick test which

requires a minimum of
patient's cooperation
It involves several chest
scintiphotograms once an initial
radioactive Xenon gas has been
intravenously injected. The test
demonstrates the locations of the
decreased alveolar gas washout,
revealing the sites of tiny airway
obstruction that results from
edema or fibrin cast formation
 • There is generally no single
standard management
protocol for inhalation
injury. The mainstay of
Management treatment of inhalation
injury is supportive care.
This is achieved by acute
hospitalization and
rehabilitation
Supportive Care

Airway Obstructive Casts

Bronchodilators

• Bronchodilators decrease airflow resistance

and improve airway compliance. Albuterol and
salbutamol which are β2-adrenergic  agonists
reduce airway pressure by causing a relaxation
of smooth muscles and inhibiting
bronchospasm to increase the PaO2/FiO2 ratio
Muscarinic Receptor Antagonists

• To reduce airway pressures and mucus secretion, muscarinic

receptor antagonists like tiotropium are employed to limit
cytokine release through smooth muscle constriction in the
airways, and to cause a stimulation of submucosal glands. To
reduce the inflammatory response of the host after an inhalation
injury, muscarinic receptor antagonists and beta agonists can be
used. Structurally, muscarinic and adrenergic receptors are in
the lining of the respiratory tract, although its impact on the
inflammatory and host response is not fully understood. They
however have been demonstrated to reduce the activity of pro-
inflammatory cytokines following stress.
Inhaled (Nebulized) Mucolytic Agents and Anticoagulants

• To address the airway obstruction that occurs following

mucus, fibrin cast formation and cellular debris after an
inhalation injury, mucolytic agents are used; in particular, N
Acetylcysteine (NAC). NAC has anti-inflammatory properties
and it is an antioxidant and free radical scavenger. It acts as a
strong mucolytic agent that reduces the damage caused by
ROS. Inhaled anticoagulants are also employed to reduce
airway obstruction from fibrin casts.
Respiratory Support

• Since a significant upper airway edema usually

results from an inhalation injury, and the
resuscitation of the burn injury often worsen
the airway edema, it is often important to
obtain and maintain a patent airway in the
management of inhalation injury
Physiotherapy

A number of studies have

demonstrated that a techniques
such as gravity-assisted bronchial
drainage when combined with
chest percussion and vibrations.
are effective in the removal of
secretions.
Bronchial Drainage / Positioning

• This is a modality that employs the use of gravity-assisted

positioning targeted at improving the hygiene of pulmonary
system in patients with inhalation injury and/or retained
secretions. Due to skin grafts, donor sites, and the use of air
fluid beds, clinical judgment might influence the most
appropriate decisions. In fact, positioning in the Trendelenburg
and various other positions may acutely worsen hypoxemia. It
has been shown that a patient may experience a decline in the
level of arterial oxygenation positioning.
Percussion

• Percussion allows secretions to be removed from the

tracheobronchial tree. It is essential to position a suitable
padding between the patient and the physiotherapist's hands
to prevent skin irritation during the process of
percussion. Percussion is applied over the bronchial
segments to be drained using their surface landmarks.
Incisions, skin grafts, and bony prominence should be
avoided during percussion.
Vibration / Shaking

• Vibration / Shaking mobilizes loosened secretions into larger

airways to enable easy cough up or removal through
suctioning. Vibrations can be performed mechanically, and
this type of vibrations have also been reported to produce
good clinical results. For patients who cannot tolerate
manual percussion, gentle mechanical vibration may be
indicated.
Early Ambulation

• To prevent respiratory complications, ambulation can be commenced early

for patients with inhalation injury. Patients who are on continuous
ventilatory support can also be placed into a chair with appropriate use of
analgesics. There are establish therapeutic effects of the sitting position
which include:
• The patient can breathe with lungs regions that are normally
hyperventilated
• Muscular strength and tone can be preserved
• Contractures are prevented and exercise tolerance is maintained
Prognosis

• It is noteworthy that mortality rates for inhalation injury have not

changed over the past five decades, though improvements in
standards of care for severe burn injuries have. Supportive strategies
are vital in the management of inhalation injury. Yet, more trials are
needed to demonstrate sufficient evidence for many of the
pharmacological agents. Also, more promising results have been
achieved with unconventional modes of ventilation such as HFPV in
addressing physiologic derangements from inhalation injury.
 • At home, practice fire safety, which includes
preventing fires and having a plan in case
there is a fire
• If there is smoke from a wildfire nearby or lots
You can take steps of particulate pollution in the air, try to limit
your time outdoors. Keep your indoor air as
to try to prevent clean as possible, by keeping windows closed
inhalation injuries: and using an air filter. If you have asthma,
another lung disease, or heart disease, follow
your health care provider's advice about your
medicines and respiratory management plan.
• If you are working with chemicals or gases,
handle them safely and use protective
equipment
ANAPHYLAXIS
NCM 118
 ANAPHYLAXIS

• Anaphylaxis is a potentially fatal allergic

reaction. It can happen seconds or
minutes after you've been exposed to
anything you're allergic to, such peanuts
or bee stings.
CAUSES:

The most common anaphylaxis triggers in children are food

allergies, such as to peanuts and tree nuts, fish, shellfish,
wheat, soy, sesame and
milk. Besides allergy to peanuts, nuts, fish, sesame and shellfish,
anaphylaxis triggers in adults
include:
• Certain medications, including antibiotics, aspirin and other
pain relievers available without a prescription, and the
intravenous (IV) contrast used in some imaging tests
• Stings from bees, yellow jackets, wasps, hornets and fire ants
• Latex
SIGNS & SYMPTOMS:

• Skin reactions, including hives and itching

and flushed or pale skin
• Low blood pressure (hypotension)
• Constriction of the airways and a swollen
tongue or throat, which can cause wheezing
and trouble breathing
• A weak and rapid pulse
• Nausea, vomiting or diarrhea
• Dizziness or fainting
 Dependent & Independent
Interventions

1. Call for help

2. Epinephrine or adrenaline
3. Oxygen therapy
4. Medications
5. Intravenous antihistamine & steroids
6. Beta-agonists
7. Antiemetics
8. Intravenous fluids
9. Bronchodilators