Airway
obstruction
Tracheal obstruction may present acutely as a life-threatening emergency or insidiously with little in the way of symptoms until critical narrowing and stridor occur. The more common causes of airway narrowing are outlined in Table 47.1 .
Treatment
depends on the underlying cause. Tracheal resection is a very specialised
problem but in expert hands up to 6 cm of trachea may be resected without undue
tension on the anastomosis. Tracheostomy may be required to overcome the
obstruction but there are few indications
Inhaled
foreign bodies
This is a regrettably common occurrence in
small children and is often marked by a choking incident which then apparently
passes. Surprisingly large objects can be inhaled and become lodged in the wider
calibre and more vertically placed right main bronchus. If not removed, an
obstructive emphysema may result but, if there is total occlusion of the
bronchus, the air distally will be absorbed and the secretions may become
infected. There are three possible presentations:
1.asymptomatic;
2.wheezing (from airway narrowing) with a persistent cough and signs of
obstructive emphysema;
3.pyrexia with a productive cough from pulmonary suppuration.
A
chest radiograph is vital as the object may be radio-opaque. Often it is not
radio-opaque or is obscured by the cardiac shadow or the inflammatory response.
Bronchoscopy is required by an experienced operator with an experienced
anaesthetist to administer the anaesthetic. The procedure may be very difficult
if there is a severe inflammatory reaction. The rigid bronchoscope is best for
retrieving inhaled foreign bodies. Failure to remove the object may necessitate
a bronchotomy through a formal thoracotomy. If the object has caused chronic
lung damage it may be necessary to remove the affected lobe.
Haemoptysis
There is a variety of conditions giving rise
to repeated haemoptysis, including carcinoma, bronchiectasis, carcinoid tumours
and certain infections. Severe rheumatic mitral stenosis is a rare cause. All
patients with haemoptysis should be investigated at the very least by chest
radiography and bronchoscopy and those with normal findings carefully followed
up. Haemoptysis following trauma may be from a lung contusion or injury to a
major airway. Severe haemoptysis is unusual and the treatment depends on the
underlying cause.