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 to do this as an emergency and, in this situation, a crico­thyroidotomy is probably preferable. Tracheal replacement with artificial substitutes has so far been unsuccessful. Sleeve resections of the major bronchi are also possible. Reversible airway obstruction (e.g. asthma) is the domain of respiratory physicians.

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.