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Cracking the Case of Foreign Body Aspiration

Hayes, Margaret MD*; Feller-Kopman, David MD, FCCP; Yarmus, Lonny DO, FCCP

Journal of Bronchology & Interventional Pulmonology: July 2011 - Volume 18 - Issue 3 - p 290–291
doi: 10.1097/LBR.0b013e3182238374
Brief Reports
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Foreign body aspiration, although a leading cause of unintentional deaths in children, is relatively uncommon in adults. The typical objects are food particles, which are aspirated in patients with altered mental status or pharyngeal dysfunction. We report an atypical case of foreign body aspiration in an adult presenting with dyspnea and pleuritic chest pain. The patient was found to have central airway obstruction secondary to an aspirated crack vial in his left mainstem bronchus, requiring urgent rigid bronchoscopic removal.

*Department of Medicine

Division of Interventional Pulmonology, The Johns Hopkins Hospital, Baltimore, MD

Disclosures: Drs Hayes, Feller-Kopman, and Yarmus have no disclosures or conflicts of interest to report.

Reprints: Lonny Yarmus, DO, FCCP, Division of Interventional Pulmonology, The Johns Hopkins Hospital, Baltimore, MD (e-mail: lyarmus@jhmi.edu).

Received March 28, 2011

Accepted May 3, 2011

Foreign body aspiration in adults is rare.1 Aspirated objects vary widely across age, range, and region, but some of the notably banal objects include nuts, meat, tacks, and teeth. Although there are reports of drug-related ingestions, primarily within the gastrointestinal tract, we report the first case of aspiration of an intact crack vial.2,3

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CASE REPORT

A 51-year-old African American man with a past medical history significant for substance abuse presented to the emergency department with dyspnea and pleurisy. Six days before admission, while pursued by the police, he attempted to swallow a crack vial to avoid arrest. Afterward, he reported experiencing a productive cough and left-sided pleuritic chest pain. On physical examination, he was afebrile, tachycardic, and normotensive with a normal respiratory rate and an oxyhemoglobin saturation of 99% on room air. On cardiovascular examination, he had a regular rate and rhythm with no rub appreciated. On lung auscultation, he had a focal central inspiratory and expiratory wheeze on the left. His white blood cell count and other basic laboratory parameters were normal. A chest roentogram revealed a cylindrical foreign body within the left lower lobe bronchus (Fig. 1). Given the high clinical suspicion for aspiration of a large foreign body and the associated concern for a fatal drug overdose from mucous membrane absorption within the respiratory tract,3 the patient was taken urgently to the operating room for rigid bronchoscopy to facilitate rapid and safe retrieval. His left mainstem bronchus was found to be completely occluded with a glass cylinder with a green cap (Fig. 2A). Using a combined rigid and flexible bronchoscopic approach with a 4-pronged retrieval device, (Fig. 2B) an intact crack vial (Fig. 2C) was retrieved. After removal, airway inspection revealed a patent left mainstem and distal segments. The patient was admitted for overnight observation and discharged the next day after authorities declined attempts at prosecution.

FIGURE 1

FIGURE 1

FIGURE 2

FIGURE 2

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DISCUSSION

Although aspiration is classically more common in children, our case illustrates an adult who aspirated a crack vial in an attempt to conceal evidence during a police pursuit. The majority of patients with foreign body aspiration present with a cough, fever, or hemoptysis and aspiration typically occurs into the right mainstem. However, our patient presented with dyspnea and left mainstem obstruction.

Although drug ingestions in the gastrointestinal tract are quite common,4 drugs in the respiratory tract are not only aberrant but also quite challenging to manage. On account of the size and nature of the foreign body, we used rigid bronchoscopy for retrieval to allow for rapid and secure access into the central airway. Although flexible bronchoscopy has been previously used for drug retrieval within the airways,2 the size and location of the vial precluded its use in our case. Intubating the patient with a rigid bronchoscope, allowed for complete airway control, and the ability to both rapidly and safely retrieve the crack vial from the central airway with no risk of vocal cord damage. The operative time for intubation and retrieval was <3 minutes.

The use of rigid bronchoscopy for foreign body removal was first performed in 1887 by Dr Gustav Killian of Freiburg, Germany, who removed a pork bone from the right mainstem bronchus of a farmer who had aspirated it while eating soup. Rigid bronchoscopy has significantly decreased the morbidity and mortality previously associated with foreign body aspiration. As it allows for immediate airway control and the use of multiple techniques for foreign body removal, rigid bronchoscopy remains the procedure of choice for foreign body removal at institutions with expertise in its use. Using both rigid and flexible bronchoscopy, we chose to use a pronged snare retrieval device to rapidly remove the crack vial, but a number of instruments could be used through the rigid scope, including grasping forceps, retrieval baskets, and cryotherapy.

Foreign body aspiration, although less common in adults than children, still does occur. Prompt recognition is required so that there is no delay in retrieval of the foreign body. Although foreign body removal can be performed with flexible bronchoscopy under moderate sedation, the success rate of using rigid bronchoscopy approaches 100%.5 Our case, as one can see, was clearly atypical from presentation to retrieval and gives new meaning to the term “crack lung.”

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REFERENCES

1. Rafanan AL, Mehta AC. Adult airway foreign body removal: what's new? Clin Chest Med.. 2001;22:319–330
2. Zaas D, Brock M, Yang S, et al. An uncommon mimic of an acute asthma exacerbation Chest.. 2002;121:1707–1709
3. Bobaugh DJ, Schneider SM, Benitez JG, et al. Cocaine balloon aspiration: successful removal with bronchoscopy Am J Emerg Med.. 1996;15:544–546
4. Introna F, Smialek J. The “mini-packer” syndrome Am J Forensic Med Pathol.. 1989;10:21–24
5. Wei-chung H, Tsung-shiann S, Chia-der L, et al. Clinical experiences of removing foreign bodies in the airway and esophagus with a rigid endoscope: a series of 3217 cases from 1970 to 1996 Otolaryngol Head Neck Surg.. 2000;122:450–454
Keywords:

foreign body aspiration; rigid bronchoscopy; flexible bronchoscopy; foreign body retrieval

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