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Clinical Case Report

Aspiration pneumonia caused by an organic foreign body

A case report

Ghazanfar, Haider MDa,∗; Gaddam, Maneesh MDb; Milian, Antonio MDa; Niazi, Masooma MDc; Matela, Ajsza MDb

Author Information
Medicine Case Reports and Study Protocols: November 2020 - Volume 1 - Issue 1 - p e0012
doi: 10.1097/MD9.0000000000000012
  • Open

Abstract

1 Introduction

The prevalence of aspiration pneumonia is estimated to be between 5% and 24%.[1,2] According to a multicenter prospective study done on 589 patients the incidence of aspiration pneumonia in community-acquired and hospital-acquired pneumonia was found to be 60.1% and 86.7% respectively.[3] A retrospective multicenter study found a 23% overall in-patient mortality in those with aspiration pneumonia.[4] Foreign body (FB) aspiration although less frequent in adults in comparison to the pediatric population is more commonly seen in the elderly. The diagnosis of aspiration is difficult as patients may not present with typical signs and symptoms. Early detection and treatment of FB aspiration are required to prevent serious complications. We report a case of an 88-year-old female who was diagnosed with acute respiratory failure due to aspiration pneumonia caused by an organic FB.

2 Case presentation

The patient is an 88-year-old female who was bought to the emergency department 30 minutes after she was found unresponsive by her granddaughter. The patient had been having a dry cough, generalized weakness, decreased appetite, and lethargy for the past 2 days. There was no history of chest pain, shortness of breath, fever, chills, witnessed seizures, witnessed falls, abdominal pain, or vomiting.

The patient did not follow up with any physician and had no significant past medical or surgical history. The patient needed the assistance of 2 people to walk and was mostly bedbound during most of the day.

In the emergency department, the patient was found to be unresponsive and in severe respiratory distress. The patient had a blood pressure of 66/55, a heart rate of 117 beats per minute, respiratory rate of 41, and was saturating 75% while on a non-rebreather mask. On physical examination, the patient was cachectic, unkempt, and had cold and clammy skin. Chest examination revealed bilateral diffuse crackles. The patient was found to have 2 stages 3 sacral decubitus ulcers. The patient was intubated and sepsis protocol was initiated. Initial blood gas showed a pH of 7.220, Pco2 OF 39.1 mmHg, Po2 OF 57.1 mmHg, and lactic acid of 2. mmoles/L. The patient had a normal white blood cell count and had Hemoglobin of 8.0 g/dL in the admission labs. Patient chest x-ray showed diffuse bilateral infiltrates which were more on the right side as compared to the left. This has been shown in Figure 1.

F1
Figure 1:
Chest radiography showing bilateral infiltrates, more prominent on the right.

The patient's computed tomography (CT) head without contrast showed chronic diffuse brain atrophy. Patient CT chest with contrast revealed diffuse bilateral alveolar and interstitial infiltrates. This has been shown in Figure 2.

F2
Figure 2:
Computed tomography of the chest with contrast showing bilateral infiltrates and small pleural effusions.

The patient was started on intravenous Antibiotics and pneumonia and septic workup were sent. ICU was consulted for sepsis and acute respiratory failure and was accepted for the same. Wound care was consulted for the decubitus ulcers.

The patient underwent fiberoptic flexible bronchoscopy which showed thick mucopurulent secretions noted in the right upper and lower lobe. It also revealed a 1.5 x 1.5 cm FB in the right upper lobe. This has been shown in Figure 3 and Figure 4.

F3
Figure 3:
Foreign body suctioned from the right bronchial tree during flexible bronchoscopy.
F4
Figure 4:
Histopathology of the foreign body.

The pathology report of the FB was consistent with vegetable material. The patient's septic and pneumonia workup was negative. The patient failed multiple attempts to liberate her from the ventilator and showed no clinical improvement during hospitalization. The family opted for comfort measures and palliative was consulted. The patient underwent palliative extubation and expired shortly afterward.

3 Discussion

Aspiration can be divided into 3 clinical subcategories that comprise chemical pneumonitis, bacterial infection, and airway obstruction. Some of the risk factors for aspiration include advanced age, impaired consciousness, dysphagia from neurological disorders, sedative use, esophageal dysfunction, and bad oral health.[5,6] According to a retrospective study of 322 patients, dementia (odds ratio, 5.26) and poor performance status (odds ratio, 3.31) were the most important risk factors. The study showed that a higher number of aspiration risk factors is associated with increased mortality and pneumonia recurrence.[7]

Aspiration can have variable clinical manifestations, from being completely asymptomatic to causing life-threatening complications. The most common clinical signs and symptoms include choking followed by productive cough, shortness of breath, chest pain, and low-grade fevers. Nonspecific symptoms like fatigue, mental status changes, and lack of appetite occur more frequently in the elderly population.[8] Patients may have stridor, unilateral wheezing, or decreased breath sounds. The diagnosis of FB aspiration might be delayed in the geriatric population as most of the patients do not recall aspiration event. In a study by Lin et al only 29% of patients in the geriatric group provided a history of aspiration events in comparison to 50% of nongeriatric patients.[8]

The most common aspirated foreign bodies in the geriatric population include food particles, such as bone fragments and plants, parts of dental prosthesis, and tablets.[8–10] The nature of the FB in adults varies from organic to inorganic material. The degree of tissue reaction and respiratory system injury depends on the type of FB. Aspiration of organic FB is more common in the geriatric population. It is associated with severe airway mucosal inflammation resulting in the formation of granulation tissue which can act as a nidus for superimposed bacterial infection.[11]

According to a prospective study of critically ill patients with aspiration pneumonia Streptococcus pneumonia, Staphylococcus aureus, Haemophilus influenza, and Enterobacteriaceae were the most common isolates in community-acquired cases. Gram-negative bacilli, including Pseudomonas aeruginosa, were mostly found in patients with hospital-acquired pneumonia.[12] A prospective study of seventy-six patients over 80 years of age showed higher levels of urea, creatinine, and sodium, and lower estimated glomerular filtrate rate in patients with aspiration pneumonia.[13]

Chest radiography of patients with aspiration pneumonia usually reveals infiltrates in gravity-dependent lung segments. Superior lower lobe and posterior upper lobe segments are affected if the patient is in a supine position during the event. Basal segments of the lower lobe are involved if the patient is upright.[14] Chest radiography can be initially negative in FB aspiration as many of the FBs are radiolucent and are not identified on the chest radiography.[15] A chest CT scan is more sensitive in diagnosing aspiration pneumonia as compared to a chest radiograph. According to a study of 208 patients with pneumonia, the chest radiograph was found to be negative in 28% of patients in whom pneumonia was later confirmed on the CT scan.[16] The failure of chest radiographs to diagnose pneumonia was higher in the group of patients from nursing homes and extended care facilities. The sensitivity of imaging modalities is lower in the geriatric population as compared to non-geriatric patients. A retrospective study by Lin at al. showed that a CT scan of the chest detected a FB in 21% of geriatric patients in comparison to 35% in the non-geriatric group.[8]

If clinical suspicion for FB aspiration is high, bronchoscopy should be performed even if the imaging studies are negative. Bronchoscopic examination confirms the diagnosis of FB aspiration via direct visualization. Extraction of the FB is usually accomplished by flexible bronchoscopy as this modality allows easy access to proximal and distal airways. The success rate of flexible bronchoscopy varies from 60 to 90%.[17–19]

Rat tooth forceps are used in removing FB with a smooth surface, while inflatable balloon catheters are helpful in the retrieval of foreign bodies which are located distally. Magnet extractors can be used for retrieval of mobile metallic objects. Electrocautery or laser can be utilized in the removal of the FB surrounding granulation tissue. Cryotherapy has shown to be useful in removing organic foreign bodies.[20] Flexible bronchoscopy is considered a safe procedure. The complication rate varies from 0.08 to 6.8%.[21–22] Common complications include transient hypotension and hypoxia, nasal discomfort, sore throat, and mild hemoptysis. Hemorrhage and pneumothorax are rare.

FB retrieval with flexible bronchoscopy can potentially cause migration of the FB to more distal sites or contralateral lung, or result in airway obstruction. Bronchoscopy via the endotracheal tube is preferred over a nasal or oral approach as this access to the bronchial tree is associated with a lower risk of losing a FB during the procedure.[23]

The advantages of rigid bronchoscopy include better visualization, better airway control, and easier access to a FB. It also allows the passage of multiple instruments and the use of larger instruments.[20] Rigid bronchoscopy is preferred in the removal of foreign bodies in the pediatric population and children have a success rate of 90%.[24] In the adult population, rigid bronchoscopy and rarely surgery may be necessary for certain situations. Surgical intervention is required in cases where the bronchoscopy procedure fails to extract the FB or if FB aspiration leads to irreversible bronchial or lung complications.[25] In these cases, a thoracotomy procedure is performed.

In the event of vegetable material aspiration as in our patient, the final diagnosis required the help of a histopathological examination. Therefore, the pathologist must be familiar with the appearance of commonly aspirated foreign objects including food.[10] Confirming a diagnosis is crucial so steps can be taken to prevent potential complications and the occurrence of aspiration in the future.

4 Conclusion

In conclusion, we present a case of an elderly woman admitted with acute hypoxemic respiratory failure and septic shock secondary to pneumonia caused by aspiration of vegetable material. FB aspiration is an important cause of morbidity and mortality in the elderly. Aspiration should be considered in those with known risk factors even if clinical and radiographic findings are absent. The diagnosis can be challenging therefore a high index of suspicion is required. The majority of foreign bodies aspirated by adult patients can be successfully retrieved with flexible bronchoscopy.

Author contributions

All the authors made substantial contributions to the conception and design of the study; drafting the article and revising it critically for important intellectual content and approval of the version to be published.

References

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Keywords:

aspiration; bronchoscopy; elderly; foreign body; mortality; pneumonia

Copyright © 2020 the Author(s). Published by Wolters Kluwer Health, Inc.