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Case in Point

Flexible Bronchoscopic Removal of 3 Foreign Objects

Consider flexible bronchoscopy as an option to retrieve aspirated foreign bodies in the airway.
Federal Practitioner. 2018 September;35(9)a:24-26
September 10, 2018|Federal Practitioner
Javier Ramos-Rossy, MD;Onix Cantres, MD;Alfonso Torres, MD;Jesús Casal, MD;Yomayra Otero, MD;Ginger Arzon-Nieves;William Rodriguez-Cintrón, MD
Author and Disclosure Information

Dr. Ramos-Rossy and Dr. Otero are Fellows; Dr. Cantres and Dr. Torres are Attending Physicians; Ms. Arzon-Nieves is a Research Coordinator; and Dr. Rodríguez-Cintrón is Attending Physician, Section Chief, and Program Director, all in the Pulmonary and Critical Care Medicine Program at the VA Caribbean Healthcare System in San Juan, Puerto Rico.
Correspondence: Dr. Rodriguez-Cintrón (william@prmail.net)

Author disclosures
The authors report no actual or potential conflicts of interest with regard to this article.

Disclaimer
The opinions expressed herein are those of the authors and do not necessarily reflect those of Federal Practitioner, Frontline Medical Communications Inc., the US Government, or any of its agencies. This article may discuss unlabeled or investigational use of certain drugs. Please review the complete prescribing information for specific drugs or drug combinations—including indications, contraindications, warnings, and adverse effects— before administering pharmacologic therapy to patients.

Airway foreign-body aspiration may cause no symptoms, although it can produce acute and life-threatening central airway obstruction.1 In the US, at least 2,700 people, including more than 300 children, die of foreign-body aspiration each year.2 Most foreign-body aspirations occur in children and elderly patients.3 In adults, dementia, drug intoxication, strokes, seizures, and neurologic disorders may predispose patients to aspiration.3 Some of the consequences of an aspirated object are complete or partial airway obstruction, respiratory distress and failure, pneumothorax, and hemorrhage.2 In addition, inadvertent aspiration of foreign objects in asymptomatic patients may not be evident for months, resulting in late complications as postobstructive pneumonia, bronchiectasis, or lung abscess.2

We present a case of a patient with documented schizophrenia with nonadherence to his antipsychotic medications who aspirated different objects. Flexible bronchoscopy was performed since rigid bronchoscopy is not available at our institution. Several bronchoscopy tools were required to successfully remove the objects and avoid further invasive interventions, such as cardiothoracic surgery.

 

Case Presentation

A 55-year-old man with schizophrenia on antipsychotics developed cough, shortness of breath, and dysphagia of 1-month of evolution. Because his symptoms worsened, his mother brought him to the emergency department. Peripheral oxygen saturation was 97% at room air. Lung auscultation was remarkable for bilateral scattered rhonchi and wheezes.

Laboratory results showed leukocytosis with neutrophilia and hypotonic hypovolemic hyponatremia. 

In view of shortness of breath, cough, wheezes, and leukocytosis, a chest radiograph was performed, showing a rounded metallic density and 2 metallic objects (appearing to be a screw and a nail) at the right main stem bronchus for which the pneumology service was consulted (Figures 1A and 1B).

The patient stated that he did not remember swallowing any objects, although his mother confirmed that he was not adherent with his antipsychotic medications, which could have predisposed him to aspiration secondary to possible psychotic episodes. 

A chest computer tomography (CT) scan without contrast confirmed the presence of the materials (Figures 2A and 2B) and a possible prevertebral abscess, which could explain the patient’s dysphagia.

Piperacillin/tazobactam 4.5 g every 8 hours was started to cover anaerobic bacterial organisms causing abscess, and IV fluids were given for hypovolemia. Flexible bronchoscopy (rigid bronchoscopy is superior although not available at our institution) was planned to be performed in the operating room (OR) because we predicted a difficult and prolonged retrieval in view of multiple and different-sized objects.

A bronchoscopy was performed, showing a disk-shaped metallic foreign body at the right main stem bronchus. After multiple attempts using the tripod retrieval tool, a coin was removed (Figures 3A and 3B). 

Using a snare retrieving tool, the surgeons removed a screw from the right main stem bronchus as well (Figures 4A and 4B). 
A third foreign object with the appearance of a nail (Figure 5) was visualized distal in the right main stem bronchus. Because of the difficult position where the object was lodged, initial attempts to retrieve the object were unsuccessful. The airway was secured with endotracheal intubation, and the patient was sedated. 
Then multiple attempts at retrieval of this foreign object were performed with the tripod and snare tools. The object was finally advanced toward the endotracheal tube (ETT), yet it was larger than the caliber of the ETT. Therefore, the cuff was deflated, and the ETT was removed at the same time the bronchoscope was retrieved while holding the last foreign body.

The patient was reintubated without any complications. A postprocedure chest radiograph showed the absence of foreign bodies and no pneumothorax. The patient completed IV antibiotic with piperacillin/tazobactam and supportive therapy with clinical improvement and successful extubation within 2 days. Cardiothoracic surgery was not required. Psychiatry service recommended to continue the same antipsychotic medications, administered only by his mother to assure adherence and to avoid similar future events. The patient was discharged home without any immediate complications despite having had a coin, nail, and screw aspiration (Figure 6).

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