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Gómez-Ríos MÁ, Sastre JA, Onrubia-Fuertes X, López T, Abad-Gurumeta A, Casans-Francés R, Gómez-Ríos D, Garzón JC, Martínez-Pons V, Casalderrey-Rivas M, Fernández-Vaquero MÁ, Martínez-Hurtado E, Martín-Larrauri R, Reviriego-Agudo L, Gutierrez-Couto U, García-Fernández J, Serrano-Moraza A, Rodríguez Martín LJ, Camacho Leis C, Espinosa Ramírez S, Fandiño Orgeira JM, Vázquez Lima MJ, Mayo-Yáñez M, Parente-Arias P, Sistiaga-Suárez JA, Bernal-Sprekelsen M, Charco-Mora P. Spanish Society of Anesthesiology, Reanimation and Pain Therapy (SEDAR), Spanish Society of Emergency and Emergency Medicine (SEMES) and Spanish Society of Otolaryngology, Head and Neck Surgery (SEORL-CCC) Guideline for difficult airway management. Part II. REVISTA ESPANOLA DE ANESTESIOLOGIA Y REANIMACION 2024; 71:207-247. [PMID: 38340790 DOI: 10.1016/j.redare.2024.02.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/28/2023] [Accepted: 08/28/2023] [Indexed: 02/12/2024]
Abstract
The Airway Management section of the Spanish Society of Anesthesiology, Resuscitation, and Pain Therapy (SEDAR), the Spanish Society of Emergency Medicine (SEMES), and the Spanish Society of Otorhinolaryngology and Head and Neck Surgery (SEORL-CCC) present the Guide for the comprehensive management of difficult airway in adult patients. Its principles are focused on the human factors, cognitive processes for decision-making in critical situations, and optimization in the progression of strategies application to preserve adequate alveolar oxygenation in order to enhance safety and the quality of care. The document provides evidence-based recommendations, theoretical-educational tools, and implementation tools, mainly cognitive aids, applicable to airway management in the fields of anesthesiology, critical care, emergencies, and prehospital medicine. For this purpose, an extensive literature search was conducted following PRISMA-R guidelines and was analyzed using the GRADE methodology. Recommendations were formulated according to the GRADE methodology. Recommendations for sections with low-quality evidence were based on expert opinion through consensus reached via a Delphi questionnaire.
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Affiliation(s)
- M Á Gómez-Ríos
- Anesthesiology and Perioperative Medicine, Complejo Hospitalario Universitario de A Coruña, A Coruña, Spain.
| | - J A Sastre
- Anesthesiology and Perioperative Medicine, Complejo Asistencial Universitario de Salamanca, Salamanca, Spain
| | - X Onrubia-Fuertes
- Department of Anesthesiology, Hospital Universitary Dr Peset, Valencia, Spain
| | - T López
- Anesthesiology and Perioperative Medicine, Complejo Asistencial Universitario de Salamanca, Salamanca, Spain
| | - A Abad-Gurumeta
- Department of Anesthesiology, Hospital Universitario Infanta Leonor, Madrid, Spain
| | - R Casans-Francés
- Department of Anesthesiology, Hospital Universitario Infanta Elena, Valdemoro, Madrid, Spain
| | | | - J C Garzón
- Anesthesiology and Perioperative Medicine, Complejo Asistencial Universitario de Salamanca, Salamanca, Spain
| | - V Martínez-Pons
- Department of Anesthesiology, Hospital Universitari i Politècnic La Fe, Valencia, Spain
| | - M Casalderrey-Rivas
- Department of Anesthesiology. Complejo Hospitalario Universitario de Ourense, Ourense, Spain
| | - M Á Fernández-Vaquero
- Department of Anesthesiology, Hospital Clínica Universitaria de Navarra, Madrid, Spain
| | - E Martínez-Hurtado
- Department of Anesthesiology, Hospital Universitario Infanta Leonor, Madrid, Spain
| | | | - L Reviriego-Agudo
- Department of Anesthesiology, Hospital Clínico Universitario, Valencia, Spain
| | - U Gutierrez-Couto
- Biblioteca, Complejo Hospitalario Universitario de Ferrol (CHUF), Ferrol, A Coruña, Spain
| | - J García-Fernández
- Department of Anesthesiology, Hospital Universitario Puerta de Hierro-Majadahonda, Majadahonda, Madrid, Spain; President of the Spanish Society of Anesthesiology, Resuscitation and Pain Therapy (SEDAR), Spain
| | | | | | | | | | - J M Fandiño Orgeira
- Emergency Department, Complejo Hospitalario Universitario de A Coruña, A Coruña, Spain
| | - M J Vázquez Lima
- Emergency Department, Hospital do Salnes, Vilagarcía de Arousa, Pontevedra, Spain; President of the Spanish Emergency Medicine Society (SEMES), Spain
| | - M Mayo-Yáñez
- Department of Otorhinolaryngology/Head Neck Surgery, Complexo Hospitalario Universitario A Coruña, A Coruña, Spain
| | - P Parente-Arias
- Department of Otorhinolaryngology/Head Neck Surgery, Complexo Hospitalario Universitario A Coruña, A Coruña, Spain
| | - J A Sistiaga-Suárez
- Department of Otorhinolaryngology, Hospital Universitario Donostia, Donostia, Gipuzkoa, Spain
| | - M Bernal-Sprekelsen
- Department of Otorhinolaryngology, Hospital Clínic Barcelona, University of Barcelona, Barcelona, Spain; President of the Spanish Society for Otorhinolaryngology Head & Neck Surgery (SEORL-CCC), Spain
| | - P Charco-Mora
- Department of Anesthesiology, Hospital Universitari i Politècnic La Fe, Valencia, Spain
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Harischandra DVT, Jayaweera JMRG, Wickramasinghe A, Firmin RK. Use of extracorporeal membrane oxygenation for bronchoscopic removal of a tracheal foreign body in a child. J Laryngol Otol 2023; 137:1058-1061. [PMID: 36168724 DOI: 10.1017/s0022215122002171] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND Bronchoscopic removal of a foreign body is a common emergency procedure in paediatric otolaryngology. It is potentially life-threatening, as complete airway obstruction caused by the foreign body can lead to hypoxic cardiac arrest during the manipulation of the object. CASE REPORT This paper presents a child who had aspirated a foreign body that could not be extracted conventionally via rigid bronchoscopy in the first instance. Subsequently, it was extracted at repeat bronchoscopy under controlled respiratory conditions maintained by an extracorporeal gas exchange circuit - extracorporeal membrane oxygenation, using a polypropylene hollow fibre oxygenator commonly employed in cardiac surgery (rather than a more expensive polymethyl pentene oxygenator commonly used in extracorporeal membrane oxygenation). CONCLUSION Extracorporeal membrane oxygenation use can be considered in exceptional cases of upper airway emergencies, even in resource-poor settings, and can avoid more hazardous thoracotomy and bronchotomy procedures.
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Affiliation(s)
| | - J M R G Jayaweera
- Department of ENT, District General Hospital - Matara, Matara, Sri Lanka
| | | | - R K Firmin
- Cardiothoracic Unit, Glenfield Hospital, University Hospitals of Leicester, Leicester, UK
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Ginter D, Johnson KT, Venettacci O, Vanderlaan RD, Gilfoyle E, Mtaweh H. Case report: Foreign body aspiration requiring extracorporeal membrane oxygenation. Front Pediatr 2023; 11:1189722. [PMID: 37492608 PMCID: PMC10364471 DOI: 10.3389/fped.2023.1189722] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2023] [Accepted: 06/23/2023] [Indexed: 07/27/2023] Open
Abstract
Introduction Foreign body aspiration is a common cause of respiratory distress in pediatrics, but the diagnosis can be challenging given aspirated objects are mostly radiolucent on chest radiographs and there is often no witnessed choking event. We present a case of a patient who was initially managed as severe status asthmaticus, requiring veno-arterial extracorporeal membrane oxygenation (VA-ECMO) for refractory hypercarbia and hypoxemia, but was later found to have bilateral bronchial foreign body aspiration. This case is unique in its severity of illness, diagnostic dilemma with findings suggesting a more common diagnosis of asthma, and use of ECMO as a bridge to diagnosis and recovery. Patient case A previously healthy 2-year-old boy presented during peak viral season with a 3-day history of fever, cough, coryza, and increased work of breathing over the prior 24 h. There was no reported history of choking or aspiration. He was diagnosed with asthma and treated with bronchodilator therapy. Physical examination revealed pulsus paradoxus, severe work of breathing with bilateral wheeze, and at times a silent chest. Chest radiographs showed bilateral lung hyperinflation. Following a brief period of stability on maximum bronchodilator therapies and bilevel positive pressure support, the patient had a rapid deterioration requiring endotracheal intubation, with subsequent cannulation to VA-ECMO. A diagnostic flexible bronchoscopy was performed and demonstrated bilateral foreign bodies, peanuts, in the right bronchus intermedius and the left mainstem bronchus. Removal of the foreign bodies was done by rigid bronchoscopy facilitating rapid wean from VA-ECMO and decannulation within 24 h of foreign body removal. Conclusion Foreign body aspiration should be suspected in all patients presenting with atypical history and physical examination findings, or in patients with suspected common diagnoses who do not progress as expected or deteriorate after a period of stability. Extracorporeal life support can be used as a bridge to diagnosis and recovery in patients with hemodynamic or respiratory instability.
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Affiliation(s)
- Dylan Ginter
- Department of Critical Care Medicine, The Hospital for Sick Children, Toronto, ON, Canada
| | - K. Taneille Johnson
- Department of Critical Care Medicine, The Hospital for Sick Children, Toronto, ON, Canada
| | - Oliver Venettacci
- Department of Critical Care Medicine, The Hospital for Sick Children, Toronto, ON, Canada
| | - Rachel D. Vanderlaan
- Division of Cardiovascular Surgery, Hospital for Sick Children, Toronto, ON, Canada
| | - Elaine Gilfoyle
- Department of Critical Care Medicine, The Hospital for Sick Children, Toronto, ON, Canada
| | - Haifa Mtaweh
- Department of Critical Care Medicine, The Hospital for Sick Children, Toronto, ON, Canada
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Yogo N, Mizutari S, Honda K, Asai H. Child requiring tracheostomy for removal of an airway foreign body at the tracheal bifurcation. BMJ Case Rep 2022; 15:e250399. [PMID: 35835483 PMCID: PMC9289016 DOI: 10.1136/bcr-2022-250399] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
Airway foreign bodies are typically removed orally using a rigid bronchoscope. We present a rare case of a foreign body at the tracheal bifurcation that required removal via tracheostomy. A child turned pale while eating nuts and was suspected to have choked on a foreign body. CT revealed a foreign body at the tracheal bifurcation. As his respiratory condition was unstable, tracheal intubation and removal were attempted using a rigid bronchoscope. Tracheal obstruction during oral removal resulted in respiratory failure and bradycardia. Following emergency tracheostomy, the foreign body was removed via the tracheal stoma after his respiratory condition stabilised. The patient was discharged 21 days later without neurological sequelae. To avoid hypoxaemia during airway foreign body removal, as in this case, assessing the size of the upper airway and foreign body is necessary. Tracheostomy and foreign body removal through the tracheal opening should be considered proactively.
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Affiliation(s)
- Naoki Yogo
- Department of Pediatrics, Division of Pediatric Emergency and Critical Care, Japanese Red Cross Kumamoto Hospital, Kumamoto, Japan
| | - Sachiko Mizutari
- Otolaryngology, Japanese Red Cross Kumamoto Hospital, Kumamoto, Japan
| | - Kei Honda
- Pediatrics, Japanese Red Cross Kumamoto Hospital, Kumamoto, Japan
| | - Hidetoshi Asai
- Otolaryngology, Japanese Red Cross Kumamoto Hospital, Kumamoto, Japan
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AlKhalifah AS, AlJassim NA. Venovenous extra corporeal life support in an infant with foreign body aspiration: A case report. Respir Med Case Rep 2022; 37:101636. [PMID: 35330590 PMCID: PMC8938911 DOI: 10.1016/j.rmcr.2022.101636] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2021] [Revised: 01/28/2022] [Accepted: 03/17/2022] [Indexed: 11/27/2022] Open
Abstract
Background Foreign body aspiration (FBA) is a life-threatening emergency and a common cause of morbidity and morbidity in children. FBA can lead to rapidly progressive respiratory failure. Stabilizing patients after FBA for bronchoscopic removal of the aspirated object can be complex and may necessitate advanced support such as high-frequency oscillatory ventilation (HFOV) or extracorporeal membrane oxygenation (ECMO). This case report presents the feasibility of using ultrasound (US) in percutaneous catheterization in infants and the benefit of using venovenous ECMO (VV-ECMO) as rescue therapy in FBA. Case summary A 10-month-old girl accidently aspirated a metallic piece that was dislodged further to the right main bronchus after failed trials to remove it. She was intubated and mechanically ventilated, complicated by milk aspiration and bilateral pneumothoraces secondary to high-pressure lung ventilation. She had refractory mixed respiratory failure despite high settings of HFOV and inhaled nitric oxide. Venovenous ECMO (VV-ECMO) was initiated for stabilization and a bridge for bronchoscopic foreign body removal and awaiting lung recovery. She was weaned off ECMO after 166 hours. The patient was extubated after a few days and discharged home 28 days after admission without clinical evidence of neurological or respiratory complications. ECMO has been described in the literature as rescue therapy for FBA resulting in respiratory failure. However, ECMO cannulation in children under these circumstances is challenging because of vessel size restrictions. Two-vessel cannulation or dual-lumen cannulation are available options via open cut-down or percutaneous cannulation techniques, depending on the general expertise. The use of vascular ultrasound to assess vessel size is a helpful tool for cannulating infants. Conclusion VV-ECMO support is expanding for respiratory failure in pediatric patients. Percutaneous cannulation in infants and children for VV-ECMO is safe and feasible.
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Li XY, Hou HJ, Dai B, Tan W, Zhao HW. Adult with mass burnt lime aspiration: A case report and literature review. World J Clin Cases 2021; 9:9935-9941. [PMID: 34877333 PMCID: PMC8610930 DOI: 10.12998/wjcc.v9.i32.9935] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2021] [Revised: 08/28/2021] [Accepted: 09/08/2021] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Foreign body aspiration mainly occurs in children, which can cause a severe concurrent syndrome and even death without timely treatment. As a rare foreign body, aspiration of lime is seldom reported, and most cases involve a small amount of hydrated lime. Although the symptoms are usually severe, the prognosis is good after suitable treatment. Experience of treatment for lime aspiration is lacking, and this report provides novel evidence for treatment of mass burnt lime aspiration using bronchoscopy.
CASE SUMMARY We report an adult with a large amount of burnt lime aspiration. Because of delay in clearance of the inhaled lime in the trachea and bronchus at the local hospital, he suffered several severe complications, including complete occlusion of the right primary bronchus, aeropleura, aerodermectasia, pneumomediastinum, secondary infection and hypoxemia at 4 d after injury. After transferring to our department, bronchoscopy was immediately carried out to clear the lime in the major airway, using foreign body forceps, biopsy forceps, puncture needle, and hairbrush. The patient’s condition recovered rapidly and at 3-months’ follow-up, he demonstrated good recovery of the bronchus and lung parenchyma.
CONCLUSION After mass lime aspiration, flexible fiberoptic bronchoscopy is suggested as early as possible, using clamping, flushing or cryotherapy.
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Affiliation(s)
- Xin-Yu Li
- Department of Respiratory and Critical Care Medicine, The First Affiliated Hospital of China Medical University, Shenyang 110001, Liaoning Province, China
| | - Hai-Jia Hou
- Department of Respiratory and Critical Care Medicine, The First Affiliated Hospital of China Medical University, Shenyang 110001, Liaoning Province, China
| | - Bing Dai
- Department of Respiratory and Critical Care Medicine, The First Affiliated Hospital of China Medical University, Shenyang 110001, Liaoning Province, China
| | - Wei Tan
- Department of Respiratory and Critical Care Medicine, The First Affiliated Hospital of China Medical University, Shenyang 110001, Liaoning Province, China
| | - Hong-Wen Zhao
- Department of Respiratory and Critical Care Medicine, The First Affiliated Hospital of China Medical University, Shenyang 110001, Liaoning Province, China
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Shiralkar S, Fletcher J, Balasubramaniam M. An Unusual Complication of Electronic Cigarette Use: Missed Inhaled Foreign Body Causing Acute Respiratory Failure. Cureus 2021; 13:e15731. [PMID: 34285842 PMCID: PMC8286427 DOI: 10.7759/cureus.15731] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/17/2021] [Indexed: 11/23/2022] Open
Abstract
We present a case of a young woman who was admitted to the hospital with persistent pneumonia and cough productive of purulent green sputum. She was admitted to the intensive care unit due to type 1 respiratory failure. Chest computerised tomography (CT) showed a large right-sided hydropneumothorax, for which a right-sided chest drain was inserted. Despite intubation, oxygenation continued to deteriorate and the patient was commenced on veno-venous extracorporeal membrane oxygenation (ECMO) and transferred to the regional ECMO centre. Bronchoscopy revealed a plastic coil from an electronic cigarette at the entrance to the right lower lobe. Following its removal, the patient’s condition rapidly improved and she was successfully weaned from ECMO and discharged from the cardiothoracic critical care unit. There are very few reports of tracheobronchial foreign body (FB) aspiration secondary to electronic cigarette use, and tracheobronchial FB aspiration in adults requiring veno-venous ECMO to treat respiratory failure is uncommon. This case highlights the importance of considering tracheobronchial FB aspiration as a potential diagnosis in patients who present with more than two weeks of pneumonia not responding to treatment.
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Affiliation(s)
- Saarth Shiralkar
- Department of Anaesthetics and Critical Care, Royal Bolton Hospital, Bolton, GBR
| | - James Fletcher
- Department of Cardiothoracic Anaesthesia, Critical Care and ECMO, Wythenshawe Hospital, Manchester, GBR
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Tanaka S, Yoshida K, Muramatsu K, Yamagishi S, Obara S, Watanabe K. An experience of subglottic airway foreign body removal in a patient under tracheal intubation: a case report. JA Clin Rep 2020; 6:76. [PMID: 33011931 PMCID: PMC7533046 DOI: 10.1186/s40981-020-00382-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2020] [Revised: 09/23/2020] [Accepted: 09/25/2020] [Indexed: 11/16/2022] Open
Abstract
Background Removal of an airway foreign body is challenging to anesthesiologists. We report successful removal of an extremely rare foreign body between a tracheal tube and the trachea in patients under tracheal intubation. Case presentation A 57-year-old male received total aortic arch replacement and postoperative mechanical ventilation. An airway foreign body was detected just below the glottis, outside the tracheal tube during mechanical ventilation after surgery in the intensive care unit. Before the removal procedure, we planned multiple strategies to cope with unexpected airway and breathing troubles. As a result, the foreign body was successfully removed orally by using a bronchial fiber, without extubation of the tracheal tube, under general anesthesia with dexmedetomidine and ketamine. Conclusions We reported the successful removal of a foreign body in the subglottic airway of a patient under tracheal intubation.
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Affiliation(s)
- Shiori Tanaka
- Department of Anesthesiology, Aidu Chuo Hospital, 1-1, Tsuruga-machi, Aizuwakamatsu, Fukushima, 965-8611, Japan. .,Department of Anesthesiology, Fukushima Medical University, 1, Hikariga-oka, Fukushima, Fukushima, 960-1297, Japan.
| | - Keisuke Yoshida
- Department of Anesthesiology, Aidu Chuo Hospital, 1-1, Tsuruga-machi, Aizuwakamatsu, Fukushima, 965-8611, Japan.,Department of Anesthesiology, Fukushima Medical University, 1, Hikariga-oka, Fukushima, Fukushima, 960-1297, Japan
| | - Kenichi Muramatsu
- Department of Cardiovascular Surgery, Aidu Chuo Hospital, 1-1, Tsuruga-machi, Aizuwakamatsu, Fukushima, 965-8611, Japan
| | - Shigeki Yamagishi
- Department of Pulmonology, Aidu Chuo Hospital, 1-1, Tsuruga-machi, Aizuwakamatsu, Fukushima, 965-8611, Japan
| | - Shinju Obara
- Department of Anesthesiology, Fukushima Medical University, 1, Hikariga-oka, Fukushima, Fukushima, 960-1297, Japan
| | - Kazuhiro Watanabe
- Department of Anesthesiology, Aidu Chuo Hospital, 1-1, Tsuruga-machi, Aizuwakamatsu, Fukushima, 965-8611, Japan
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Simpson R, Myer IV C, Siracusa C. Acute Respiratory Distress Syndrome immediately following the removal of an aspirated foreign body. Respir Med Case Rep 2020; 29:100978. [PMID: 31886126 PMCID: PMC6921229 DOI: 10.1016/j.rmcr.2019.100978] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2019] [Revised: 11/19/2019] [Accepted: 12/06/2019] [Indexed: 11/19/2022] Open
Abstract
Acute Respiratory Distress Syndrome (ARDS) is a form of diffuse lung injury with many potential etiologies, pneumonia being the most common cause developing outside of the hospital. Foreign body (FB) aspiration is a risk factor for pneumonia, and therefore, ARDS. Although these associations exist, the development of ARDS immediately following the removal of an aspirated FB appears quite rare. We present the case of an 11 year old male who was found to have a right-sided, post-obstructive pneumonia secondary to an aspirated FB obstructing the bronchus intermedius. Relief of the obstruction allowed for rapid, endobronchial spread of infection and within 6 hours of FB removal, our patient developed severe ARDS requiring initiation of extracorporeal membrane oxygenation (ECMO). Streptococcus constellatus was isolated from lower respiratory cultures obtained during initial bronchoscopy.
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Affiliation(s)
- Ryne Simpson
- Division of Pulmonary Medicine, Cincinnati Children's Hospital, Cincinnati Children's Hospital and Medical Center, 3333 Burnet Avenue, MLC 7041, Cincinnati, OH, 45229-3026, USA
- Corresponding author.
| | - Charles Myer IV
- Department of Otolaryngology, Cincinnati Children's Hospital, Cincinnati Children's Hospital and Medical Center, 3333 Burnet Avenue, MLC 7041, Cincinnati, OH, 45229-3026, USA
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati Children's Hospital and Medical Center, 3333 Burnet Avenue, MLC 7041, Cincinnati, OH, 45229-3026, USA
| | - Christopher Siracusa
- Division of Pulmonary Medicine, Cincinnati Children's Hospital, Cincinnati Children's Hospital and Medical Center, 3333 Burnet Avenue, MLC 7041, Cincinnati, OH, 45229-3026, USA
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati Children's Hospital and Medical Center, 3333 Burnet Avenue, MLC 7041, Cincinnati, OH, 45229-3026, USA
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