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Šimon R, Šimonová J, Čuchrač L, Klimčík R, Vašková J. Foreign Body in the Airway Mimicking Tumour in an Adult: A Case Report. Cureus 2024; 16:e58584. [PMID: 38765362 PMCID: PMC11102659 DOI: 10.7759/cureus.58584] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/18/2024] [Indexed: 05/22/2024] Open
Abstract
Foreign body (FB) aspiration is an infrequent cause of respiratory distress in adults. Advancing age, central nervous system disorders or trauma, drug or alcohol addiction, neuromuscular diseases, and mental health issues and illnesses are the main risk factors. The authors present an atypical clinical presentation of a 3-week-lasting foreign body aspiration mimicking a tumour that led to severe acute respiratory insufficiency and required aggressive artificial lung ventilation. Diagnosis of FB was based on the results of the chest computed tomography (CT) scans and flexible bronchoscopy, which, however, initially assumed a neoplastic disease in the right main bronchus. During FB extraction via flexible fiberoptic bronchoscopy inserted through an 8.5 mm endotracheal tube high-frequency ventilation through a catheter placed between the vocal cords was used to ensure adequate alveolar ventilation and maintain sufficient oxygenation. After extraction of the FB, thoracosurgical intervention was performed to resolve empyema as a septic complication of the FB aspiration. After this therapy, a complete resolution of pleural empyema and lung atelectasis was observed.
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Affiliation(s)
- Róbert Šimon
- 1st Department of Surgery, Pavol Jozef Šafarik University, Košice, SVK
| | - Jana Šimonová
- 1st Department of Anaesthesiology and Intensive Medicine, Pavol Jozef Šafarik University, Košice, SVK
| | - Lukáš Čuchrač
- 1st Department of Anaesthesiology and Intensive Medicine, Pavol Jozef Šafarik University, Košice, SVK
| | - Roman Klimčík
- Department of Pneumology and Phthiseology, Pavol Jozef Šafarik University, Košice, SVK
| | - Janka Vašková
- Department of Medical and Clinical Biochemistry, Pavol Jozef Šafarik University, Košice, SVK
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Abstract
The clinical manifestations of foreign body (FB) aspiration can range from an asymptomatic presentation to a life-threatening emergency. Patients may present with acute onset cough, chest pain, breathlessness or sub-acutely with unexplained hemoptysis, non-resolving pneumonia and at times, as an incidental finding on imaging. Patients with iatrogenic FB such as an aspirated broken tooth during difficult intubation or a broken instrument are more common scenarios in the intensive care unit (ICU). Patients with post-obstructive pneumonia with or without sepsis, or variable degree of hemoptysis often require ICU level of care and bronchoscopic interventions. Rigid bronchoscopy has traditionally been the modality of choice; however, with the innovation in instrumentation and wider availability of flexible bronchoscopes, most of the FB removal is now successfully performed using flexible bronchoscopy. Proceduralists choose instruments in accordance with their training and expertise. We describe the use of most common instruments including forceps, balloon catheters, and baskets. Role of cryoprobe and LASER in FB removal is reviewed as well. In general, larger working channel bronchoscopes are preferred; however, smaller working channel bronchoscopes may be used in situations when the patients are intubated with a smaller diameter endotracheal or tracheostomy tubes. Large size FB are removed en bloc with the grasping tool, bronchoscope, and endotracheal or tracheostomy tube, requiring preparation to safely re-establish the airway. After FB removal, bronchoscopy is re-performed to identify any residual FB, assess any injury to the airway, suction post-obstructive secretions or pus, control any active bleeding and remove granulation tissue that may be obstructing the airway. Additional interventions like balloon dilatation may be required to dislodge an impacted FB or to maintain patency of bronchial lumen. If bronchoscopic methods fail, surgery may be required for retrieval of FB in symptomatic patients or to resect suppurative or necrotizing lung process. Multidisciplinary approach involving intensivists, surgeons, and anesthesiologists is the key to optimal patient outcomes.
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Affiliation(s)
- Divyansh Bajaj
- Department of Medicine, Quinnipiac University Frank H. Netter MD School of Medicine, St. Vincent's Medical Center, Bridgeport, CT, USA
| | - Ashutosh Sachdeva
- Division of Pulmonary and Critical Care, Department of Medicine, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Desh Deepak
- Department of Respiratory Medicine, Dr. RML Hospital & Atal Bihari Vajpayee Institute of Medical Sciences, New Delhi, India
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Fernandez-Trujillo L, López-Castilla V, Morales EI, Zúñiga-Restrepo V, Bautista DF. Unsuspected foreign-body aspiration in adult patient with status asthmaticus: Case report. Ann Med Surg (Lond) 2020; 56:1-4. [PMID: 32551105 PMCID: PMC7292887 DOI: 10.1016/j.amsu.2020.05.026] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2020] [Revised: 05/14/2020] [Accepted: 05/18/2020] [Indexed: 11/25/2022] Open
Abstract
Introduction Accidental foreign body aspiration can cause severe damage to the airway and threaten the patient's life. This situation requires multidisciplinary and systematic approach from the medical and surgical team, in order to achieve complete resolution maintaining airway permeability. Presentation of case This is a 49 y/o man who presented with a severe asthma attack, in whom an unsuspected foreign body in the inferior airway was diagnosed, which was possibly the result of aspiration during the initial emergency care, causing worsening of the already critical condition. Discussion We described the clinical course, radiologic and endoscopic findings, and outcome of the patient, highlighting the importance of considering the possibility of a foreign body in the airway, when there is no improvement in refractory status asthmaticus. This is particularly important in a university hospital. Moreover, the implementation of checklists when invasive procedures are performed can avoid loss of material, preventing iatrogenic aspiration events. Conclusion Foreign body aspirations may remain undetected due to lack of suspicion, especially in adults, in whom they can cause chronic symptoms, or worsen chronic respiratory conditions turning them into more complex diseases. This cause must be considered in the differential diagnosis of refractory status asthmaticus. Accidental foreign body aspiration can cause severe damage to the airway. This situation can threaten the patient's life. Requires multidisciplinary and systematic approach from the medical and surgery team. The goal is to achieve complete resolution maintaining airway permeability.
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Affiliation(s)
- Liliana Fernandez-Trujillo
- Department of Internal Medicine, Pulmonology Service, Interventional Pulmonology, Fundación Valle del Lili, Cali, Colombia.,Faculty of Health Sciences, Department of Internal Medicine, Universidad Icesi, Cali, Colombia
| | - Valeria López-Castilla
- Faculty of Health Sciences, Department of Internal Medicine, Universidad Icesi, Cali, Colombia
| | - Eliana I Morales
- Department of Internal Medicine, Pulmonology Service, Fundación Valle del Lili, Cali, Colombia.,Faculty of Health Sciences, Department of Internal Medicine, Universidad Icesi, Cali, Colombia
| | | | - Diego F Bautista
- Department of Critical Care Medicine, Fundación Valle del Lili, Cali, Colombia.,Faculty of Health Sciences, Department of Internal Medicine, Universidad Icesi, Cali, Colombia
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Utility of Flexible Bronchoscopy for Airway Foreign Bodies Removal in Adults. J Clin Med 2020; 9:jcm9051409. [PMID: 32397612 PMCID: PMC7290307 DOI: 10.3390/jcm9051409] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2020] [Revised: 05/06/2020] [Accepted: 05/07/2020] [Indexed: 12/16/2022] Open
Abstract
Foreign body aspiration is relatively infrequent in adults. Airway foreign bodies (AFBs) can be removed by flexible bronchoscopy (FB) or rigid bronchoscopy (RB). We performed a retrospective analysis of FBs performed in our centre over a 25 year period, focusing on the procedures that revealed an AFB during the examination stage. We recorded demographic data, clinical characteristics and radiological and bronchoscopic findings. During the study period, 12,588 FBs were performed in adults. Airway foreign bodies were identified in 32 of these cases, giving a prevalence of 0.25%. The most frequent clinical presentation was cough, sputum and fever. The most frequent radiological findings were alveolar infiltrates and atelectasis. In 94% of cases, AFBs were removed successfully by FB; RB was necessary in only 6% of cases. There were no FB-related complications. The most common AFB location was the right bronchial tree (69%). We classified AFBs as organic (85%: animal 57%; vegetable 28%), inorganic (6%) and iatrogenic (9%). Bronchial infection occurred in 51% of cases, and Actinomyces spp. was the most common causal microorganism. In conclusion, AFBs are a rare entity with nonspecific clinical presentation, most AFBs were organic, and FB is a safe and effective method for AFB removal.
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Ng J, Kim S, Chang B, Lee K, Um SW, Kim H, Jeong BH. Clinical features and treatment outcomes of airway foreign body aspiration in adults. J Thorac Dis 2019; 11:1056-1064. [PMID: 31019795 DOI: 10.21037/jtd.2018.12.130] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Background There are few reports comparing flexible and rigid bronchoscopy in adult foreign body (FB) aspiration. The aim of this retrospective study was to review the clinical characteristics, outcomes and factors associated with success in adult patients who underwent flexible or rigid bronchoscopy for airway FB removal. Methods We retrospectively reviewed the records of 103 patients who underwent bronchoscopy to remove airway FB at Samsung Medical Center, South Korea from January 1999 to March 2017. Results The median patient age was 64 years, and 70% were males. Among the 54 patients who underwent flexible bronchoscopy as first-line treatment, 43 (80%) patients had their FB successfully removed. Previous attempts at other hospitals was significantly associated with failed flexible bronchoscopy [9/11 (82%) vs. 3/43 (7%), P<0.001]. Delayed diagnosis (median 29 vs. 5 days, P=0.074) and peripherally located airway FB [9/12 (75%) vs. 23/48 (48%), P=0.115] were factors that trended towards flexible bronchoscopy failure. All of the 59 patients who underwent rigid bronchoscopy had their FB successfully removed. Rigid bronchoscopy was preferred to flexible bronchoscopy in patients with no comorbidities [38/59 (64%) vs. 18/44 (41%), P=0.018], previous attempts at other hospitals [34/59 (58%) vs. 4/44 (9%), P<0.001], delayed diagnosis (median 162 vs. 5 days, P<0.001), and hard FBs [48/62 (77%) vs. 21/49 (43%), P<0.001]. Conclusions Our data suggest that previous failed attempts and delayed diagnosis are associated with flexible bronchoscopy failure. However, rigid bronchoscopy could be effective in removing an airway FB even in these cases. Further studies to identify factors to facilitate optimal patient selection will minimize failure rates and optimize resource utilization.
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Affiliation(s)
- Jeffrey Ng
- Division of Respiratory and Critical Care Medicine, University Medicine Cluster, National University Hospital, Singapore.,Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Seyoung Kim
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Boksoon Chang
- Department of Pulmonary and Critical Care Medicine, Kyung Hee University Hospital at Gangdong, School of Medicine, Kyung Hee University, Seoul, Republic of Korea
| | - Kyungjong Lee
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Sang-Won Um
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Hojoong Kim
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Byeong-Ho Jeong
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
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Hewlett JC, Rickman OB, Lentz RJ, Prakash UB, Maldonado F. Foreign body aspiration in adult airways: therapeutic approach. J Thorac Dis 2017; 9:3398-3409. [PMID: 29221325 DOI: 10.21037/jtd.2017.06.137] [Citation(s) in RCA: 67] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Tracheobronchial foreign body (FB) aspiration is an uncommon but potentially life-threatening event in adults. Symptoms typically consist of a choking event followed by cough and dyspnea, however, these findings are inconsistent and symptoms may mimic more chronic lung diseases such as asthma or chronic obstructive pulmonary disease. Chest radiography and computed tomography can provide information regarding the location and characteristics of foreign bodies and aid in diagnosis. Bronchoscopy remains the gold standard for diagnosis and management of FB aspiration. The authors describe the typical clinical presentation, diagnostic evaluation, and bronchoscopic management of foreign bodies in adult airways with a focus on bronchoscopic techniques and potential complications of FB extraction.
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Affiliation(s)
- Justin C Hewlett
- Division of Allergy, Pulmonary and Critical Care, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Otis B Rickman
- Division of Allergy, Pulmonary and Critical Care, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Robert J Lentz
- Division of Allergy, Pulmonary and Critical Care, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Udaya B Prakash
- Department of Pulmonary and Critical Care Medicine, Mayo Clinic College of Medicine, Rochester, MN, USA
| | - Fabien Maldonado
- Division of Allergy, Pulmonary and Critical Care, Vanderbilt University Medical Center, Nashville, TN, USA
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Kendigelen P. The anaesthetic consideration of tracheobronchial foreign body aspiration in children. J Thorac Dis 2016; 8:3803-3807. [PMID: 28149580 DOI: 10.21037/jtd.2016.12.69] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Cases of tracheobronchial foreign body aspiration are frequently encountered emergency cases of childhood; and, delays in its recognition and treatment do result in serious morbidity and mortality. Diagnosis mainly relies on taking history which should indicate what the foreign body is, when it has been aspirated and where it is located. Belated consultation can cause misdiagnosis with the mixing of the symptoms and data with those of other pathologies common to childhood and further delays in the correct diagnosis. Bronchoscopy is required for the differential diagnosis of suspected tracheobronchial foreign body aspiration in order to eliminate other common pediatric respiratory concerns. Given the shared use of the airways by the surgeon and the anaesthesiologist, bronchoscopy is a challenging procedure requiring experienced teams with an efficient method of intercommunication, and also well planning of the anaesthesia and bronchoscopy ahead of the procedures. Despite the recent popularisation of the fiberoptic brochoscopes, the rigid bronchoscopy remains to be used commonly and is regarded to provide the gold standard technique. There have been reports in the literature on the uses of inhalation and/or intravenous (IV) anaesthesia and spontaneous or controlled ventilation methods without any demonstration of the superiority of one technique over the other. The most suitable methods of anaesthesia and ventilation would be those that reduce the risks of complications, morbidity and mortality; and, preventive measures should be taken with priority against childhood cases of tracheobronchial foreign body aspiration.
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Affiliation(s)
- Pinar Kendigelen
- Department of Anesthesiology and Intensive Care, Cerrahpasa Medical Faculty, Istanbul University, Kocamustafapasa, Istanbul, Turkey
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Blanco Ramos M, Botana-Rial M, García-Fontán E, Fernández-Villar A, Gallas Torreira M. Update in the extraction of airway foreign bodies in adults. J Thorac Dis 2016; 8:3452-3456. [PMID: 28066626 DOI: 10.21037/jtd.2016.11.32] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Foreign body (FB) aspiration into the airway is lees common in adults than children. Nevertheless its incidence does not decrease through time. We present clinical relevant aspects of airway FBs on the basis of a selective review of pertinent literature retrieved by a search in the PubMed database. The most common aspirated FBs by adults are organics, especially fragments of bones and seeds. Symptoms usually are cough, chocking and dyspnea. Right localization, especially bronchus intermedius and right lower lobe, is more frequent. Chest radiography can be normal in up to 20% of the cases and FBs can be detected in 26% of the patients. FBs can safely remove in the majority of patients under flexible bronchoscopy. Surgical treatment must be reserved for cases in which bronchoscope fails or there are irreversible bronchial or lung complications.
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Affiliation(s)
- Montserrat Blanco Ramos
- Thoracic Surgery Department, Alvaro Cunqueiro University Clinical Hospital, EOXI Vigo, Spain
| | - Maribel Botana-Rial
- Pneumology Department, Alvaro Cunqueiro University Clinical Hospital, EOXI Vigo, Spain
| | - Eva García-Fontán
- Thoracic Surgery Department, Alvaro Cunqueiro University Clinical Hospital, EOXI Vigo, Spain
| | | | - Mercedes Gallas Torreira
- Senior Lecturer in Comprehensive Adult Dental Care, Faculty of Medicine and Dentistry, University of Santiago de Compostela, A Coruña, Spain
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Hsu AAL. Endoscopic intervention of lower airway foreign matter in adults-a different perspective. J Thorac Dis 2015; 7:1870-7. [PMID: 26623114 DOI: 10.3978/j.issn.2072-1439.2015.10.50] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
BACKGROUND Lower airway foreign matter (FM) is uncommonly encountered in adults. This study reviews FM in the lower airway that required bronchoscopic intervention. METHODS A retrospective review of patients with FM in the lower airway seen at a tertiary hospital between 1996 and 2014 was undertaken. RESULTS Lower airway FM was removed in 80 out of 18,650 bronchoscopies performed. Forty-seven were males, with mean age of 50.8 (range, 29-78) years and mean symptom duration of 10.3 months (range, 1 day -20 years). The most common symptoms were persistent cough, followed by dyspnea, hemoptysis, episodes of choking and fever. Three-quarters of the patients had risk factors of either aspiration or iatrogenic cause for FM in the airway. FM identified following bronchoscopy was classified as: organic (31.3%), inorganic (46.3%) and endogenous matter (22.4%). Iatrogenic etiology was evident in four-fifths of the patients with inorganic FM (stents being the most common). Forty-eight (60.0%) patients had FM removed via flexible bronchoscopy, and the remainder via rigid bronchoscopy. The majority (27 out of 32) of FM removed by rigid bronchoscopy could not be removed using the flexible scope. This was primarily due to retrieval of stents [24] could only be done with the rigid bronchoscope. There were four FM-related complications (three bronchostenosis, one actinomycosis). CONCLUSIONS There is an increasing indication for bronchoscopists to retrieve FM, particularly of iatrogenic and endogenous sources, lodging in the lower airway of adults. There may be a reversing trend in the utilization of rigid bronchoscopy, mainly due to the increasing need to remove airway stents as more are deployed.
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Affiliation(s)
- Anne Ann Ling Hsu
- Department of Respiratory and Critical Care Medicine, Singapore General Hospital, Singapore
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