An aspirated foreign body during the COVID-19 pandemic.

Case description

A 43-year-old man presented during the COVID-19 pandemic with decreased responsiveness. EMS had given 2 mg intranasal dose of naloxone with good response. No obvious signs of trauma were noted. In the ED he became more somnolent with decreased respirations and constricted pupils, requiring escalating doses of naloxone and eventually the initiation of a drip. During this time the patient became severely agitated, likely secondary to the naloxone. This necessitated both physical restraints and added sedation to avoid injury to the patient and staff. While agitated he was gnashing his teeth and resisting restraints with profound strength. Reassessment after calming the patient showed he was wearing dentures and that the bridge was partially broken. Portable chest radiograph was obtained. (Fig. 1 )

Fig. 1

 

Diagnosis and discussion

Aspiration of a 4 piece dental bridge aspirated in the bronchus intermedius (arrow) on frontal portable chest radiograph. A vague left midlung opacity was concerning for clinically occult viral pneumonia (arrow heads). The patient did not experience any respiratory distress, chest discomfort, or hypoxia after the initial event. COVID testing was negative, however precautions with adequate PPE were necessary given the findings on chest radiograph. Bronchoscopy was successful in retrieving the foreign body from the bronchus intermedius. Denture aspiration is a rare event. Etiologies are multiple including neuromuscular dysfunction, trauma, altered mental status, and agents that decrease gag reflex. Unique features of this case (young age, drug overdose poorly responding to reversal therapy, and bruxism) emphasize the need to always evaluate the airway in cases of respiratory compromise, assessing for the dental removable devices. In addition, a high index of suspicion for viral infection is required even in asymptomatic patients during COVID-19 pandemic.

Questions

Question 1

In the event of a foreign body causing respiratory compromise and inability to visualize the foreign body due to likely distal tracheal obstruction, what is the best intervention?

advance foley catheter into trachea and inflate when distal to foreign body to pull out of trachea

advance bougie until you meet resistance to determine location of foreign body

intubation to attempt to push foreign body distally and ventilate remaining open mainstem

initiate bipap to improve ventilation

Correct answer: c) intubation to attempt to push foreign body distally and ventilate remaining open mainstem

Explanation: Adequate ventilation is key, and this is accomplished by advancing the foreign body distally so that at the least one of the mainstem bronchi can be ventilated mechanically. This ensures that the patient can be oxygenated until definitive measures (bronchoscopy) can be done. Do not attempt to advance foley or bougie into the airway. Bipap will not be successful if the foreign body is obstructing and will likely not provide enough positive pressure to advance the foreign body distally.

Question 2

In the pediatric population, what is the most frequently aspirated foreign body?

magnets

nuts

jewelry

pieces of toys

Correct answer: b) nuts

Explanation: Nuts (especially peanuts) are the most commonly aspirated foreign body in the pediatric population as a whole. For younger patients (infants and toddlers) food aspiration is more common. With increasing age, the rates of inorganic aspiration (toys, jewelry, magnets) increases.