Bilateral Pneumothoraces and Subcutaneous Emphysema Caused by Foreign Body Aspiration in an Adult

First Author(s)

• 

  James McGee

  Atlantic Health System
  Morristown, NJ

  Disclosure information not submitted.

  Slides and Audio

Co-Author(s)

• WK

  Wahaaj Khan, MBBS

  Resident physician
  Atlantic Health System - Morristown Medical Center, United States

  Disclosure information not submitted.

Title: Bilateral Pneumothoraces and Subcutaneous Emphysema caused by Foreign Body Aspiration in Adult
Case Report Body:

Introduction: Pneumothoraces (PTX) and subcutaneous emphysema (SE) are two conditions often associated with severe lung disease or mechanical ventilation. In children, these conditions are sometimes encountered secondary to foreign body aspiration (FBA). In adults however, FBA is low on the differential for PTX and SE, often leading to delayed diagnosis and complicated sequelae.

Description: A 58 year-old male with past medical history of squamous cell carcinoma of the base of the tongue with dysphagia requiring tracheostomy and PEG tube, Crohn's disease with multiple small bowel resections, pancytopenia on active chemotherapy who presented to emergency department with dyspnea and cough. Patient was found to be in acute hypoxic respiratory failure requiring 10L oxygen through trach mask, septic shock secondary to E. faecalis and P. aeruginosa bacteremia requiring vasopressor support, and pancytopenia requiring multiple transfusions.

Chest x-ray was performed which raised concerns for bilateral pneumothorax. Emergent chest tubes were placed which improved patient’s dyspnea but cough continued. CT chest revealed bilateral pneumothoraces, left greater than right, multifocal patchy and nodular airspace opacities bilaterally concerning for multifocal pneumonia, 0.8cm radiopaque density within distal right lower lobe bronchus and extensive subcutaneous emphysema involving left chest and abdominal wall. Due to concerns for foreign body aspiration, patient was placed on full ventilator support and immediate flexible bronchoscopy was performed which revealed a large tablet lodged in right lower lobe bronchus. Attempts at removal were initially unsuccessful, so procedure was converted to rigid bronchoscopy and the entire pill was then removed successfully. Patient tolerated the procedure well. PTX and SE resolved rapidly after intervention.

Discussion: FBA is a very rare occurrence in the adult population, especially in patients with tracheostomy and PEG tube. Rigid bronchoscopy is recommended over flexible bronchoscopy for higher chance of successful first attempt extraction. Additionally, foreign bodies are typically encountered in the central airways, whereas our patient’s was found in the distal airway. FBA should be on the differential for all patients with PTX and SE as prompt intervention can be reduce mortality.