Introduction

Foreign body aspiration (FBA) possess a catastrophic life-threatening event. Although commonly seen in children, FBA cases involving adults are occasionally encountered (Kam et al. 2013). In adults, risk factors include drug or alcohol intoxication, impairment in the swallowing reflex, neurological impairment, loss of consciousness due to trauma, or anaesthesia (Boyd et al. 2009). Faint presentation with a sparsity of radiological findings in adult FBA has made clinical suspicion extremely crucial. Direct visualisation of the foreign body by bronchoscopy is mandated for definitive diagnosis and appropriate treatment (Sehgal et al. 2015). We discuss a case of tetraplegic adult presenting with loss of consciousness and oxygen desaturation.

Case REPORT

A 31-year-old male, was admitted to a rehabilitation hospital for physiotherapy due to underlying tetraplegia & neurogenic bladder as a result of seventh cervical vertebra fracture. He was last seen well around 1 am at the rehabilitation hospital and was talking to his wife, while eating chips. There was no history of choking or coughing as noted by his wife. At 3 am, he was found to be unconscious by the rehabilitation nurse with no spontaneous breathing but the pulse was present. 

The initial vital signs included blood pressure 63/30 mmHg, heart rate 36 bpm, and oxygen saturation (SpO2) 36% (under room air). Patient was resuscitated with fluids and was put on inotrope IVI dopamine 5 mcg/kg/min. Intubation was attempted but failed due to stiff neck. Bag-valve-mask ventilation was performed and saturation was able to be maintained at 100%. He was immediately transferred to a tertiary referral hospital for further management. The referral to the tertiary hospital was made prior transfer, so the receiving team was ready to receive the patient. 

In the tertiary referral hospital immediate resuscitation was commenced. He was intubated. However, it was noted that the saturation decreased progressively until it reached the lowest of 76% despite on FiO2 of 1.0. The chest X-ray (CXR) showed right lung atelectasis with the trachea deviated to the right and an hyperinflated left lung (Figure 1). Arterial blood gas (ABG) showed respiratory acidosis with type 2 respiratory failure, pH 7.1, pO2 41 mmHg, HCO3 28.9 mmol/L, BE -3.7 and pCO2 95 mmHg.

Suspicion for foreign body aspiration was based on history of food ingestion in the patient with impaired swallowing reflex, in addition to an acute oxygen desaturation and radiological finding on CXR (Figure 1) led to a decision for diagnostic bronchoscopy using flexible fibre optic by the emergency physician in the ED.

Flexible bronchoscopy (FBr) revealed a thick mucus plug at the right main bronchus. Suction was done through a working channel of the fibre optic bronchoscope. However, there was a limitation on suctioning and lavage that could be achieved through the flexible bronchoscope. CXR showed some improvement after the FBr but was inadequate (Figure 2).

Immediate referral to a respirologist was made for a proper bronchoscopy with a rigid bronchoscope. Rigid bronchoscopy found a thick mucus plug at the right upper lobe and was removed with lavage and washing. However, the left lung was normal. The impression of this was a case of aspiration, secondary to foreign body.  

Rapid improvement was seen after suctioning and bronchoalveolar lavage. SpO2 increased from 76% to 100% and lowering of FiO2 was made possible (Table 1). Carbon dioxide (CO2) retention resolved and respiratory acidosis was neutralized. Patient ABG improved to pH 7.31, pO2 175 mmHg, pCO2 42 mmHg (with FiO2 0.5). Improvement of CXR could be seen, as well (Figure 3). The patient was admitted to the Intensive Care Unit (ICU), extubated on day-3 of admission and subsequently discharges well.

Discussion

FBA is rarely seen in adults compared to children, with about 80% of FBA cases occurring in children younger than 15 years (Oke et al. 2015).  In adults, especially if there is no history of asphyxiation, FBA often goes unnoticed as a potential cause of airway obstruction. Adults with risk factors such as drug abuse, neuromuscular conditions, mental retardation and alcoholism are inclined to aspiration. However, in adults, accidental aspiration without the above-mentioned risk factors have been described (Berzlanovich et al. 2005). Commonly aspirated foreign bodies in adults are food and broken fragments of teeth. In adults, most of the foreign bodies (FBs) are embedded in the right bronchial tree, whereas no compelling difference was appreciated between left and right bronchial tree in children. Unlike in children, FBs lodged in the proximal airways are seen in less than half of adults (Baharloo et al. 1999). Whatever be the cause of FBA, the ability to maintain a patient airway is of utmost importance. 

In the absence of symptoms of asphyxiation, we need to correlate with clinical findings. In cases with acute desaturation, loss of conciousness with CXR of lung atelectasis, mediastinal shift, hyperinflated lung and pneumonia, we should have a high index of suspicion for FBA. (Boufersaoui et al. 2013). Pulmonary abscesses and bronchiectasis are late manifestations of a retained FB in the airway (Denney et al. 1968). If FBA is known to have occurred or is strongly suspected, bronchoscopy is the procedure of choice to identify and remove the object. 

Gustav Killian, an otolaryngologist, introduced the usage of bronchoscopy for the removal of FB in 1897 (Prowse & Makura 2012 ). In 1968 Shigeto Ikeda developed FBr for easier handling and manoeuvring (Niwa et al. 2009). Zavala and Rhodes (1974) performed animal studies that showed FBr could be used to recover various FBs by using the bronchoscope grasping forceps (Zavala & Rhodes 1974). Thereafter, FBr has attained prevalence over rigid bronchoscopy. For initial diagnosis of FB in adults, FBr is considered as the diagnostic test of choice. The advantages of FBr over the rigid bronchoscopy are better viewing of the smaller peripheral airway with smooth handling and can be performed under local anaesthesia. It can be done in c-spine and pharyngeal deformities like this case. It is also comparatively safer and easier procedure in skilled-hands (Rafanan & Mehta 2001). 

Rigid bronchoscopy foreign body retrieval was acquired in 43 out of 44 patients, along with 6 of 7 patients in whom, fibre optic bronchoscopy recovery had failed (Limper & Prakash 1990). The success rate was 60% among 23 patients, in whom a fibre optic bronchoscopy recovery was attempted (Limper & Prakash 1990). They discovered that flexible fibre optic bronchoscopy was notably beneficial in patients with foreign bodies too distal in the airways for access using a rigid bronchoscope, and in whom severe cervicofacial trauma hinders hyperextension of the neck that was essential for rigid bronchoscopy examination (Limper & Prakash 1990).

Conclusion

There were few key-points that can be taken away from this case. First, in the event of inability to intubate, the most important thing, is the ability to maintain oxygenation. In emergency situation, where intubation attempts fail, ability to maintain oxygenation can buy time for transferring the patient to the more experience handler. Second, there is importance of communication between two teams. The rehabilitation hospital team alerted the tertiary team regarding the transfer of difficult intubation patient. This vital information led to preparation of equipment and experienced personnel at the receiving hospital. Third, the presence of emergency physician who had high index of suspicion and knew how to manoeuvre a flexible bronchoscope led to early diagnosis and urgent referral to the respirologist for specific management. This resulted in swift recovery of the patient. Finally, the clinical presentation of non-asphyxiating foreign bodies in the airway is variable. High clinical index of suspicion is the most valuable diagnostic factor. Although rigid bronchoscopy continues to be the preferred instrument for removal of non-asphyxiating foreign bodies in the airways in most hospitals, a flexible fibre optic bronchoscope provides a valuable therapeutic option in selected conditions and could be really helpful in the ED.