Large-volume aspiration of activated charcoal is a rare complication of overdose management, and often leads to profound respiratory failure and death. We present a case of severe, refractory hypoxemia due to charcoal aspiration that was treated successfully with exogenous surfactant administration.
A 19-year-old male was admitted to an outside facility after being found unresponsive at home; he required intubation upon arrival to the Emergency Department due to hypercarbic respiratory failure. Initial oxygen saturation was 100%. Toxicology screen was positive for alcohol, marijuana, and benzodiazepines; there was also concern the patient may have ingested a fentanyl patch. A nasogastric tube was unknowing placed past the endotracheal tube cuff into the trachea, and several hundred milliliters of activated charcoal were instilled. The patient became rapidly hypoxemic and difficult to ventilate, with high airway pressures and oxygen saturations in the 70’s. He was emergently flown to our intensive care unit; his oxygen saturations remained in the 70’s despite pressure-control ventilation with an FiO2 of 1.00 and high levels of PEEP, neuromuscular paralysis, inhaled nitric oxide, and proning. Bronchoscopy revealed charcoal plugs impacted in virtually all of the distal airways; attempts to remove them via aggressive bronchoscopic lavage and use of an external percussion vest were unsuccessful. Repeat bronchoscopy was performed, with the instillation of 80 milliliters of beractant (Survanta (R), Ross USA) into each lobe. Oxygen saturations improved dramatically, increasing to the low 90’s by completion of the procedure (Figure 1). Delivered tidal volumes also increased. Copious amounts of charcoal, suspended in surfactant, were expressed from the endotracheal tube in the ensuing hour. The patient’s oxygen requirements decreased by 50% over the following 48 hours, and he was successfully extubated on hospital day 8. The patient ultimately recovered, with minimal residual pulmonary and neurologic sequelae.
Activated charcoal is often administered in cases of known or suspected toxic ingestion. Although occult aspiration of small amounts of charcoal is not uncommon in mechanically ventilated patients (1), large-volume aspiration is rarely reported (2–5), and usually leads to life-threatening hypoxemia. Charcoal-mediated increases in pulmonary microvascular permeability have been suggested as a mechanism (6). In our patient, we believe that the primary cause of respiratory compromise was charcoal impaction in the small airways, and that exogenous surfactant was beneficial more due to its ability to penetrate and loosen charcoal plugs than due to its effects on alveolar surface tension. The rapid improvement in this patient’s oxygen saturation and concomitant increase in delivered volumes on pressure-control ventilation after surfactant administration argue for an immediate mechanical benefit. To our knowledge, this is the first reported use of surfactant for this purpose.
Mechanical small airway obstruction can complicate charcoal aspiration; the use of exogenous surfactant may aid in dislodging charcoal plugs.
LeRoy Essig, None.