Critical Care: Student/Resident Case Report Poster - Critical Care IV |

Yes, An Apple a Day Keeps the Doctor Away; But You “Gotta” Know Your Apples: A Case of Delayed Diagnosis FREE TO VIEW

Gautam Sikka, MD; Aditya Gupta, MBBS; Amit Misra, MBBS; Moses Bachan, MD; Zinobia Khan, MD
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Bronx VA Medical Center, Bronx, NY

Copyright 2016, American College of Chest Physicians. All Rights Reserved.

Chest. 2016;150(4_S):439A. doi:10.1016/j.chest.2016.08.452
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SESSION TITLE: Student/Resident Case Report Poster - Critical Care IV

SESSION TYPE: Student/Resident Case Report Poster

PRESENTED ON: Tuesday, October 25, 2016 at 01:30 PM - 02:30 PM

INTRODUCTION: Foreign body aspiration (FBA) is a life-threatening event that is more common in children but incidence rises again with deaths from FBA peaking at age 85 years. In adults, the nature of objects causing FBA is inorganic (brushes, denture-debris etc.) or organic substances for examples un-chewed meat and pills.

CASE PRESENTATION: Mr. R, is a 69 years old nursing home resident with history of diabetes, hypertension, valvular heart disease, DVT, seizures and stroke with residual hemiparesis and motor aphasia. He was admitted to the ICU with acute respiratory failure and agitation 2 days after being treated and discharged for aspiration pneumonia. His wife reported that he was eating when he suddenly started “choking”. On admission he was afebrile, normotensive but tachycardic and chest X-ray was significant for a chronic right base infiltrate. He was intubated after failing oxygen via Non-Rebreather Mask (NRM) with saturation of 80%. A GlideScope Video Laryngoscope was used; it was a difficult intubation with visible “white mucous plugging”. He was restless and agitated after intubation. Two days later he self-extubated; he saturated 96% on NRM for a few hours, and then he was in respiratory distress. A bed-side scope showed a foreign body (FB) in the larynx. He taken to the Operating Room emergently, re-intubated and a FB was removed from the right lung, which turned out to be piece of apple. Patient’s respiratory and mental status improved and he was successfully liberated from ventilator shortly after FB removal.

DISCUSSION: Risk factors for FBA include loss of consciousness, drug or alcohol intoxication or anesthesia, age-related dysphagia, medication use, stroke related dysphagia, neurologic diseases and prior aspiration episode, which was present in our patient. Imaging is useful to exclude other causes but majority of FB are radiolucent and not easily identified on plain film. A delay in diagnosis is not uncommon given the lower incidence, variable presentation (mostly subtle with distal wedging of FB in lower lobe bronchi) and confounding factors such as chronic cough and presence of ETT. Bronchoscopy has become the mainspring of both the diagnosis and treatment of patients with suspected FBA.

CONCLUSIONS: FBA is a constant strong irritant for mental status changes and a reversible cause of acute respiratory failure; one should always suspect FBA in a patient with risk factors for aspiration and acute symptoms of upper airway obstruction. It could very well be an “apple”!

Reference #1: Rafanan, A. L. (2001). Adult airway foreign body removal: what's new?. Clinics in chest medicine, 22(2), 319-330

Reference #2: Feinberg, Michael J., et al. “Aspiration and the elderly.” Dysphagia 5.2 (1990): 61-71.

Reference #3: Mehta, Atul C., and Albert L. Rafanan. “Extraction of airway foreign body in adults.” Journal of Bronchology & Interventional Pulmonology 8.2 (2001): 123-131.

DISCLOSURE: The following authors have nothing to disclose: Gautam Sikka, Aditya Gupta, Amit Misra, Moses Bachan, Zinobia Khan

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