Imaging: Fellow Case Report Poster - Imaging |

This Is Not a Right Mainstem Bronchus Intubation FREE TO VIEW

Pavan Irukulla, MBBS; Yizhak Kupfer, MD; Kavitha Mamindla, MD; Chanaka Seneviratne, MD; Mangalore Amith Shenoy, MBBS; Igor Brichkov, MD; Hatem Desoky, MD; Manveen Dassan, MD; Pavan Gorukanti, MD; Ishan Malhotra, MBBS; Amit Agarwal, MD; Sudhamshi Toom, MBBS; Anand Kumar Rai, MBBS; Prarthna Chandar, MBBS; Amogh Gajankush, MBBS
Author and Funding Information

Maimonides Medical Center, Brooklyn, NY, Brooklyn, NY

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

Chest. 2016;150(4_S):652A. doi:10.1016/j.chest.2016.08.746
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SESSION TITLE: Fellow Case Report Poster - Imaging

SESSION TYPE: Affiliate Case Report Poster

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

INTRODUCTION: Foreign body aspiration (FBA) is more common in children than in adults, 80 percent of cases occur in patients younger than age of 15 years [1]. Death from FBA is the fourth leading cause of accidental home and community deaths in the United States [1]. Nasal intubation can result in significant nasal trauma including turbinate avulsion on the side of the intubation. We report nasal trumpet, a foreign body appearing as right mainstem bronchus intubation on Chest X-ray (CXR).

CASE PRESENTATION: A 65 years old male with no significant past medical history presented with to the emergency room with right sided weakness. An emergent CT head ruled out intracranial hemorrhage. In view of the patient being in the window period for thrombolytic therapy, alteplase was administered for ischemic stroke. Patient subsequently developed respiratory distress and stridor due to angioedema secondary to alteplase needing ventilatory support. Oral intubation was deemed difficult due to swollen tongue therefore nasal intubation with assistance of nasal trumpet was pursued. Patient was found to have high peak airway pressures and compromised ventilation, prompting the switch to oral intubation followed by CXR. CXR seemed as right mainstem bronchus intubation but on careful tracing of the tube showed nasal trumpet in the right mainstem bronchus (Fig 1). Thoracic surgery was consulted and the nasal trumpet was removed with the help of flexible bronchoscopy and biopsy forceps. Nasal trumpet was first pulled into the endotracheal tube (ET) and then patient was extubated along with the removal of nasal trumpet in the ET tube. Patient was then re-intubated using video laryngoscope. Peak airway pressures normalized after removal of the nasal trumpet. Our patient had a survived and was discharged to rehab due to stroke.

DISCUSSION: FBA are associated with higher morbitdity and mortality. We hope to raise awareness that nasal intubation is not a benign procedure and should be attempted only if absolutely warranted. The size of the tube used in nasal intubation are smaller compared to oral intubation which pose difficulties in ventilating patient, apart from causing nasal trauma and other complications.

CONCLUSIONS: Multi disciplinary approach with Thoracic and Otolaryngology surgical departments is often beneficial in the retrieval of a foreign body and can be done at the bedside.

Reference #1: National Safety Council. Report on injuries. Injury Facts. 2015 information online: www.nsc.org/library/report injury usa.htm

DISCLOSURE: The following authors have nothing to disclose: Pavan Irukulla, Yizhak Kupfer, Kavitha Mamindla, Chanaka Seneviratne, Mangalore Amith Shenoy, Igor Brichkov, Hatem Desoky, Manveen Dassan, Pavan Gorukanti, Ishan Malhotra, Amit Agarwal, Sudhamshi Toom, Anand Kumar Rai, Prarthna Chandar, Amogh Gajankush

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