Maimonides Medical Center, Brooklyn, NY
Copyright 2016, American College of Chest Physicians. All Rights Reserved.
SESSION TITLE: Student/Resident Case Report Poster - Procedures
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) post endotracheal intubations are well known but post tracheostomies have rarely been reported1. FBA may cause asphyxia, post obstructive pneumonia, and atelectasis.We present an interesting case of tooth aspiration post tracheostomy.
CASE PRESENTATION: 51 year old male with past medical history of stage 4 Glioblastoma Multiforme was admitted to hospital for seizures and altered sensorium. He was subsequently intubated for respiratory distress and concern for airway protection. Post intubation imaging confirmed placement of endotracheal tube. Patient required continous mechanical ventilation and due to inability to wean by day 15, thoracic surgery was consulted and tracheostomy was performed. A size 8 Distal cuff tracheostomy tube was placed. Patient tolerated the procedure well, and post procedure imaging confirmed the placement of the tube. 2 weeks later due to concern for ileus, a CT abdomen was obtained which actually showed a foreign body possibly a tooth in the right lower bronchus (Fig 1). Pulmonary team was called and patient was scheduled for urgent bronchoscopic removal. Basket catheter was used for grasping the tooth (Fig 2). The size of extracted tooth was 2.7 x 0.9 x 0.5 cm which could not be retrieved through the tracheostomy tube as the internal diameter of size 8 tube is 7.5mm, therefore while extraction of the tooth secured in the basket, the tracheostomy tube was also removed simultaneously and a new tracheostomy tube was placed. Patient tolerated the procedure well and maintained adequate saturation throughout the procedure. Patient oral cavity was thoroughly evaluated and it was noted that patient had multiple loose teeth which were electively removed by the dental surgeon to prevent further complications.
DISCUSSION: Patient with dentures or loose teeth, alcoholics, undergoing oral surgery or endotracheal intubations are at high risk for FBA. As demonstrated in our case initial chest xary could be normal which may overlook the possible complication. A two week delay in diagnosis fortunately was not with complications in this patient but could easily have been life threatening. FBA post tracheostomy is rare due to minimal oral manipulation but still possible2. What makes this case unique is the large size of the tooth, and the technique used in aspirating the content.Maintaining good oxygenation during procedure is of prime importance.
CONCLUSIONS: A high index of suspicion should be maintained for foreign body aspiartion after therapeutic procedures like endotracheal intubation and tracheostomies to avoid potential complications and early detection.
Reference #1: Steelman, R., Millman, E., Steiner, M. and Gustafson, R. (1997), Aspiration of a primary tooth in a patient with a tracheostomy. Special Care in Dentistry, 17: 97-99.
Reference #2: Zhang M, Zhou GJ, Zhao S, Yang JX, Lu X, Gan JX, et al. Delayed diagnosis of tooth aspiration in three multiple trauma patients with mechanical ventilation. Crit Care 2011;15(3):424.
DISCLOSURE: The following authors have nothing to disclose: Sushilkumar Gupta, Pavan Gorukanti, Pavan Irukulla, Amit Agarwal, Selma Demir, Mangalore Amith Shenoy, Omar Taha, Moshe kerstein, Igor Brichkov
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