Airway foreign-body aspiration may cause no symptoms, although it can produce acute and life-threatening central airway obstruction.1 In the US, at least 2,700 people, including more than 300 children, die of foreign-body aspiration each year.2 Most foreign-body aspirations occur in children and elderly patients.3 In adults, dementia, drug intoxication, strokes, seizures, and neurologic disorders may predispose patients to aspiration.3 Some of the consequences of an aspirated object are complete or partial airway obstruction, respiratory distress and failure, pneumothorax, and hemorrhage.2 In addition, inadvertent aspiration of foreign objects in asymptomatic patients may not be evident for months, resulting in late complications as postobstructive pneumonia, bronchiectasis, or lung abscess.2
We present a case of a patient with documented schizophrenia with nonadherence to his antipsychotic medications who aspirated different objects. Flexible bronchoscopy was performed since rigid bronchoscopy is not available at our institution. Several bronchoscopy tools were required to successfully remove the objects and avoid further invasive interventions, such as cardiothoracic surgery.
Case Presentation
A 55-year-old man with schizophrenia on antipsychotics developed cough, shortness of breath, and dysphagia of 1-month of evolution. Because his symptoms worsened, his mother brought him to the emergency department. Peripheral oxygen saturation was 97% at room air. Lung auscultation was remarkable for bilateral scattered rhonchi and wheezes.
Laboratory results showed leukocytosis with neutrophilia and hypotonic hypovolemic hyponatremia.
The patient stated that he did not remember swallowing any objects, although his mother confirmed that he was not adherent with his antipsychotic medications, which could have predisposed him to aspiration secondary to possible psychotic episodes.
Piperacillin/tazobactam 4.5 g every 8 hours was started to cover anaerobic bacterial organisms causing abscess, and IV fluids were given for hypovolemia. Flexible bronchoscopy (rigid bronchoscopy is superior although not available at our institution) was planned to be performed in the operating room (OR) because we predicted a difficult and prolonged retrieval in view of multiple and different-sized objects.
A bronchoscopy was performed, showing a disk-shaped metallic foreign body at the right main stem bronchus. After multiple attempts using the tripod retrieval tool, a coin was removed (Figures 3A and 3B).
The patient was reintubated without any complications. A postprocedure chest radiograph showed the absence of foreign bodies and no pneumothorax. The patient completed IV antibiotic with piperacillin/tazobactam and supportive therapy with clinical improvement and successful extubation within 2 days. Cardiothoracic surgery was not required. Psychiatry service recommended to continue the same antipsychotic medications, administered only by his mother to assure adherence and to avoid similar future events. The patient was discharged home without any immediate complications despite having had a coin, nail, and screw aspiration (Figure 6).