A 48-year-old Caucasian female with a past medical history including but not limited to hypertension and hypothyroidism was in a usual state of health until the morning of presentation to the emergency room (ER). She mentioned that she accidently aspirated her Iron pill (Ferrous sulfate). After about a couple of hours following aspiration, she developed an intractable cough. Cough appeared in short episodes lasting a few minutes and each episode was associated with the expectoration of yellowish sputum with occasional blood stains. She also developed retrosternal chest discomfort. Pain was localized with no radiation or referral. She described new onset dyspnea at rest.
On evaluation in the emergency room, she was in acute distress. Blood pressure measured 100/70 mmHg; heart rate was 120 beats per minute in sinus rhythm. She was breathing 25-30 times per minute with the use of accessory muscles of breathing. Saturation was 81% on room air and improved to 93% with supplemental oxygenation using a face mask at 6 L per minute. Initial laboratory assessment in ER was essentially unremarkable except white blood cell count of 14 thousand per deciliter with 89% neutrophils. Serum electrolytes and renal function parameter were within normal limits. Plain x-ray of chest was otherwise unremarkable except for chronic elevation of the right hemidiaphragm. Given the history of Iron pill aspiration and strong consideration of airway injury, a decision was made to proceed with emergent bronchoscopy.
Bronchoscopy was performed under general anesthesia. Immediately after crossing the vocal cords, diffuse erythema and inflammation of the trachea was noted starting at the superior end of the trachea distal to the vocal cords. We advanced to the left bronchial tree which had erythema but noticeably less that resolved after the first subsegment level. Washings were done and no abnormality was noted. On the right, however, we immediately encountered a mucous-coated plug with an obvious foreign body resembling a partially dissolved pill in the bronchus intermedius just past the take-off from the RUL. This was retrieved rather easily with an endobronchial basket, however tissue that was very necrotic. A second amount of pill was able to be taken out and at that point mucous and necrotic material came from the bronchi. Once this was removed, a severe amount of damaged mucosa was noted in the airway starting at the middle lobe take off from the bronchus intermedius but largely involving the orifice to the lower lobe. The scope was reintroduced to the affected area and the medial basal and superior segments were completely obliterated by shredded, necrotic material partially attached to the orifice of those respective airways, and pill fragments were noted in a granular state. The material was attempted to be suctioned but was unable to do so due to the necrotic material occluding the scope. Therefore, we attempted to retrieve the pill granular parts with forceps and the basket, but they were too friable. At that point, a number three endobronchial blocker was advanced into the airway past the pills and inflated slightly. This allowed the fragments to be pulled out of the area with the issue fragments and could then be suctioned out. Afterward, the extent of the damage to the bronchi was noted and there was a severe chemical burn with necrosis in this area that had weblike fragments hanging from the airway and partially occluding the medial basal and superior segments as well as the remaining lower lobe segments. Using forceps, this area was debrided partially, removing the fragments of tissue that were occluding the airway. There was minimal bleeding from the removal, but it did not require any intervention to control and stopped nearly immediately and spontaneously. After several fragments were removed and collected into a formalin container, the medial basal and lower lobe segments (anterior, lateral, and posterior) were able to open. A small fragment of granulated pill was seen and removed with suctioning only from the medial basal segments. The visible portion of the medial basal segment had less severe damage, but normal tissue could notbe visualized. Flushing the segment returned clear fluid. The anterior, lateral, and posterior segments however were noted to have completely normal tissue just past the orifice to the individual segments. We were able to navigate past the damaged tissue there in each segment and washings in those area returned clear form as well. We then turned our attention to the superior segment of the lower lobe which had more damaged mucosa appearing more as macerated tissue. This was removed with forceps and minimal to no bleeding was noted. Following this, the segment had a visible split into two subsegments but was extremely inflamed and had more dead tissue. Because of the narrow nature of the segment and damage that would likely be caused by attempts at further tissue removal, we did not remove any additional tissue here and flushes of the area were clear of any obvious remaining pill fragments. After this, the area was largely open with all airways again in communication with the mainstem. No bleeding was noted. The middle lobe itself was then inspected again and other than some inflammation, no damage was noted past the initial take off to the middle lobe. Pictographic evidence of findings during bronchoscopy are summarized in Fig. 1.
At this point, the concern would be a collapse of that segment onto itself and healing in a stricture-type fashion as well as potentially life-threatening hemoptysis as the additional necrotic material cleared. For this reason, the decision was made to leave the patient intubated with a positive end-expiratory pressure (PEEP) of 10 to splint the airway open and monitor her for the next several days as the area healed.
The patient was subsequently transferred to the intensive care unit. Received mechanical ventilator support along with supportive measures. Methylprednisone was administered at a dose of 1 mg per Kg body weight to suppress the inflammatory response. A revision bronchoscopy was performed 48 hours later. It revealed substantial resolution of inflammatory changes of the airway mucosa and overall airway wall. There was no evidence of airway collapse while using a low PEEP trial. Thus, the patient was successfully extubated after two days. The patient was subsequently discharged on the fifth day of hospitalization. She did not require supplemental oxygen at discharge.
The patient was evaluated with a pulmonary function test (PFT) 4 weeks after discharge. It revealed mild restrictive physiology (total lung capacity: 4L-79% predicted) along with reduced DLCO (54% predicted) in setting of reduced VA (55% predicted). Collectively findings were likely suggestive of post-inflammatory fibrotic restriction along with parenchymal volume loss. Other PFT findings are summarized in Table 1.
A follow-up bronchoscopy was performed at six weeks after discharge. Suctioning was performed in the bronchus intermedius and in the right lower lobe and the airway was cleared. There was a prior mucosal injury. There was evidence of some tissue necrosis in the bronchus intermedius as well as the medial basal segment of the right lower lobe. Otherwise, the right upper and middle lobes were clear as well as the anterior, lateral, and posterior segments (Fig. 2). The left side was clear.
The patient has had substantial clinical recovery. Her residual respiratory symptoms are unremarkable except for dyspnea on exertion equivalent to mMRC grade 0. She does not have residual orthopnea and cough. She continues to follow up at the pulmonary clinic.