CASE REPORT
foreign body, esophageal; respiratory distress
Acute Respiratory Distress Secondary to a Proximal Esophageal Foreign Body From the Department of Emergeney Medicine~Trauma, Hartford Hospital, Hartford, Connecticut;and Department of Surgery, Division of Emergency Medicine, Universityof Connecticut School of Medicine, Farmington. Receivedfor publication June 10, 1991. Acceptedfor publication July 3, 1991.
Theresa M Gabana, MD John D Lynch, MD, FACEP
We report the case of a 76-year-old woman who presented with acute respiratory distress from a proximal esophageal foreign body. Fiberoptic endoscopy(bronchoscopy)was essential for the diagnosis and successful management of this case. [Gabana TM, LynchJD: Acute respiratory distress secondaryto a proximal esophageal foreign body. Ann Emerg Med January 1991; 21:86-87.] INTRODUCTION Respiratory distress secondary to a proximal esophageal foreign body is not commonly recognized; its presentation closely mimics that of an upper airway foreign body in both signs and symptoms. A 76-year-old woman presented in severe respiratory distress secondary to an esophageal foreign body. Fiberoptic endoscopy was the key to initial diagnosis and management of this case.
CASE REPORT A 76-year-old woman with a history- of Parkinson's disease presented to the emergency department with acute respiratory distress. The onset occurred abruptly while she was eating pork. On presentation, she was in acute respiratory distress, hunched forward, gasping for air, extremely agitated, and unable to speak. The patient was ashen and diaphoretic, but no inspiratory stridor was noted. Vital signs were blood pressure, 126/80 mm Hg; pulse, 76; respirations, 28; and she was afebrile. The trachea was midline, and there was no jugular venous distension. No wheezing, rales, or rhonchi were noted. The heart rate and rhythm were regular, and there was no murmur, gallop, or rub. The rhythm strip was normal sinus with no ectopy. The abdomen was distended but nontender. The extremities had good capillary refill. Oxyhemoglobin saturation by digital oximeter read 79%, with pulse of 70 to 80. The Heimlich maneuver produced no relief. A portable, lateral soft-tissue radiograph of the neck failed to definitively localize a foreign body. We contemplated establishing a surgical airway but realized that the location of the presumed tracheal foreign
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body remained uncertain. Therefore, transnasal fiberoptic bronehoscopic examination was performed. The trachea and cords were patent. There were copious pharyngeal secretions and a piece of pork measuring approximately 3.5 em in diameter in the proximal esophagus. Two milligrams of IV glucagon were given. The patient was intubated with a 7.0 nasotracheal tube over the fiberoptic bronchoscope. Oxyhemoglobin saturation improved to 97% to 98% by manual bag ventilation with an FKo2 of 1.0. A portable chest radiograph revealed the nasotracheal tube to be in the trachea with clear lung fields. We arranged an ears, nose, and throat consult for definitive management of the foreign body. DISCUSSION
This case demonstrates an unusual presentation of respiratory distress secondary to an esophageal foreign body. The dilemmas in our case were the location of the foreign body and how to manage the airway in this agitated patient. In a series of 88 patients at the University of South Carolina with esophageal foreign bodies, only 4.5% of patients presented with airway obstruction. Dysphagia was the most common presenting symptom reported (42%), followed by pain (23.9%) and foreign body sensation (20.5%) 1.
JANUARY 1992
21:1
Brooks included chest or throat discomfort, gagging, vomiting or excessive salivation, and dysphagia as common symptoms. 2 In 1974, Smith et al demonstrated that esophageal foreign bodies can be elusive and often unsuspected causes of stridor or pneumonia in infants. 3 Laryngeal spasm has been reported by Camarata and Salyer to be a complication of foreign bodies in the esophagus. 4 In contrast, according to Brooks, symptoms of foreign bodies in the air passages include sudden episodes of coughing, gagging, cyanosis, wheezing, and near respiratory arrest; vomiting is not unusual. 2 Our patient presented a very confusing picture. She predominantly had signs and symptoms of airway obstruction (ie, taehypnea with respirations of 28, inability to phonate, cyanosis, decreased breath sounds bilaterally, and profound orthopnea and dyspnea). However, no stridor, or wheezing was noted. Dysphagia and foreign body sensation, symptoms of esophageal foreign bodies, were clearly present. The inability of our patient to clear her oropharyngeal secretions, possibly because of her Parkinson's disease, added to her respiratory distress. Lieberman et al noted that dysphagia may be present in as many as 50% of patients with Parkinson's
ANNALS OF EMERGENCY MEDICINE
disease; sialorrhea is also common.5 In retrospect, the Heimlich maneuver was potentially hazardous-for it could have dislodged the foreign body into the airway. In 1974, Heimlieh originally described forceful expulsion of air in removing life-threatening foreign bodies. 6 This was based, however, on the assumption that the foreign body was in the laryngeal or supralaryngeal area, not in the proximal esophagus, v Options for airway management were limited. Specifically, blind nasotracheal intubation, so useful in orthopneic and dyspneic patients, could have further impacted a tracheal foreign body, making cricothyrotomy and tracheostomy potentially useless. Because the level of the presumed tracheal foreign body was not known, cricothyrotomy or tracheostomy might not have bypassed the obstruction. In patients with airway obstruction, the use of neuromuscular blocking agents is, as an adjunct to intubation, at best highly controversial.8 We elected not to use these agents until a definite airway was established. Fiberoptic bronchoscopic examination was instrumental in the diagnostic and therapeutic management of the airway in this case. We used it to determine the location and level of the foreign body. Unexpectedly, after pharyn-
geal secretions were suctioned by the bronchoscope, we located the foreign body in the proximal esophagus. The meat was removed from the esophagus by the ears, nose, and throat specialist under general anesthesia without complication. SUMMARY
We report the case of a woman with a proximal esophageal foreign body who was in respiratory distress. Emergency fiberoptic endoscopy (bronchoscopy) was instrumental in the diagnosis, and therapeutic intervention, and airway management. • REFERENCES 1. ChaikheuniA, KratzJM, Crawfard FA: Foreign bodies of the esophagus.Am Surg 1985; 51:173-179. 2. BrooksJW: Foreign bodies in the air and food passages.Ann Surg1972;I 75:720-732. 3. Smith PC, Swischuk LE~FaganCJ: An elusive and often unsuspectedcause of st@or or pneumonia(the esophagealforeigr body). Am J RoentgenolRadiumThorNucl Med 1974;I22: 80-89. 4. Camarata SJ, Satyer JM: Management of foreign bodies air passagesand esophagus under general anesthesia. Am Surg 1965; 31:725-728. 5. LiebermanAN, Horowitz L, RedmondP, et ah Dysphagia in Parkinson'sdisease. Am J Gastroenterol1980;74:157-160. 6. Heimtich JH: A life-saving maneuverto prevent food-choking. JAMA 1975;234: 398-401. 7. Heimlich HJ: "Pep goes the cafe coronary." EmergMad 1974;6:154-155. 8. Delaney KA, Hesler R: Emergencyflexible fiberoptic nasotracheal intubatien: A report of 60 cases.Ann EmergMad 1988;17:919-926.
Address for reprints: John D Lynch, MD, FACEP, EMS/Trauma Program, Hartford Hospital, 80 Seymour Street, Hartford, Connecticut 06115.
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foreign body, esophageal; respiratory distress
Acute Respiratory Distress Secondary to a Proximal Esophageal Foreign Body From the Department of Emergeney Medicine~Trauma, Hartford Hospital, Hartford, Connecticut;and Department of Surgery, Division of Emergency Medicine, Universityof Connecticut School of Medicine, Farmington. Receivedfor publication June 10, 1991. Acceptedfor publication July 3, 1991.
Theresa M Gabana, MD John D Lynch, MD, FACEP
We report the case of a 76-year-old woman who presented with acute respiratory distress from a proximal esophageal foreign body. Fiberoptic endoscopy(bronchoscopy)was essential for the diagnosis and successful management of this case. [Gabana TM, LynchJD: Acute respiratory distress secondaryto a proximal esophageal foreign body. Ann Emerg Med January 1991; 21:86-87.] INTRODUCTION Respiratory distress secondary to a proximal esophageal foreign body is not commonly recognized; its presentation closely mimics that of an upper airway foreign body in both signs and symptoms. A 76-year-old woman presented in severe respiratory distress secondary to an esophageal foreign body. Fiberoptic endoscopy was the key to initial diagnosis and management of this case.
CASE REPORT A 76-year-old woman with a history- of Parkinson's disease presented to the emergency department with acute respiratory distress. The onset occurred abruptly while she was eating pork. On presentation, she was in acute respiratory distress, hunched forward, gasping for air, extremely agitated, and unable to speak. The patient was ashen and diaphoretic, but no inspiratory stridor was noted. Vital signs were blood pressure, 126/80 mm Hg; pulse, 76; respirations, 28; and she was afebrile. The trachea was midline, and there was no jugular venous distension. No wheezing, rales, or rhonchi were noted. The heart rate and rhythm were regular, and there was no murmur, gallop, or rub. The rhythm strip was normal sinus with no ectopy. The abdomen was distended but nontender. The extremities had good capillary refill. Oxyhemoglobin saturation by digital oximeter read 79%, with pulse of 70 to 80. The Heimlich maneuver produced no relief. A portable, lateral soft-tissue radiograph of the neck failed to definitively localize a foreign body. We contemplated establishing a surgical airway but realized that the location of the presumed tracheal foreign
114/86 B
ANNALS OF EMERGENCYMEDICINE 21:1 JANUARY1992
RESPIRATORY
DISTRESS
Gabana & Lynch
body remained uncertain. Therefore, transnasal fiberoptic bronehoscopic examination was performed. The trachea and cords were patent. There were copious pharyngeal secretions and a piece of pork measuring approximately 3.5 em in diameter in the proximal esophagus. Two milligrams of IV glucagon were given. The patient was intubated with a 7.0 nasotracheal tube over the fiberoptic bronchoscope. Oxyhemoglobin saturation improved to 97% to 98% by manual bag ventilation with an FKo2 of 1.0. A portable chest radiograph revealed the nasotracheal tube to be in the trachea with clear lung fields. We arranged an ears, nose, and throat consult for definitive management of the foreign body. DISCUSSION
This case demonstrates an unusual presentation of respiratory distress secondary to an esophageal foreign body. The dilemmas in our case were the location of the foreign body and how to manage the airway in this agitated patient. In a series of 88 patients at the University of South Carolina with esophageal foreign bodies, only 4.5% of patients presented with airway obstruction. Dysphagia was the most common presenting symptom reported (42%), followed by pain (23.9%) and foreign body sensation (20.5%) 1.
JANUARY 1992
21:1
Brooks included chest or throat discomfort, gagging, vomiting or excessive salivation, and dysphagia as common symptoms. 2 In 1974, Smith et al demonstrated that esophageal foreign bodies can be elusive and often unsuspected causes of stridor or pneumonia in infants. 3 Laryngeal spasm has been reported by Camarata and Salyer to be a complication of foreign bodies in the esophagus. 4 In contrast, according to Brooks, symptoms of foreign bodies in the air passages include sudden episodes of coughing, gagging, cyanosis, wheezing, and near respiratory arrest; vomiting is not unusual. 2 Our patient presented a very confusing picture. She predominantly had signs and symptoms of airway obstruction (ie, taehypnea with respirations of 28, inability to phonate, cyanosis, decreased breath sounds bilaterally, and profound orthopnea and dyspnea). However, no stridor, or wheezing was noted. Dysphagia and foreign body sensation, symptoms of esophageal foreign bodies, were clearly present. The inability of our patient to clear her oropharyngeal secretions, possibly because of her Parkinson's disease, added to her respiratory distress. Lieberman et al noted that dysphagia may be present in as many as 50% of patients with Parkinson's
ANNALS OF EMERGENCY MEDICINE
disease; sialorrhea is also common.5 In retrospect, the Heimlich maneuver was potentially hazardous-for it could have dislodged the foreign body into the airway. In 1974, Heimlieh originally described forceful expulsion of air in removing life-threatening foreign bodies. 6 This was based, however, on the assumption that the foreign body was in the laryngeal or supralaryngeal area, not in the proximal esophagus, v Options for airway management were limited. Specifically, blind nasotracheal intubation, so useful in orthopneic and dyspneic patients, could have further impacted a tracheal foreign body, making cricothyrotomy and tracheostomy potentially useless. Because the level of the presumed tracheal foreign body was not known, cricothyrotomy or tracheostomy might not have bypassed the obstruction. In patients with airway obstruction, the use of neuromuscular blocking agents is, as an adjunct to intubation, at best highly controversial.8 We elected not to use these agents until a definite airway was established. Fiberoptic bronchoscopic examination was instrumental in the diagnostic and therapeutic management of the airway in this case. We used it to determine the location and level of the foreign body. Unexpectedly, after pharyn-
geal secretions were suctioned by the bronchoscope, we located the foreign body in the proximal esophagus. The meat was removed from the esophagus by the ears, nose, and throat specialist under general anesthesia without complication. SUMMARY
We report the case of a woman with a proximal esophageal foreign body who was in respiratory distress. Emergency fiberoptic endoscopy (bronchoscopy) was instrumental in the diagnosis, and therapeutic intervention, and airway management. • REFERENCES 1. ChaikheuniA, KratzJM, Crawfard FA: Foreign bodies of the esophagus.Am Surg 1985; 51:173-179. 2. BrooksJW: Foreign bodies in the air and food passages.Ann Surg1972;I 75:720-732. 3. Smith PC, Swischuk LE~FaganCJ: An elusive and often unsuspectedcause of st@or or pneumonia(the esophagealforeigr body). Am J RoentgenolRadiumThorNucl Med 1974;I22: 80-89. 4. Camarata SJ, Satyer JM: Management of foreign bodies air passagesand esophagus under general anesthesia. Am Surg 1965; 31:725-728. 5. LiebermanAN, Horowitz L, RedmondP, et ah Dysphagia in Parkinson'sdisease. Am J Gastroenterol1980;74:157-160. 6. Heimtich JH: A life-saving maneuverto prevent food-choking. JAMA 1975;234: 398-401. 7. Heimlich HJ: "Pep goes the cafe coronary." EmergMad 1974;6:154-155. 8. Delaney KA, Hesler R: Emergencyflexible fiberoptic nasotracheal intubatien: A report of 60 cases.Ann EmergMad 1988;17:919-926.
Address for reprints: John D Lynch, MD, FACEP, EMS/Trauma Program, Hartford Hospital, 80 Seymour Street, Hartford, Connecticut 06115.
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