A 67-Year-Old Man With Chest Pain and Wheezing

Carla R. Sterling, MD; Niccole Bart, MD


July 15, 2015


The patient was admitted for presumed pneumonia, and antibiotic coverage for community-acquired pneumonia was started with ceftriaxone (Rocephin®) and azithromycin (Zmax®). While he was in the emergency department, he had a coughing fit and experienced an acute drop in consciousness and oxygen saturation, with not only cessation of right-sided wheezing but also loss of breath sounds on the right side. He was urgently intubated and transferred to the intensive care unit. A chest radiograph was obtained (Figure 3).

CT of the chest revealed an obstruction in the lower right lobe bronchus with collapse of the same lobe. The critical care pulmonologist performed bronchoscopy and the obstruction was removed, with improvement in respiratory function and subsequent imaging studies revealing reexpansion of the right lower lung lobe. Oxygenation improved, and the patient was extubated the following morning.

After 24 hours with stable respiratory function and vital signs, the patient was transferred to the medicine floor, where he was continued on pneumonia treatment and eventually discharged to his home at his baseline state. Aspirated foreign bodies are more common in children than adults. In general, 50% of all foreign body cases occur in children younger than 4 years.[1] Children are more likely to aspirate inorganic material, whereas adults are more likely to aspirate organic material, such as food. The most commonly aspirated foreign bodies are nuts and seeds.[2] Fish or chicken bones can also be commonly lodged in the oropharynx.

Certain adult populations are higher risk for foreign body aspiration, including those with neurologic disorders; a history of alcoholism; any loss of consciousness, such as trauma or syncope; or any impaired swallowing mechanism. Adults older than 75 years and those who wear dentures also have high risk owing to loss of palatal sensation. The most common location of aspirated foreign bodies in adults is the right main stem bronchus.[3]

Aspiration of foreign bodies in adults can often result in chronic symptoms that may go undiagnosed. Multiple case series demonstrate chronic symptoms that are often masked as bronchitis.[4] Chronic cough or hoarseness secondary to bronchial irrigation can go undiagnosed for extended periods, with some case studies reporting that symptoms continue without diagnosis for months to years.

Consider foreign body in patients with respiratory symptoms that are not responding to typical therapy. Also imperative is clinical suspicion in patients who may be predisposed to aspiration; eliciting the history by asking the patient specific questions about possibility of aspiration may be helpful.


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