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

Carla R. Sterling, MD; Niccole Bart, MD

Disclosures

July 15, 2015

Airway obstruction with aspirated foreign bodies can be divided into three phases:

  • Acute choking episode (initial lack of air entry while the patient is still alert);

  • Lack of consciousness with intact pulses; and

  • Cardiopulmonary arrest.

Acute choking presentations are more common in children but may occur in adults as well. Complete obstructions result in cardiopulmonary arrest if not reversed. Incomplete obstructions may cause more variations in symptoms. Unilateral diminished breath sounds have a low sensitivity of approximately 75%, with a similar but wider-ranging specificity.[5]

Initial symptoms and complications include the following:

  • Choking;

  • Dysphagia;

  • Odynophagia;

  • Dysphonia;

  • Stridor;

  • Cyanosis;

  • Partial or total lung collapse; and

  • Respiratory distress.

Later symptoms and complications include the following:

In the acute phase, patients should be encouraged to cough. In the second stage, cardiopulmonary resuscitative maneuvers, such as the Heimlich maneuver, should be initiated. Other airway maneuvers include jaw thrust to open the airway. More definitive management, such as intubation or cricothyrotomy, may be urgently indicated in complete airway obstruction. In the case of partial obstruction, the patient is typically stable for further imaging and can continue to attempt removal through such means as coughing. Partial obstructions can present as stable, but if the obstruction advances to complete obstruction abruptly, the patient can quickly become unstable, with progression to cardiopulmonary arrest within minutes.

Many foreign bodies are radiolucent and will not be seen on radiography. Therefore, when the index of suspicion is high, bronchoscopy should be performed. Although flexible bronchoscopy has largely replaced rigid bronchoscopy, a rigid scope may be used in selected cases of larger, more proximal objects, given the larger luminal diameter.[6]

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