A recent patient who presented after choking on a peanut butter and jelly sandwich…
This was an interesting case because of the post-intubation conundrum we faced. The patient came in peri-arrest from hypoxia, GCS was 3 with very poor respiratory effort and oxygen saturation of 60%. Therefore we were unable to get a great respiratory exam prior to intubation. Bag-valve mask ventilation with 100% oxygen did not improve the situation and the patient was very difficult to bag due to obviously increased airway pressure. The intubation was very difficult and as we were checking for bilateral breath sounds post-intubation, we noticed none on the left side. Capnography color change was good, no gastric sounds were heard, and moisture was in the tube. Pulling back the endotracheal tube did not change the lack of left sided lung sounds. The patient continued to be difficult to bag with hypoxia very slowly improving from initial saturations in the 60s now to the mid-70s. At this point all of our heart rates were around 150 and we had that sinking feeling that occurs when oxygenation doesn’t improve after intubation.
For a few minutes we were concerned about pneumothorax on the left side. As you can tell from the xray our external landmarks such as tracheal deviation, jugular venous distention were severely limited by body habitus. Bedside ultrasound using the linear probe was limited as well and no lung-sliding was visualized. We basically couldn’t identify what we were seeing on ultrasound (later we found out the lung was completely collapsed and we may have been seeing diaphragm, heart, and non-aerated lung). In the heat-of-the-moment the ED treatment team was perplexed on how to rule out a tension pneumothorax in this situation.
Luckily the patient’s oxygenation creeped above 90% and the patient didn’t have any blood pressure problems. We took a deep breath, relaxed, and made the decision to obtain the above portable chest xray before performing empiric thoracostomy. This turned out to be the correct decision as she had a complete obstruction of the left mainstem bronchus from aspiration of a peanut-butter sandwich. CT chest (above) shows the obstruction at the level of the carina with collapse of the left lung. Bronchoscopy was performed and a large amount of peanut butter, jelly, and sandwich fragments were removed with improvement in the patient’s chest xray post-procedure.
Moral of the story: not all patients have pneumothorax or a malpositioned endotracheal tube when lung sounds are absent.
A brief alternative differential diagnosis when a patient has absent lung sounds on one side:
- Mainstem bronchus obstruction or compression
- Diaphragmatic hernia
- Large pleural effusion
- History of pneumonectomy
I’ve noticed a trend in ED training toward increased reliance on bedside ultrasound. It is important to realize that if you are going to use ultrasound in the resuscitation decisions such as this, make sure that you are seeing something that reliably indicates the pathology you are seeking to correct. We did not see signs that supported or refuted pneumothorax and thus the ultrasound was non-diagnostic. I apologize for not having the ultrasound images. We forgot to save them as we all had that panicked feeling when you’ve intubated someone and their pulse ox isn’t improving very fast!
Author: Russell Jones, MD