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(Chest. 2000;117:1205-1207.)
© 2000 American College of Chest Physicians

Acute Airway Obstruction Secondary to Bilateral Broncholithiasis*

Nicole C. Hodgson, MD and Richard I. Inculet, MD, FCCP

* From the Division of Thoracic Surgery, University of Western Ontario, London, Ontario, Canada.

Correspondence to: Richard I. Inculet, MD, FCCP, Associate Professor of Surgery, Division of Thoracic Surgery, University of Western Ontario, Suite N346, 375 South St, London, Ontario N6A 4G5, Canada; e-mail: rinculet{at}lhsc.on.ca


   Abstract
TOP
 Abstract
Introduction
 Case Report
 Discussion
 References
 
We report a case of acute airway obstruction secondary to bilateral broncholiths. Successful management was achieved with rigid bronchoscopy.

Key Words: acute airway obstruction • broncholithiasis


   Introduction
TOP
 Abstract
 Introduction
Case Report
 Discussion
 References
 
Broncholithiasis, the "spitting of stones," was initially described by Aristotle in 300 BC.1 It is defined as an uncommon condition in which a calcified mass is found within or eroding into the lumen of a bronchus. The most frequent cause of broncholithiasis is calcification of lymph nodes secondary to tuberculosis or histoplasmosis.2 Massive hemoptysis due to broncholithiasis has been reported.3 We report a case of sudden respiratory failure as a result of bilateral obstructing broncholiths.


   Case Report
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 Abstract
 Introduction
 Case Report
Discussion
 References
 
An 80-year-old woman presented initially with a history of nonproductive cough and symptoms clinically consistent with asthma of approximately 28 months’ duration. Her pulmonary function test revealed a FEV1 of 1.03 L (62%); FVC, 1.81 (85%); and FEV1/FVC, 57%. Predicted values were FEV1 of 1.6 L; FVC, 2.09 L; and FEV1/FVC, 76%. One year prior to presentation, she experienced a 2-month history of hemoptysis followed by an episode of broncholithoptysis. A chest radiograph revealed a calcified granuloma in the left mid lung field and right hilar calcified nodes. Bronchoscopy revealed a large broncholith that was almost completely occluding the right main bronchus. The left main bronchus was clear. Management was conservative at that time.

The patient remained asymptomatic for almost 12 months, until she experienced recurrent hemoptysis, cough, and increasing dyspnea over 2 days. She presented to another hospital with cyanosis and in respiratory distress.

Physical examination revealed a heart rate of 120 beats/min; respiratory rate, 36 breaths/min; BP, 178/80 mm Hg, and oxygen saturation, 95% on pulse oximetry (fraction of inspired oxygen, 30%). She was diaphoretic, cyanotic, and verbally unresponsive. Her saturation dropped to 86% on an fraction of inspired oxygen of 50%. Auscultation revealed bilateral expiratory wheezes. Capillary blood gases on supplemental oxygen were as follows: pH, 7.09; PCO2, 88 mm Hg; PO2, 150 mm Hg; and bicarbonate, 26 mEq/L. She was intubated and transferred to our ICU. Therapy included IV steroids and bronchodilator inhalation.

Flexible bronchoscopy was performed due to a history of obstructing broncholiths and revealed bilateral broncholiths, with complete occlusion of the right main bronchus and partial occlusion of the left main bronchus. A chest radiograph showed calcified lymph nodes at the right tracheobronchial angle and a left mid lung granuloma. A CT scan of the chest was performed to assess the relationship of the broncholith to the pulmonary vasculature (Fig 1 ).



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  		Figure 1.. CT chest scan identifying the calcified broncholiths.

 
Intraoperative rigid bronchoscopy was performed. Bilateral obstructing broncholiths were visualized. Two large broncholiths were extracted from the right bronchus intermedius and one from the left main bronchus. The patient did well postoperatively and was extubated 36 h after removal of stones and discharged home shortly thereafter. Follow-up pulmonary function tests showed complete resolution of her obstructive symptoms: FEV1, 2.05 L; FVC, 2.49 L; and FEV1/FVC, 83%.


   Discussion
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 Abstract
 Introduction
 Case Report
 Discussion
References
 
Broncholiths most frequently result from erosion of a contiguous calcified granuloma through the bronchial wall, accelerated by the constant motion of respiration and cardiac movement.2 The cause of broncholithiasis is usually infection and involves Histoplasma capsulatum and Mycobacterium tuberculosis. Other infections healing with multiple residual calcifications include cryptococcosis, nocardiosis, actinomycosis, and coccidiodomycosis.4 Silicosis is the only documented noninfectious cause of broncholithiasis.5 Broncholiths are found equally in men and women, predominantly in the fifth or sixth decade. They most commonly occur in the right bronchial tree. Our patient initially had right-sided involvement. Her respiratory failure requiring intubation was due to bilateral obstructing broncholiths. To date, there are no other reports of successful management of respiratory failure secondary to bilateral broncholithiasis. One case report described bilateral broncholithiasis noted at autopsy with death that not related to the presence of broncholiths.6

Complications of broncholithiasis include hemoptysis, recurrent pneumonia, bronchoesophageal fistula, and aortotracheal fistula.7 Endoscopic removal of broncholiths may result in massive hemoptysis, and hence its utility is controversial. CT is useful in defining location of broncholiths, proximity of vessels, and bronchial distortion.2 Flexible bronchoscopy may allow for better definition of the stones. Extraction should be limited to the stones that extend well into the bronchial lumen. Excess traction should be avoided for risk of developing a bronchial tear. Rigid bronchoscopy allows for efficient aspiration of blood and tamponment of the bleeding site if hemorrhage is brisk. Bleeding occurs most often from erosion of a bronchial artery and rarely from major pulmonary vessels.2 We used biopsy forceps to manipulate and assess the mobility of the broncholiths via the rigid scope prior to deciding to go ahead with stone removal. A small defect, consistent with the site where the stone had eroded through, was visualized in the bronchus intermedius after removal of the second right-sided stone with minimal bleeding. Microscopic examination revealed no evidence of microorganisms. Interestingly, in 2 months follow-up, the patient’s pulmonary function tests were markedly improved with no evidence of asthma. Some studies advocate that surgical resection should be reserved for cases of massive hemoptysis, fistula, or esophageal traction diverticula.

Broncholithiasis is rare. We report the only case of bilateral obstructing broncholiths resulting in respiratory compromise. Cautious rigid bronchoscopy is an effective management tool in initial assessment and removal of broncholithiasis. Thoracotomy should be reserved for complications of broncholith erosion or recurrent hemorrhage.

Received for publication April 8, 1999. Accepted for publication October 25, 1999.


   References
TOP
 Abstract
 Introduction
 Case Report
 Discussion
 References
 

  1. Ferguson, TB (1983) Bacterial infection of the lung. Shiel, TW eds. General thoracic surgery ,563-588 Lea & Febiger Philadelphia, PA.
  2. Cole, FH, Cole, FH, Jr, Khandekar, A, et al (1991) Management of broncholithiasis: is thoracotomy necessary? Ann Thorac Surg 42,255-257[Abstract]
  3. McLean, TR, Beall, AC, Jones, JW (1991) Massive hemoptysis due to broncholithiasis. Ann Thorac Surg 52,1173-1175[Abstract]
  4. Bhagavan Bs, Rao, DRG, Weinberg T. Histoplasmosis producing broncholithiasis [abstract]. Arch Pathol 1971; 91:577
  5. Kelley, WA (1979) Broncholithiasis: current concepts of an ancient disease [abstract]. Postgrad Med 66,81
  6. Hirashima, T, Tamanoi, M, Kojima, S (1993) A case of multiple broncholithiasis caused by mucus retention. Nihon Kyobu Shikkan Gakkai Zasshi 31,70-83
  7. Bollengier, WE, Guernsey, JM (1997) Broncholithiasis with aortotracheal fistula. J Thorac Cardiovasc Surg 68,588-592[ISI][Medline]



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