(Chest. 2002;121:1707-1709.)
© 2002
American College of Chest Physicians
An Uncommon Mimic of an Acute Asthma Exacerbation*
David Zaas, MD;
Malcolm Brock, MD;
Stephen Yang, MD, FCCP and
J. T. Sylvester, MD
* From the Department of Medicine (Drs. Zaas and Sylvester) and the Division of Thoracic Surgery (Drs. Brock and Yang), The Johns Hopkins Hospital, Baltimore, MD.
Correspondence to: J. T. Sylvester, MD, Division of Pulmonary and Critical Care Medicine, The Johns Hopkins School of Medicine, Johns Hopkins Asthma and Allergy Center, 5501 Hopkins Bayview Circle, Baltimore, MD 21224; e-mail: jsylv{at}jhmi.edu
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Abstract
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Foreign body aspiration in adults has a variety of clinical presentations and often goes unrecognized. We describe the case of a patient who experienced crack cocaine aspiration and presented with symptoms of an acute asthma exacerbation requiring mechanical ventilation until the eventual diagnosis and bronchoscopic removal of the foreign body.
Key Words: aspiration • asthma • cocaine
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Introduction
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Foreign body aspiration is common in children < 4 years old, but in adults the diagnosis is infrequent and often delayed. Obstruction of the tracheobronchial tree by a foreign body has a variety of clinical presentations. We report an unusual case in which the aspiration of plastic bags containing crack cocaine into the tracheobronchial tree mimicked acute asthma.
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Case Report
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A 35-year-old African-American man with a history of heroin and cocaine use was brought to the emergency department by ambulance after becoming unresponsive during a confrontation with police. According to the arresting officer, the patient may have swallowed illicit drugs in an attempt at concealment. In the emergency department, the initial arterial blood gas measurements revealed the following: pH, 6.89; PCO2, 172 mm Hg; pO2, 188 mm Hg; and bicarbonate, 32 mEq/L. The patient was emergently intubated because of hypercapnic respiratory failure, which was presumed to be secondary to a drug overdose, and was administered naloxone. He experienced mild improvement of symptoms before his transfer to the ICU.
His medical history included only illicit drug use and the occasional use of his mother’s asthma inhalers for relief of wheezing and shortness of breath. His physical examination was notable for fever, bilateral expiratory wheezing, and scattered inspiratory crackles. The chest radiograph made at hospital admission demonstrated moderate bilateral alveolar infiltrates, which was compatible with aspiration or hemorrhage. A toxicology screening test was positive for cocaine and opiates.
After treatment with inhaled bronchodilators, steroids, and antibiotics, the infiltrates cleared rapidly, but the patient’s wheezing and low-grade fever persisted. Because of high peak airway pressures, ventilator settings were adjusted, and paralytic and sedative agents were administered intermittently to minimize auto-positive end-expiratory pressure and the risk of barotrauma. He appeared to respond to this therapy with decreased wheezing and auto-positive end-expiratory pressure. However, an attempt at extubation on hospital day 3 was unsuccessful. On day 4, a left chest tube was placed because of the presence of tension pneumothorax. On day 6, a continuous IV infusion of aminophylline was begun. Extubations on hospital days 11 and 14 were again unsuccessful due to wheezing and hypoventilation after extubation. On hospital day 16, peak airway pressures remained elevated. CT scans of the chest (Fig 1
) revealed foreign matter in the trachea just below the level of the endotracheal tube extending into the right mainstem bronchus. On day 18, the patient was taken to the operating room, where fiberoptic bronchoscopy revealed near-complete obstruction of the distal trachea and right mainstem bronchus with what appeared to be plastic material (Fig 2
). A partially torn 20-cm plastic bag containing five white rocks (later confirmed to be crack cocaine) individually wrapped with 2-cm plastic storage bags were removed under direct visualization (Fig 3
). All five individual cocaine bags appeared to be unopened and intact. Three passes with the flexible bronchoscope were required to remove all five bags. After returning to the ICU, the patient had no further wheezing, and airway resistance normalized. A repeat toxicology screening test was positive for cocaine. He was successfully extubated later that day.
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Discussion
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Our patient’s clinical presentation was consistent with a severe asthma exacerbation. The persistence of high airway resistance after > 2 weeks of treatment led to the delayed diagnosis of a foreign body aspiration. Tracheobronchial obstruction by a foreign body was first noted as a cause of wheezing by Struthers in 1852.1
In adults, the most common etiologies of foreign body obstruction of the large airways are food products, specifically vegetables, peanuts, and bones. Foreign bodies that are able to pass through the vocal cords often lodge at the carina and the right mainstem bronchus.2
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Turbulent airflow around the narrowed airway may cause stridor or localized wheezing. Irritation of the airways may cause bronchospasm and produce generalized wheezing that is indistinguishable from asthma.
When a history of foreign body aspiration is not obtained at presentation, diagnosis is often delayed by hours or by as much as 13 years.2
3
In this case, symptoms commonly associated with aspiration such as dyspnea, cough, hemoptysis, and chest pain2
3
were absent, probably due to obtundation from heroin and cocaine use. Foreign body aspiration in adults is thought to be more common in the setting of alcohol and drug use, underlying neurologic disease, poor dentition, and advanced age.3
4
A history of asthma does not increase the likelihood of foreign body aspiration. However, it may contribute to the delay in diagnosis because of the indistinguishable clinical presentations. The chest radiograph did not reveal a radiopaque foreign body, and findings that were suggestive of foreign body obstruction, such as atelectasis, localized air trapping, focal infiltrates, or mediastinal shift, were absent. Pneumothorax is an uncommon complication of foreign body aspiration, and in our patient presumably it resulted from the transient occlusion of his right mainstem bronchus and overexpansion of his left lung while receiving positive-pressure ventilation. The chest CT scan was helpful not only in identifying the suspected foreign body, but also in demonstrating its large size and location.
The aspiration of cocaine presents additional management challenges. Drug overdoses during attempts to conceal illicit drugs in the GI tract are well-recognized in "mini-packers" (ie, individuals who swallow bags of drugs to avoid arrest) and "body packers" (ie, individuals who swallow bags of drugs in a smuggling attempt).5
In this case, our patient had attempted to swallow a large plastic bag containing the five individually wrapped crack cocaine rocks during a confrontation with the police and, instead, had inadvertently aspirated the objects. There is limited information regarding the management of the aspiration of these dangerous foreign bodies.6
The mucous membranes of the respiratory tract allow rapid absorption of drugs such as cocaine, and our patient had evidence of continued absorption of cocaine on hospital day 18. Case reports have described increased wheezing and even fatal asthma exacerbations associated with crack cocaine usage.7
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Clinical studies have shown that cocaine inhalation significantly increases airway resistance in nonasthmatic individuals as well.9
Physicians should also be alert to the possible aspiration of other drug-related paraphernalia such as needles, syringe parts, tubing, marijuana leaves, and portions of marijuana cigarettes. In addition to foreign body aspiration, the differential diagnosis of refractory asthma includes vocal cord dysfunction, gastroesophageal reflux disease, tracheobronchitis, endobronchial tumors, pulmonary embolism, sleep apnea, hyperventilation syndrome, and psychiatric illness.10
The patient was taken to the operating room for the bronchoscopic removal of these large foreign bodies. In this case, flexible bronchoscopy was used because of the operator’s technical facility with the procedure. Flexible bronchoscopy is successful at removing 60 to 90% of foreign bodies in the smaller airways and has largely replaced rigid bronchoscopy for the removal of foreign bodies in the airways.3
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However, rigid bronchoscopy should be considered for the retrieval of objects too large to grasp firmly via the flexible fiberoptic scope.
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Conclusion
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We presented a case of crack cocaine aspiration mimicking an acute asthma exacerbation, in which the unusually large foreign body was successfully removed by flexible bronchoscopy. We hope that a heightened awareness of this situation by clinicians, especially in cases in which illicit drugs may be involved, will improve the diagnosis and management of this life-threatening condition.
Received for publication May 31, 2001.
Accepted for publication October 8, 2001.
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References
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Abstract
Introduction
