Food For Thought

Timely intervention saved a man’s life using Bronchoscopy

THE CASE
A 72 year old diabetic man on insulin with a history of CABG done 3 years ago was admitted with complaints of increasing breathlessness, cough and high fever for the past 7 days. He was prescribed antibiotics by Physicians but there was no response. On admission, his X-ray chest showed right lower lobe partial collapse with right middle lobe consolidation. There was eventration of left dome of diaphragm. WBC counts were 26000 with neutrophilia. Patient was admitted in ICU in view of the respiratory distress and saturation of 81%. Immediately injectable cephalosporins and clarithromycin were given. With no clinical improvement inspite of nebulistation, antibiotics and non invasive ventilation, a diagnostic and therapeutic Bronchoscopy was planned on the basis of the clinical findings of partial collapse and inability to expectorate. Considering patient’s age, cardiac status and respiratory distress, it was a high risk procedure.

THE PROCEDURE
Bronchoscopy revealed right lower lobe bronchus partially blocked with food material. There were thick pus plugs along the right middle lobe / lower lobe segments. The foreign material was removed with help of Bronchoscopy forceps and basket. Therapeutic saline wash was given with suctioning. On detailed examination, the food material removed by Bronchoscopy revealed walnut shells and pieces. Retrospective history from the relatives proved that 2 days prior to the fever and cough the patient had a severe bout of cough while chewing and swallowing walnuts. The cough bout was so severe that it lead to vomiting. Subsequently, for 2 days the patient was fine until he developed symptoms of fever and breathlessness.

THE RESULT
Post Bronchoscopy the patient showed marked clinical improvement with complete clearance of the partial obstruction and pus. WBC count came to near normal. The patient was then shifted to ward. After 24 hours, saturation improved more than 91%. The patient was discharged in a week and was advised nebulisation and chest Physiotherapy.

Prof. Dr. Salil Bendre
Head - Pulmonary Medicine
Department, Nanavati Super
Speciality Hospital, Mumbai