Massive Cerebral Air Embolism Following Bronchoscopic Intervention for Extraction of Aspirated Tooth

Document Type

Conference Proceeding

Publication Date

5-2024

Publication Title

American Journal of Respiratory and Critical Care Medicine

Abstract

Introduction Pulmonary aspiration of foreign bodies include dislodged or broken teeth requires removal by bronchoscopic intervention. Delayed removal of may lead to impaction in the bronchial mucosa and require multiple tools including forceps, balloon catheter, basket, cryoprobe, snare and electrocautery. Significant bleeding, infection and pneumothorax are common complications. We report a rare case of cerebral air embolism (CAA) following such an intervention. Description A 29-year-old male with myotonic muscular dystrophy (MMD) presented with dyspnea secondary to pneumonia. Due to worsening hypoxia, he was subsequently intubated. However, his post-intubation Xray and computed tomography (CT) scan of the chest revealed a radiopaque body, consistent with a dislodged tooth, impacted in the mucosa of left lower lobe distal bronchus. The opacity was surrounded by post-obstructive consolidation and an adjacent abscess. The patient underwent bronchoscopic intervention where different tools were used to remove the impacted tooth including forceps, snare and electrocautery. The procedure lasted three hours before successful removal of the tooth. Two hours late, the patient became unresponsive with dilated pupils and minimal gag reflex. A CT scan was performed which showed massive air emboli in the cerebral hemispheres with cerebral edema which progressed to brainstem herniation and death. Discussion A prolonged bronchoscopic mucosal cauterization and instrumentation procedure may pierce a cavity, air cyst, or bronchus and a nearby pulmonary vein. If the pressure in the air cyst or bronchus or cavity exceeds venous pressure, large amounts of air may pass from the lung to the pulmonary vein to the left atrium, left ventricle and ultimately into the systemic arterial circulation as seen in our patient. CAA is a an extremely rare complication which can occur after bronchoscopy or bronchoscopic interventions and should be suspected in patients with focal neurologic deficits, deteriorating neurologic status or who remain unresponsive after the procedure. In these patients, CAA should be investigated with a CT scan of the head, which is the current gold standard for diagnosis. Early detection can help in the timely initiation of supportive measures, including hyperbaric oxygen therapy, which can lead to improved outcomes when instituted early during the course of events.

Volume

209

Issue

Suppl

First Page

A4827

Comments

International Conference of the American Thoracic Society, May 17-22, 2024, San Diego, CA

DOI

10.1164/ajrccm-conference.2024.209.1_MeetingAbstracts.A4827

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