Challenging Case: Aspiration of a Pretzel

pretzel aspirationA 2.5-year-old boy presented to South Shore Hospital Emergency Department (ED) during a severe snowstorm having aspirated a chocolate-covered pretzel.

On arrival he was awake and crying, but would begin falling asleep when not stimulated, raising fears of hypercarbia and impending respiratory failure. He was in severe respiratory distress, with suprasternal and subcostal retractions and biphasic stridor. He was tachycardic, tachypneic, with an oxygen saturation of 84 percent on room air. Prior to arrival, his mother had performed the Heimlich maneuver, and emergency medical services had administered racemic epinephrine to alleviate continued stridor and cough, with minimal improvement.

His exam was notable for facial petechiae, most pronounced in periorbital areas. He had mild perioral cyanosis. His lung exam was significant for diffuse bilateral wheezing, and significantly diminished breath sounds over the entire left lung field. An oropharyngeal exam revealed erythema, but no visible foreign bodies or lesions.

Rapid sequence intubation revealed edematous aretynoids; no foreign body was visualized. On auscultation, there were significantly diminished breath sounds on the left side and wheezing on the right. Oxygen saturations continued to fluctuate, occasionally dipping below 80 percent, with elevated pCO2.

Serial x-rays revealed progressive white-out of left lung, thus it was assumed that a foreign body had occluded the left mainstem bronchus, with additional foreign material in the right mainstem bronchus. Other etiologies considered included post-obstructive pulmonary edema (given prolonged choking and facial petechiae), aspiration pneumonitis, reactive airways component and allergic/inflammatory response possibly caused by the chocolate pretzel (chocolate being an irritant to lung tissue).

pretzel aspiration serial x-rayThe South Shore ED was in constant communication with Boston Children’s Intensive Care unit using TeleConnect, a real-time video teleconferencing service. The goal was to fine-tune ventilator settings so as to optimize gas exchange while avoiding overexpansion and pneumothorax of the right lung, which was the patient’s sole functioning lung at this point.

The decision was made to transport the patient to Boston Children’s for continued emergency care. Transport was complicated by inclement weather. MedFlight was not available, and in the end, it took Boston Children’s Critical Care Transport team several hours to assemble, reach South Shore Hospital and transport the child to Boston.

On arrival at Boston Children’s, the child was emergently placed on ECMO. Flexible bronchoscopy revealed complete occlusion of the left mainstem bronchus, with bloody secretions and particulate matter in right mainstem bronchus. He then underwent a rigid bronchoscopy, during which bloody secretions were suctioned at the orifice of left mainstem. Very large chunks of pretzel were found completely occluding this bronchus and were extracted, requiring several passes with optical forceps to adequately clear the foreign material. In addition, many obstructing pieces of foreign material were removed from the right mainstem bronchus.

The patient was decannulated from ECMO after approximately 24 hours, then quickly and successfully weaned off ventilator, and extubated by 48 hours. He was weaned to room air by the morning of hospital day 3. He was treated with antibiotics, systemic and inhaled steroids. He was transferred to the floor by hospital day 3, and was discharged home on hospital day 5. He celebrated Christmas at home with his family. He has been doing well and has no neurologic deficits.

The patient is tolerating a regular diet, and is no longer allowed to eat pretzels.