CASE REPORT - Bilateral lung collapse due to aspirated nasal packing

Muhammad Siddique*, Imran-ul-Haq**, Anwar-ul-Haq***
*Consultant anesthesiologist, PNS Rahat, Karachi (Pakistan).

**Consultant anesthesiologist, ***Consultant ENT Specialist, PNS Shifa, Karachi (Pakistan).

Correspondence: Surg Lt Cdr Muhammad Siddique, Classified anesthesiologist, PNS Rahat, Karsaz, Habib Ibrahim Rrahmatullah Road, Karachi (Pakistan); Cell: +92-300-9870908’ e-mail: drsiddique2002@hotmail.com

ABSTRACT

An aspirated foreign body continues to present serious challenge of airway management to anesthesiologists perioperatively. These patients usually present with respiratory distress and require a high index of suspicion; need prompt assessment and recognition of the potential cause, and emergency management to obtain the best possible outcome. Nasal packing after ENT surgery has been previously reported to result in complications.  A nasal pack obstructing left bronchus completely and right bronchus partially, resulting inpost obstructive pulmonary edema is reported.This patient had aspirated the nasal pack in recovery room after tracheal extubation. The case highlights the need for close postoperativemonitoring in patients with nasal packs, the diagnostic role of fibroptic bronchoscope and therapeutic role of rigid bronchoscope in airway obstruction.

Keywords: Nasal packing, Airway obstruction, Negative pressure pulmonary edema.

Citation: Siddique M, Haq IU, Haq AU. Bilateral lung collapse due to aspirated nasal packing. Anaesth Pain & Intensive Care 2009; 13(2):75-77

INTRODUCTION

Although most of the ENT surgeons have stopped the use of customary nasal packing after nasal surgery, sometimes it may be required to stop bleeding, enhance apposition of mucosal flaps; prevent the formation of septal haematoma, and to splint the septal cartilages and nasal bones. Nasal packs, however, are uncomfortable; their removal is painful and can cause other complications like bleeding, adhesions, septal perforations and rarely infections1. Displaced nasal packs causing upper airway obstruction and respiratory distress are rare,2 requiring immediate intervention because initial symptoms may progress rapidly to complete airway obstruction and death.

Perioperative obstruction of the conductive airways (upper airway obstruction, UAO) due to any cause may result in negative-pressure pulmonary edema (NPPE).3 NPPE, also addressed as post-obstructive pulmonary edema (POPE), presents with rapid onset acute respiratory failure with dyspnea, tachypnea, and strained respiratory efforts. Additional signs are paradoxes ventilation, pink frothy sputum, stridor, and severe agitation.4
We report a patient who had a displaced nasal pack that caused acute airway compromise and post obstructive pulmonary oedema 25 minutes after emergence from general anesthesia. The rationale for our management, by utilizing an awake diagnostic fibroptic bronchoscopy followed by therapeutic rigid bronchoscopy is also detailed.

CASE REPORT

A twenty two years old serving soldier underwent septoplasty followed by nasal packing under general anesthesia at PNS Shifa Karachi. Recovery was uneventful and the patient was fully awake and breathing comfortably when shifted to post anesthesia recovery unit. Pulse oximetry and non invasive blood pressure were monitored. After 15 minutes he coughed, became restless, and partially removed his nasal packing. Thorough oral suction was done, and supportive oxygen was given with face mask. Repacking was done by the otorhinolaryngologist. He did not respond and began to struggle. Within seconds he developed inspiratory stridor with a drop of SpO2 to 88% along with chest wheeze on auscultation. Insertion of Guedel airway, oral suctioning and assisted ventilation (bag and mask) did not help and SpO2 dropped to 77%. Patient was sedated and laryngoscopy revealed blood in the oral cavity which was suctioned but did not clear the airway and the patient was intubated. Assisted ventilation with bag through ETT did not improve SpO2.The tracheal tube had blood stained secretions which were periodically suctioned. Patient was shifted to surgical intensive care unit and put on ventilator in ASV mode. SpO2 improved to 85%, but the peak inspiratory pressure was too high. Suspecting bronchospasm, he was sedated with morphine and thiopentone sodium, paralyzed with Esmeron® and ventilation mode was changed to pressure control. He was treated with Solucortef®, Ventoline® nebulization and 100% oxygen without improvement and PIP continued to rise. Arterial blood gases (ABG’s) revealed PaCO2 66 mmHg and PaO2 77%.  PIP was 60 cm of H2O. Chest X-rays were taken which revealed collapsed left lung while half of the right lung field was also collapsed, sparing only the apical areas. The pulmonologist was consulted, who endorsed the same treatment. After two hours of vigorous treatment, the ABG’s were; PaCO2 88 mmHg, PaO2 75 mmHg, SpO2 90% on FiO2 100%. PIP was 70 cm of H2O with the ventilatory setting of tidal volume 250 ml and respiratory rate 35. On chest auscultation, there was constant, variable wheeze, either inspiratory or expiratory one, or sometimes audible throughout the respiratory cycle. Increasing PIP and changing wheeze raised the suspicion of foreign body in the trachea.  Otorhinolaryngologist was requested for diagnostic fibroptic bronchoscopy, which revealed some cotton fibers at carina that were removed. Condition of the patient remained unchanged, SpO2 did not improve and PIP continued to rise. The patient was shifted to operating room for rigid bronchoscopy which revealeda blood-soaked nasal pack making a saddle at carina, which completely obstructed the left bronchus; while the right bronchus was partially obstructed. The pack was removed, suction done and the trachea was reintubated.About fifteen minutes later, pink froth in the tracheal tube suggested development of post obstructive pulmonary edema, which was successfullytreated with diuresis, morphine, steroids, nebulisation with Ventoline®, oxygen with positive pressure ventilation at normal PIP, and by elevating the head end at 30º. Twenty minutes later ABG’s were repeated and found within normal limits.

DISCUSSION

The diagnosis of foreign body aspiration (FBA) requires a high index of suspicion. A history of sudden onset of cough or a choking or gagging episode is highly suggestive of FBA7, 8. Our patient had a clinical course consistent with upper airway obstruction. Detailed history and clinical examination were strongly suggestive of a diagnosis of foreign body aspiration. We hypothesized that initial irritation and restlessness caused the patient to rub his nose and dislodgement of nasal dressing. The otorhinolaryngologist assumed that the patient had pulled out his nasal pack so he inserted another nasal pack without examining the nose. This maneuver probably pushed the first pack deep into throat, which carried with the endotracheal tube into the trachea. Efforts on positive pressure support ventilation to overcome unusual hypercarbia and increased peak inspiratory pressure lodged it in the form of a saddle which completely occluded the left main bronchus and partially blocked right main bronchus. On fibroptic bronchoscopy the otorhinolaryngologist could not appreciate the pack. There was persistent abnormal chest movement with no air entry on the left side and decreased air entry on the right side. Rigid bronchoscopy was done and a blood soaked throat pack was removed from the trachea. The patient was intubated but pink froth was noted in the tracheal tube suggestive of negative pressure pulmonary edema which resolved with positive pressure ventilation and inj. Lasix®. Although clinical manifestations of upper airway obstruction such as hypoxia, hypercarbia and raised PIP have been reported4,7previously, on review of the literature, we found only one other report describing aspiration of nasal pack causing upper airway obstruction2.

This case is unique in that a nasal pack was inadvertently pushed to carina which resulted in bilateral collapse of lungs and a rise in PaCO2 and PIP. It is interesting to note that in our case the PaO2 did not drop below 75 mmof Hg because the anesthesiologist kept on increasing the pressure support to over come the raised PIP in order to ventilate the patient.

Routine postoperative intensive care monitoring for all patients undergoing upper airway surgery is unnecessary, but selected patients must be kept in post anesthesia care units, till the time it is reasonably sure that the patients are fully awake and the protective reflexes have returned. Although high-risk patients cannot always be identified preoperatively, significant complications generally emerge within 2 hours after surgery. Therefore a decision regarding the level of postoperative monitoring may be made with confidence during the period of time that the patient is in the post anesthesia care unit10.

Nasal packing is associated with increased morbidity in terms of post-operative discomfort and pain. Yet, it may sometimes be required to control significant intra and post-operative bleeding. The use of electrocautary and tying the bleeders may be a better alternative, particularly in patients with chronic systemic diseases1. It is also to be stressed that fibroptic bronchoscopy has its limitations. Its small terminal end may easily be blurred by blood, thus limiting the visibility, and it can not be used for removal foreign bodies. Rigid bronchoscopy is the choice if there is a suspicion of foreign body in the airways.

CONCLUSION

Displaced nasal packs, causing upper airway obstruction, collapse of the lungs and a rise in PIP is a rare complication of the ENT surgery. Resultant dyspnea is an ominous sign of impending respiratory obstruction and requires prompt intervention to secure the airway. The patient with nasal bleed and subsequent packing needs close monitoring.

Acknowledgements: The authors are extremely thankful to Dr.Rubeena Nazli Shaffi, ophthalmologist, Liaquat National Hospital Karachi for drafting the manuscript of this case report.

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