Pill in the Airway of a Lung Transplant Recipient

Pill aspiration is an under recognized complication and can cause severe airway injury leading to significant morbidity and mortality. The risk in posttransplant patient is probably higher due to posttransplant gastroparesis and gastroesophageal reflux. A high index of suspicion based on history and clinical findings is required as lung transplant recipients are frequently dyspneic due to other pathologic processes like infection or rejection. Aspiration related injury to the airway may be more pronounced in lung transplant recipients and can progress to airway stenosis in the bronchial tree around the anastomosis. CASE REPORT We present the case of a 67-year-old man who underwent bilateral sequential lung transplant 2 years ago for fibrotic nonspecific interstitial pneumonia. He presented to the emergency room with acute onset of shortness of breath and cough that started the night before. He was in mild respiratory distress and his oxygen saturations were 88% on room air. His immunosuppression included tacrolimus, everolimus, and prednisone. There was no history of aspiration episodes. Physical examination was notable for wheezing in the right lung field. He underwent computerized tomography (CT) of his chest to evaluate for pulmonary embolism. CT of his chest showed a 9×6 mm high-density object in the distal right upper lobe bronchus (Figs. 1A, B) likely representing an inhaled foreign body or a broncholith. Also noted was prominent wall thickening of the bronchus intermedius with surrounding edema and focal airway narrowing. Bronchoscopy revealed a pill-like structure completely obstructing the right upper lobe bronchus (Figs. A, a, b) as well as significant granulation tissue and debris around the pill extending into the bronchus intermedius (Figs. A, a–c). The pill appeared to be a white, fragile, round structure that was actively disintegrating. The pill and debris were aggressively suctioned and endobronchial biopsies were attempted using forceps but the pill and surrounding mucosa bleed quiet easily. A bronchoalveolar lavage was performed but the bleeding associated with the excoriated mucosa contaminated the specimen. As measured drug levels on such a specimen could potentially reflect serum levels, chemical analysis was not performed on the bronchoalveolar lavage. Patency of the distal bronchi was confirmed.FIGURE 1: A, B, Computerized tomography of chest depicting horizontal cuts with a 9×6 mm high-density foreign body (white arrow) in the distal right upper lobe bronchus in mediastinal windows.FIGURE A: Bronchoscopy showed a pill-like structure with debris obstructing the right upper lobe bronchus (a, black arrow). Aggressive suctioning was used to remove the pill debris (b, yellow arrow). The excoriated right mainstem bronchus and bronchus intermedius are seen distal to the anastomosis (c, white arrow).On questioning the patient postprocedure, our patient confessed that his cough began after he took his morning medications 2 days ago but he thought it had worsened for the last 12 hours. He briefly remembered choking on medications as he attempted to swallow them all at the same time, despite clear instructions to take 1 pill (or capsule) at a given time. Given the shape, size, and color of the pill seen in the bronchus along with his medication history, it seems likely that the aspirated pill was aspirin. Almost all of his other medications were either capsules or liquid in nature. He had a history of esophageal dysmotility and was on nutritional support via tube feeds and was allowed small amounts of pleasure feeding for breakfast and lunch only. Postbronchoscopy, he was placed on vancomycin and piperacillin-tazobactam due to previous history of growing methicillin resistant Staphylococcus aureus and Pseudomonas aeruginosa. His bronchial washings did grow pseudomonas and he was discharged on intravenous antimicrobial therapy. His everolimus was held at discharge to promote airway healing. Follow-up bronchoscopy in 1 week demonstrated significant granulation tissue in the bronchus intermedius for which he underwent mechanical debridement and balloon dilation of bronchus intermedius. DISCUSSION Aspiration of a foreign body into the airways is a potentially fatal situation and can pose a diagnostic challenge, as the signs and symptoms are often nonspecific and chest radiographs are normal in 25% patients.1 The incidence of pill aspiration in the airways is significantly higher than reported in the medical literature. Pill aspiration has not been commonly reported in lung transplant recipients. These patients theoretically are at a higher risk of aspiration due to gastroparesis and esophageal dysmotility after transplant.2 Two major mechanisms of airway involvement with pill aspiration, inflammation, and obstruction.1,3 Effects depend on the chemical composition of the pill. Iron tablet aspiration is most commonly described in literature.4 It is believed the free iron released from the pill causes inflammation and granulation tissue.1,4 Symptoms of pill aspiration vary from cough, wheezing, shortness of breath to hemoptysis, fever, and chest pain that may not present immediately. The diagnosis of pill aspiration can be challenging as most patients do not have a clear history of nature and timing of the aspiration event. Chest x-rays have limited value in diagnosis as most pills are radiolucent.1 CT scan is more sensitive both in locating the pill and visualizing airway injury and stenosis. Early bronchoscopic evaluation is key to the diagnosis and management although the pill may no longer be visible at the time of bronchoscopy and may be dissolved with only signs of inflammation and stenosis.1 Extraction of the aspirated pill can be attempted with bronchoscopic tools such as forceps, baskets, snares, and balloons.5 Rigid bronchoscopy was used in some cases to remove the aspirated pill and treat the sequelae of the initial airway injury. Recurrent bronchoscopic therapy with balloon dilation, forceps debridement, or cryodebridement, argon plasma coagulation, mitomycin C, and stent placement may be required periodically to deal with late complications of stenosis.1,5 More severe complications may require definitive surgical interventions like lobectomies. Overall bronchoscopic procedures have good outcomes in most cases. Lung transplant recipients with esophageal dysmotility and gastroparesis are at a higher risk of aspiration.6,7 In addition, lung transplant recipients have a significantly higher pill burden per day.8 The effects of pill aspiration may be significantly pronounced in lung transplant recipients due to the anastomoses, chronic respiratory fungal, and bacterial colonization and the lower vascularity at the anastomotic site but this hypothesis needs further validation.9 Instruction on swallowing 1 pill at a time needs to be emphasized with patients as recommended in literature.1

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