Choking as a cause of negative pressure pulmonary oedema (NPPE) in an older adult

An 86-year-old female presented to the Emergency Department (ED) in respiratory distress after choking on a sandwich at home. Her family had noticed that she had had difficulty during and coughing after swallowing for several months. Her initial chest x-ray showed diffuse alveolar infiltrates in both lungs and blood tests showed normal white cells and C-Reactive Protein (CRP). She was started on intravenous antibiotics for presumed aspiration pneumonia and received 15 L of oxygen. However, the infiltration had dramatically improved, both radiologically and clinically, within 24 hours. She was diagnosed with negative pressure pulmonary oedema (NPPE) type 1 and made a rapid recovery. The Speech and Language Team diagnosed an impaired swallow and advised soft or bite-sized suitable foods. We discussed the ongoing risk of aspiration and long-term feeding options with the patient's family. We agreed on a conservative plan for 'risk feeding', given her frailty and co-morbidities, and began discussions on ceilings of care. This case aims to raise awareness of NPPE so that it can be diagnosed, investigated and treated promptly. Although seen most commonly by intensivists and anaesthetists, it is relevant to those on the acute medical take and geriatricians managing patients with swallowing difficulties.

Post-obstructive pulmonary edema from aspirated nuts

OBJECTIVES

Post-obstructive pulmonary edema is thought to occur from hemodynamic changes secondary to forced inspiration against the closed airway due to acute or chronic airway obstruction. We report a case of a 13 month-old boy who developed pulmonary edema from aspirated foreign body, nuts.

METHODS

He underwent emergency bronchoscopy to confirm the clinical diagnosis of aspirated nuts in the trachea and nuts were removed endoscopically. His trachea was then intubated and he was mechanically ventilated with oxygen.

RESULTS

He developed florid pulmonary edema early in the course with tracheal obstruction and during endoscopic removal of nuts. After removal of obstruction he was ventilated mechanically and pulmonary edema cleared rapidly.

CONCLUSIONS

Aspirated nuts obstructing trachea can induce obstructive pulmonary edema. Early recognition of foreign body obstruction based on clinical history and its removal resolved pulmonary edema.