Discussion:
The initial response to cinnamon aspiration in our patient appeared to be consistent with lower airways obstruction, possibly bronchospasm. As the air-trapping resolved, his oxygenation defect worsened, consistent with V/Q-mismatch and increased oxygen diffusion barrier. Moreso complicating his already precarious condition was the frequent plugging of his endotracheal tube with tenacious secretions and the onset of pulmonary air leak. Thus, in our case, deployment of ECMO was necessary for continued gas exchange.
The cellulose fibers of cinnamon can be retained for years2 and appear to elicit an acute inflammatory cell infiltration as well as a chronic, fibrosing granulomatous alveobronchiolitis3-4. Thus, in addition to other external and intrapulmonary percussive therapies, we relied on bronchoscopies for enhanced airway clearance while on ECMO. Given the apparent worsening in mucosal inflammation between the first and second bronchoscopies, and the return of cinnamon with each lavage, we may consider earlier and more frequent lavages for similar aspirations in the future, but with cautious anticipation that each session may cause temporary worsening in oxygenation.
We also opted to provide this patient with surfactant therapy following each high-volume lavage. It is presumed to help replace iatrogenic surfactant deficiency caused by total lung lavage, while another report employed this strategy to aid in the removal of a poorly water-soluble, powdered material5. That said, the contribution of surfactant therapy alone to the clinical and/or radiographic improvement in our patient is indeterminate, and more research is required before the practice can be widely adopted.