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.