Case Presentation:
A previously healthy 2 year-old male was transported from home to our
hospital following an unwitnessed powdered cinnamon aspiration. He was
described as mottled and wheezing with visibly increased work of
breathing. He was hypoxemic (SpO2 55%) in ambient air,
necessitating escalation to non-invasive bi-level positive pressure
ventilation and continuous albuterol nebulization. His first blood gas
analysis, from a venous sample, found significant respiratory acidosis
(pH 6.98, pCO2 112 mm Hg). After increasing respiratory
support, an arterial sample revealed persistent respiratory acidosis (pH
7.19, pCO2 65.2 mm Hg) without significant metabolic
contribution (bicarbonate 26 mmol/L, anion gap 14 mmol/L, lactate 1.26
mmol/L) and impaired oxygenation (pO2 66.2 mm Hg on
100% FiO2). Upon transfer to the PICU, he underwent
endotracheal intubation and initiation of synchronized intermittent
mandatory ventilation. His chest radiograph revealed lung
hyper-expansion and bilateral patchy opacities sparing the apices
(Figure 1A), and his ventilator scalars were consistent with increased
airway resistance and lower airways obstruction. Intravenous
methylprednisolone (loading dose of 2 mg/kg followed by 4 mg/kg/d) was
initiated. By hospital day (HD) 4, his ventilator scalars demonstrated
resolution of lower airways obstruction, and his hypercarbia improved,
but his oxygenation index (OI) rose to the mid-20’s (Figure 1D). We
transitioned him to airway pressure release ventilation (APRV) and
started inhaled nitric oxide.
The first diagnostic flexible bronchoscopy with lavage (30 mL of normal
saline instilled in total) was performed on HD 6. The airways of the
left lung appeared more heavily deposited than the right, with moderate
amounts of brown debris in all of the left lobes. The mucosa appeared
normal, but with mild friability after the lavage. Analysis of the
lavage fluid found increased white blood cells with a neutrophilic
predominance and the moderate presence of lipid-laden macrophages; no
analysis could be performed on the debris.
A chest radiograph attained just prior the bronchoscopy was later
interpreted as showing pneumomediastinum and subcutaneous emphysema.
Given worsening oxygenation (OI 32), the presence of air leak, ongoing
intermittent obstructions of the endotracheal tube with mucoid cinnamon,
and the need for additional bronchoalveolar lavages, the patient was
deployed at bedside onto veno-venous extracorporeal membrane oxygenation
(VV-ECMO, Figure 1B and 1D). On HD 7, he developed a new pneumothorax
requiring chest tube placement.
He underwent repeated bronchoscopies on HD 9 and HD 10 with the goal of
debris removal through high volume, total left lung lavage (120-150 mL
normal saline instilled in total per procedure). At that time, the left
lung demonstrated significantly worse mucosal inflammation than on HD 6,
with a large quantity of visible debris, most heavily deposited in the
left lower lobe (Figure 1E). After each lavage, we instilled surfactant
(1.25ml/kg and 0.625ml/kg on HD 9 and HD 10, respectively). Each
bronchoscopy was accompanied by an immediate worsening in oxygenation
followed by slow, steady improvement; this was most dramatic on HD 10,
with increasing lung compliance and tolerance of extracorporeal oxygen
blender weaning. The patient was decannulated on HD 14, extubated on HD
18, and transferred on HD 28 to a sub-acute inpatient rehabilitation
program, requiring no supplemental respiratory support. He completed the
program and is now at home. At a pulmonary medicine follow-up visit 6
months after the aspiration, his chest radiograph demonstrated
persistence of patchy opacities in the right lung base, with no
abnormalities on the left (Figure 1C), which had directly received the
bronchoalveolar lavages and surfactant. He was doing well, with no
ongoing respiratory symptoms or need for respiratory support or
medications.