Type II Myocardial Infarction and Stress Cardiomyopathy Secondary to Inhaled Foreign Body (Garden Pea)

Abstract

Description The authors present the case of an inhaled foreign body (pea) in a 69-year-old woman, without underlying risk factors for aspiration. On admission she was tachypnoeic and unable to speak in full sentences. Her computed tomography (CT) examination showed ground-glass changes and potentially superimposed infective changes. Whilst awaiting transfer for bronchoscopy, she developed severe respiratory distress with cardiovascular compromise (new left bundle branch block (LBBB), tachycardia and hypertension). She was intubated in extremis and commenced on noradrenaline. Her angiogram showed mild non-obstructive disease, and she was diagnosed with a type II myocardial infarction and stress-induced cardiomyopathy. The pea was later removed on the intensive care unit via flexible bronchoscopy. Discussion Foreign-body aspiration is an unusual event in the adult population, outside of known risk factors such as neurological disease. It typically presents as 'cough (67%), dyspnoea (28%), chest pain, cyanosis, stridor or obstruction' and 'wheezing (12.7%) and haemoptysis (23.3%)' [1]. With a bimodal distribution of incidence, this case is unusual, particularly as the patient had no underlying risk factors for aspiration. She deteriorated dramatically to the point of peri-arrest whilst awaiting transfer for bronchoscopic removal. Investigations typically include plain film radiography initially and CT, as food particulates often do not show up on routine radiography. It is important to remove foreign bodies as soon as possible to prevent parenchymal damage to the lung from inflammatory processes; however, long-term complications, such as bronchiectasis, can still occur despite removal. Anaesthetic considerations for bronchoscopic removal include the risks associated with 'shared airway' procedures, the potential for the situation to deteriorate to total airway obstruction secondary to dislodging the object with positive pressure ventilation. There are procedural risks such as causing mucosal airway trauma and inability to ventilate due to obstruction, associated with anaesthetic related risks, such as barotrauma from jet ventilation. Learning points include the potential for patients with a foreign body to deteriorate acutely, hence the need for urgent bronchoscopic removal and the potential to develop myocardial ischaemia secondary to acute respiratory distress.