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LETTER TO EDITOR
Year : 2016  |  Volume : 10  |  Issue : 1  |  Page : 113-114

Impacted tooth presenting as airway obstruction during spontaneous breathing trial


Department of Critical Care, King Saud University Medical City, King Saud University, Riyadh, Saudi Arabia

Correspondence Address:
H Ullah
Department of Critical Care, 95, 3rd Level Critical Care Building, King Khalid University Hospital, P.O. BOX: 2925, Riyadh 11461
Saudi Arabia
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/1658-354X.169491

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Date of Web Publication12-Nov-2015
 


How to cite this article:
Khan M F, Abdou M A, Rajendrum R, Ullah H. Impacted tooth presenting as airway obstruction during spontaneous breathing trial. Saudi J Anaesth 2016;10:113-4

How to cite this URL:
Khan M F, Abdou M A, Rajendrum R, Ullah H. Impacted tooth presenting as airway obstruction during spontaneous breathing trial. Saudi J Anaesth [serial online] 2016 [cited 2021 Oct 24];10:113-4. Available from: https://www.saudija.org/text.asp?2016/10/1/113/169491

Sir,

Foreign body aspiration can cause airway obstruction, consolidation or collapse. [1] However, the diagnosis can be difficult in critically ill patients in the intensive care unit who are not able to report acute symptoms. We present a case in which diagnosis of tracheal aspiration of an incisor was delayed and presented as airway obstruction during a spontaneous breathing trial (SBT).

A 60-year-old man was intubated to protect his airway after he developed an acute left subdural hematoma. 7 days later, he required re-intubation after he self-extubated during a sedation hold. Reintubation was straightforward and was performed with no obvious complications. However, the plain chest X-ray radiograph (CXR) revealed new right lower zone atelectasis [Figure 1].
Figure 1: Tooth in lung

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Two days later, liberation from mechanical ventilation was considered. During SBT trial, the patient became agitated and so was re-sedated and treated with nebulized bronchodilators and chest physiotherapy. The next morning, the lung fields on the CXR appeared clear [Figure 2], so another SBT was performed. This time the flow-volume loop ventilator graphic demonstrated airway obstruction. Careful review of the second CXR [Figure 2], an opacity was seen projected within the lumen of the endotracheal tube (ETT). On the first X-ray [Figure 1], the same opacity was associated with the right lower zone atelectasis.
Figure 2: Tooth in endotracheal tube

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On extubation, a tooth was found to be almost completely occluding the lumen of the ETT [Figure 3]. The patient remained stable after extubation and the next day, he was transferred to a medical ward.
Figure 3: Tooth with endotracheal tube

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In this case, it is likely that the patient's tooth dislodged and fell into his trachea when he self-extubated. Unfortunately, as the patient was unable to report any symptoms, this was missed. The tooth must have subsequently moved, perhaps when the patient coughed and obstructed the distal end of the ETT.

Several lessons can be learned from this case. First, it highlights the importance of examination and documentation of dentition before and after manipulation of the airway. In the emergency situation, this may not be possible. However, after stabilization, the patient's dentition should be inspected to exclude the recent loss of a tooth.

Second, it reinforces the importance of having a low threshold of suspicion for foreign body aspiration in critically ill patients. This is particularly important when the X-ray demonstrates complications of airway obstruction such as atelectasis or a mechanically ventilated patient otherwise seems suitable for liberation but fails an SBT.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Divatia J, Bhowmick K. Complications of endotracheal intubation and other airway management procedures. Indian J Anaesth 2005; 49:308-18.  Back to cited text no. 1
  Medknow Journal  


    Figures

  [Figure 1], [Figure 2], [Figure 3]



 

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