The 58-year-old woman struggled to get out of her car at the West Roxbury Veterans Affairs Medical Center just outside Boston. When she finally made it to her feet, she leaned on the trunk of her car as she gasped for air. She was wheezing so loudly that she could hear it as well as feel it rumble in her chest. This was in 2019 — a time before the novel coronavirus that causes Covid-19 turned this kind of respiratory distress into an everyday event.
In the E.R., the wheezing woman was immediately moved to the treatment area. A mask hissing with a watery mist was placed over her nose and mouth, and only then did her breathing begin to ease.
She had a long history of asthma, the woman told her E.R. doctor, but it had never been this bad. Four weeks earlier, after the start of the new year, she came down with a terrible pneumonia in her right lung. The middle lobe had collapsed completely, she was told. She spent two days in a community hospital, but even after she was sent home, she didn’t feel well. Her chest was tight, and the slightest effort turned her breaths into wheezes. Her friends at work were worried. Go back to the hospital, they urged. But she hated hospitals, so she waited as long as she could. By the time she decided to drive herself to the V.A. hospital where she got much of her care, her entire body was exhausted simply from the effort it took for her to breathe.
Exploring the Airways
In the E.R., a chest X-ray showed that she had another pneumonia. She was started on antibiotics and admitted to the hospital. A CT scan showed one possible reason for the back-to-back pneumonias. Deep in her right lung something — it wasn’t clear what — was blocking one of the main airways. Pneumonias frequently occur when an airway is occluded. The patient had a distant history of smoking, which made lung cancer a possibility. Her medical team reached out to the pulmonology service, the lung specialists, in case the patient needed a bronchoscopy — a bronch, for short. In that procedure, a small camera embedded at the end of a long tube is snaked through the nose or mouth, down the throat and into the lungs to get a closer look at the airways or something inside the airways.
Dr. Justin Rucci was the pulmonologist in training assigned to the patient’s case. If she needed a bronch, he’d be the one to do it. Rucci carefully went over the patient’s records. She didn’t have a fever, but she needed supplemental oxygen to keep her in the normal range. That was new. Her chest X-ray showed a pneumonia, and the CT scan clearly revealed a blockage, cutting off the airways into the lower lobe.
Rucci had access to the records from the hospital where the patient was treated for pneumonia the month before. He immediately clicked on the imaging. In the chest X-ray done during that hospital stay, Rucci easily identified the bright white disk against the textured gray of the lungs that indicated a pneumonia; it was in the same lung but in the middle lobe, not the lower lobe. At that time, her lower lobe looked fine. If the pneumonia she had now was caused by the obstruction they saw in the CT scan, could the same problem also have somehow caused the earlier pneumonia in the middle lobe?
A Scary Episode
Rucci had seen plenty of patients with blocked airways. The most common culprits were cancer, a mucus plug or an aspirated foreign body. A blockage caused by cancer shouldn’t move, and it shouldn’t grow fast enough to reach the lower lobe in the time between the two pneumonias. So cancer seemed unlikely. And she didn’t have any problems in her lungs like scarring or diseases like cystic fibrosis that make mucus plugs common. Foreign bodies are not often found in adults, but Rucci was pretty sure that’s what she had.
He went to see the patient late that afternoon. She was in bed and cheerful, despite the plastic tubing that delivered oxygen-enriched air to her nostrils. After hearing her story, Rucci had a question. Did she ever have problems swallowing? In fact, she did. She always had to have a big glass of water at hand to help her get her food down.
What about choking? Did she recall if she recently had a really bad choking episode — when her food had gone down the wrong pipe? She most certainly did. Maybe three months earlier, she was eating a salad and something hard dropped into her airway. She was home alone, and suddenly she couldn’t breathe at all. She couldn’t even cough, though she could feel herself trying to. She jumped up and ran out of the old farmhouse. She lived alone and the only other person she could think of on the property was her elderly landlord, and she couldn’t see him anywhere. Dark spots appeared before her eyes, and she wondered if she’d be found dead with a piece of her salad stuck in her throat. After what seemed like forever but was probably less than a minute, something shifted, and the airway popped open. Her heart raced. She was an Army veteran, but she’d never felt closer to death than she had right then.
A New Understanding of an Old Event
Afterward, her chest was sore, but her breathing was back to normal. So she hadn’t thought of it months later when the wheezing started. Even when the doctors at that first hospital told her she might have a mass, her thoughts went to cancer and not to that choking episode.
But after she was discharged that first time, she was still coughing up a storm. After one bad bout of hacking, she brought up something solid. When she fished it out of her mouth, she saw what looked like a piece of walnut and recalled those terrible moments when she thought the thing might kill her. She figured she’d gotten rid of the problem. Perhaps she’d been wrong.
On Day 5 of this second hospital stay, she was scheduled for the bronch. She was positioned in a chair that reminded her of the one in her dentist’s office. Once she was sedated, Rucci gently introduced the endoscope into her mouth, through her vocal cords and into her lungs. He directed the camera through the complex intersections of the large airways until he was all the way down to the lower lobe. And there it was — wedged in tight, blocking off the entire section. He could see a sliver of free space near the top of the object. He slid a tiny tool through the tubing past the camera, and then to the far side of the object. Once there he moved a switch and felt, rather than saw, a small net open behind the obstruction. He coaxed the net forward until he was certain he’d captured the thing. It was too large to be pulled out through the scope, so he slowly withdrew the entire instrument, keeping an eye on the captured object. The retrieved item clattered into the specimen container. Rucci squinted at the object. It was beige and hard. It was the rest of the snorted walnut. Suddenly it made sense. The patient had inhaled the nut, which got stuck in the middle lobe. Her violent cough broke it in two, and one part came up and the other, now smaller, piece dropped farther down the progressively narrower airways.
Swallowed Foreign Objects
While food is what’s usually aspirated, a surprisingly wide variety of items manage to make their way into the lungs. Chevalier Jackson, a physician during the late 19th and early 20th centuries, devoted his career to developing instruments and techniques to retrieve these misplaced items. During Jackson’s 75-year career, he extracted 2,374 inhaled or swallowed foreign bodies from patients’ throats, esophagi and lungs, including safety pins, buttons, screws, dentures and lots and lots of toys. More than 80 percent of those objects were found in children. The entire collection, along with details of the patients from whom they were retrieved and the techniques used, is housed in the Mütter Museum in Philadelphia.
Like most patients, this one did well after the object was retrieved. Once the airway was opened, the pneumonia cleared up easily. She went home a couple of days later. The patient tells me that she still has trouble swallowing. She recently heard about a kind of physical therapy that might help, and plans to try that — once her doctors start seeing patients again.
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