Sand aspiration: A case report

Sand Aspiration:

A Case Report

By Isaac Oojin Choy and Olajire Oakland, California l There have been few documented cases of sand aspiration. The authors report on a 3-year-old boy who suffered severe respiratory compromise secondary to sand aspiration. Emergency intubation and subsequent bronchoscopy were required to relieve airway obstruction. The patient did well and suffered no long-term sequelae. Copyright o 1996 by W, B. Saunders Company INDEX WORDS: Aspiration, struction, bronchoscopy.

foreign

body,

sand;

airway

ob-

F

OREIGN-BODY aspiration is a prevalent health care risk among the pediatric population. Airway obstruction is a potentially life-threatening emergency. Surgical management is the primary treatment modality for airway obstruction. There are several reports of sand, dirt, or gravel aspiration in the literature. We present a case of sand aspiration with severe ventilatory compromise, which required emergency bronchoscopic removal of obstructing particulate matter.

ldowu

left side of the chest, with coarse breath sounds on the right. A CXR obtained here showed radiopaque sand particulate matter in the right bronchial tree and complete collapse of the entire left lung, with sand filling the left bronchial system as a “sand bronchogram.” A large amount of sand also was seen in the stomach (Fig 1). ABG values at this time were: pH, 7.3; Pcoz, 37; POZ, 270; Hco~, 20; BE, -5 (F102, 100%). He was taken to the operating room immediately, where a rigid bronchoscopy was performed using a Stortz no. 3 scope. There was a large amount of sand in the trachea, right bronchi, and the left main-stem bronchus, which was impacted with sand. The airways showed evidence of mucosal irritation. Removal of the sand was performed by multiple manual extractions with bronchoscopic foreign body forceps, saline bronchial lavage, and repeated suction. The ventilation on the left side of the chest improved significantly. A postbronchoscopy CXR showed re-expansion of the left lung field and only a small amount of residual sand. He remained intubated and was returned to the intensive care unit, where his condition continued to improve. Small amounts of sand were suctioned from the endotracheal tube, and subsequent CXR findings were normal (Fig 2). He was treated empirically with antibiotics and steroids and was extubated on postoperative day 1. He continued to do well and was discharged home on postoperative day 4, in stable condition without sequelae.

CASE REPORT The patient, a 3-year-old boy who was accidentally buried when a sand castle caved in. He was extricated immediately and was in acute respiratory distress. The patient was cyanotic, but no loss of consciousness was noted. He was rushed to a nearby hospital while being ventilated with a bag-mask by paramedics. His initial vital signs were as follows: heart rate, 125 beats per minute; blood pressure, 139185 mm Hg; respiratory rate, 30 breaths per minute; temperature, 33.8”C; oxygen saturation (sat), 98%. Initial arterial blood gas (ABG) values on FIO~ of 100% were: pH, 6.98; PCOZ,91; PO?, 90; bicarbonate (Hcos) 22; base excess (BE), -13; sat, 91%. The patient was intubated and stabilized, and a subsequent ABG values were: pH, 7.29; Pcoz, 45; Paz, 109; Hcos, 22, BE, -5; sat, 97%. A chest x-ray (CXR) showed radiopaque particulate matter throughout the bronchial system, which was more prominent on the left. The patient was transferred to our hospital immediately for further management. The patient arrived intubated and had no breath sounds on the

From the Department of Surgery Children’s Hospital Oakland, and the Department of Surgery University of California Davis, East Bay, Oakland, CA. Address reprint requests to Olajire Idowy MD, Pediattic Surgical Associates of the East Bay, 744 Fifty-Second St, Oakland, CA 94609. Copyright o 1996 by WB. Saunders Company 0022-3468i96l3110-0032$03.OOiO

1448

DISCUSSION

Foreign-body aspiration is commonly encountered in the pediatric population and is treatable by bronchoscopic extraction. However, cases of sand aspiration are rare. In the present case, the left main-stem bronchus was completely occluded by the impaction of sand, seen as a sand bronchogram outlining the bronchial tree. Calcium carbonate in the sand is radiopaque on x-ray. The resultant obstruction and left lung collapse lead to severe ventilatory compromise and profound respiratory acidosis, which require immediate surgical intervention. In the present case, removing the sand bronchoscopically was difficult. The sand was adherent to the mucosa, with thick bronchial secretions and actually formed casts in the left main-stem bronchus. Some particles were larger than the diameter of our suction catheter, which caused continuous plugging. Also, the sand particles were too heavy to be lavaged easily. This required tedious, repeated manual extraction, using bronchoscopic foreign body grasping forceps to remove only a few particles at a time.

Journaloffediafric

Surgery,

Vol31,

No 10 (October),

1996: pp 1448-1450

SAND

1449

ASPIRATION

There have been several reported cases of sand, dirt, and gravel aspiration in the literature. BonillaSantiago and Fill1 described two cases of sand aspiration associated with drowning. These investigators were the first to use the term “sand bronchogram.” One of the patients was treated with bronchoscopic lavage and removal of the aspirated sand, similar to the treatment in the present case. Van Dyke and Lake2 described a case of asphyxia secondary to massive gravel aspiration, extracted bronchoscopically. Their patient’s postoperative course was complicated by severe respiratory acidosis, pulmonary edema, and prolonged mechanical ventilation. Bergeson et al3 reported a case of asphyxia owing to massive dirt aspiration, which led to cerebral anoxia and death. Again, bronchoscopy was used to remove foreign material from the airways. Two other cases4s5 have been reported, in which dirt and sand aspiration were treated conservatively, with bronchodilators, postural drainage and aggressive pulmonary toilet (Table 1). After initial stabilization, emergency bronchoscopic extraction is the treatment of choice for airway-obstructing foreign bodies that cause respiratory compromise. There have been only a few reports of sand, dirt, or gravel aspiration, mostly among the pediatric population. Of the reported cases, all but one patient treated by bronchoscopy had a good outcome. Two of the patients treated conservatively also did well, but their degree of respiratory compromise was only moderate. Our patient benefited by rapid stabilization, transport, and definitive care with bronchoscopy.

Fig 1. (A) CXR shows bronchial tree, and sand suction trap.

complete left in the stomach.

lung collapse, (B) Extracted

sand sand

in the in the

However, we were able to remove nearly all the sand, with excellent results. Empiric steroid treatment was believed to help minimize subsequent airway edema. Antibiotics were used prophylactically. The patient did well, was extubated in 24 hours, and had a good outcome.

Fig 2. Postoperative CXR shows and reexpansion of the left lung.

clearing

of the sand bronchogram

1450

CHOY

Table Patient

Reference Choy

(present

Bender

Wales

Age W report)

et al4 (1984)

et al5 (1983)

Bergeson

et al3 (1978)

Bonilla-Santiago (1978)

et aI1

Mechanism/ Agent

1. Reports

of Sand,

Degree of Respiratory Distress

Dirt, and Gravel

Duration of

Chest X-Ray Findings

Treatment

Sand

Severe

Sand on bronchogram; left lung collapse

Bronchoscopy

14

Sand

Moderate

Sand in right bronchial tree; decreased volume

Pulmonary

14

Dirt

Moderate

Dirt in right main stem, decreased volume

Pulmonary

8

Dirt

Severe

Dirt occluding trachea and bilateral main stems

Bronchoscopy

20

Drowning (autopsy)/ sand Near-drowning/sand

-

IDOWU

Aspiration

3

23

AND

Marked opacity cheobronchial

Mechanical Ventilation 1d

Good

Toilet

None

Good

Toilet

None

Good

Not known

Cerebral died Died;

of tratree

Minimal

Sand on bronchogram (right upper lung and left lower lung

Severe

Sand and gravel in trachea and major bronchi

Outcome

Bronchoscopy

None

Good

Bronchoscopy

5 d

Good

asphyxia;

postmortem

regions) Van Dyke et aI2 (1976)

12

Gravel

REFERENCES 1. Bonilla-Santiago J, Fill WL: Sand aspiration in drowning and near drowning. Radiology 128:301-302,1978 2. Van Dyke JJ, Lake KB: Survival after asphyxia secondary to gravel aspiration. Arch Intern Med 136:471-473,1976 3. Bergeson PS, Hinchcliffe

WA, Crawford,

RF, et al: As-

phyxia secondary to massive dirt aspiration. J Pediatr 92:506-507, 1978 4. Bender EM, Moore EE, Kashuk JL, et al: Conservative management of sand aspiration: Case report. Mil Med 149:98-99,1984 5. Wales J, Jackimczyk K, Rosen P: Aspiration following a cave-in. Ann Emerg Med 12:99-101,1983