swinging fevers on and off chest pain On repeat questioning the patient had remembered choking on a pin nine months previously and had since been getting an intermittent cough that was treated as asthma.
The chest radiograph revealed a radio opaque foreign body in the right bronchus causing collapse of the right middle and lower lobes with abscess formation.
The diagnosis was pneumonia with abscess formation secondary to foreign body aspiration.
He was transferred to a tertiary centre for a specialist bronchoscopic removal of this foreign body and drainage of the abscess. At broncoscopy the foreign body could not beremoved as it was imbedded in the bronchial wall, and copious amounts of pus were aspirated, soiling both lungs.
During this time he became severely hypoxic and hypotensive. The procedure was abandoned and he was intubated,ventilated and inotropes started. He was in septic shock and had aspirated into his left lung and developed acute respiratory distress syndrome.
With his increasing oxygen demands the ECMO team were consulted and the decision was made to start veno-venous ECMO. Whilst stabilised on ECMO he was taken to theatre for a thoracotomy and lobectomy.
The operation was difficult with a period of low output requiring adrenaline blouses and difficult haemostasis requiring 13 units of blood and products. Postoperative progress was slow. He was decannulated from ECMO eight days later and was extubated five days after that.
He was eventually discharged home five weeks later for Christmas with regular ward reviews. He recovered well on antibiotics and apart from a small persistent apical pneumothorax requiring pleurodesis, made an excellent recovery and suffered no neurological sequelae.
conclusion If the patient is too unstable for bronchoscopy,ECMO can be used to temporarily stabilise the patient allowing safe removal of the object. If the patient is acutely unwell and septic, ECMO should be more readily considered.