Retained tracheostomy tube brush tip manifesting as recurrent respiratory tract infection

Madam, Various types of bronchial brush may be used during bronchoscopy to collect samples for both microbiological diagnosis and cleaning tracheobronchial secretions.[12] Inadvertent breakage of this brush during any intervention or cleaning tracheostomy tube (TT) may go unnoticed. While most cases of airway foreign body (FB) are diagnosed readily from a clinical history of acute respiratory distress, some cases remain indolent and present later. We report a case in which a patient presented with recurrent respiratory tract infections following inadvertent breakage of bronchial tube brush tip during an antecedent intervention. A 62-year-old male (60 kg, 170 cm) presented to our hospital with a history of recurrent cough and purulent sputum not responding to conservative management. He was operated for carcinoma supraglottic region two years ago followed by elective tracheostomy. The patient was on regular follow-up for prolonged postoperative tracheostomy and radiotherapy. On examination of the respiratory system, there was decreased air entry over the middle and lower zones of the right lung along with rhonchi and fine crepitations. The patient was afebrile. His blood investigations were within normal limits except for eosinophilia with leukocytosis (total count 16500/cu.mm and absolute eosinophil count was 15500/cu.mm). Chest radiograph PA and lateral view revealed a radiopaque, obliquely placed cylinder like (unknown) FB in the right lower zone [Figure 1]. The finding was later confirmed with a computerized tomography scan of thorax. Retrieval of the FB was planned under general anesthesia. In the operating room, the patient was administered with 0.2 mg glycopyrrolate (IM) 30 mins before the procedure. Standard monitoring devices were attached. Oropharynx was sprayed with 10% lignocaine spray. Patient was preoxygenated (5 mins) and induction of anesthesia was accomplished with fentanyl 75 mcg (IV) and propofol 50 mg followed by initiation of dexmedetomidine infusion at 0.5 μg/kg/hour. A 6-mm rigid bronchoscope was introduced orally by the intensivist. Ventilation was maintained with side port of the rigid bronchoscope. The FB was visualized, grasped with rigid forceps, and gradually retrieved through the rigid bronchoscope. The FB was identified to be a tracheobronchial brush tip which was used previously to clean tracheobronchial secretions through tracheostomy tube [Figure 2]. The procedure lasted around 20 minutes. Postoperative chest radiograph showed absence of the FB. The patient was discharged the next day of the procedure with the advice to continue antibiotics for 7 days.Figure 1: Chest X-ray showing the presence of right lower zone bronchial FBFigure 2: Retrieval of broken bronchial brush tipIatrogenic introduction of FB in the airway is uncommon in adults but not rare. A study by Roach et al. had reported a case of retrieval of bronchial brush tip through a flexible fiberoptic bronchoscope.[3] Suratt et al. had reported breakage of four brushes during fiberoptic bronchoscopy after reviewing a series of 48,000 procedures. One brush was left in place for 18 months without complications. Another brush was removed during an exploratory thoracotomy which was performed to further evaluate a mass lesion.[4] Thus, symptoms can range from asymptomatic phase to severe respiratory distress which may even require thoracotomy for FB retrieval. We recommend careful inspection of bronchial brush before and after every cleaning which reduces the chance of iatrogenically introducing a FB during tracheostomy tube cleaning by health care workers. An intensivist should be vigilant of this potential complication of bronchial brush in a critical care setting. Declaration of patient consent The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.