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EDITORIAL
Year : 2014  |  Volume : 9  |  Issue : 1  |  Page : 1-2
A foreign body of a different kind: Pill aspiration


Respiratory Institute, Cleveland Clinic, Cleveland, OH, USA

Date of Submission18-Nov-2013
Date of Acceptance18-Nov-2013
Date of Web Publication6-Jan-2014

Correspondence Address:
Atul C Mehta
Professor of Medicine, Lerner College of Medicine Staff Physician, Respiratory Institute 9500 Euclid Avenue, A-90 Cleveland Clinic, Cleveland, Ohio, 44195
USA
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DOI: 10.4103/1817-1737.124404

PMID: 24551009

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How to cite this article:
Mehta AC, Khemasuwan D. A foreign body of a different kind: Pill aspiration. Ann Thorac Med 2014;9:1-2

How to cite this URL:
Mehta AC, Khemasuwan D. A foreign body of a different kind: Pill aspiration. Ann Thorac Med [serial online] 2014 [cited 2018 Jan 22];9:1-2. Available from: http://www.thoracicmedicine.org/text.asp?2014/9/1/1/124404


What we see depends mainly on what we look for," a famous quote by John Lubbock, an American philanthropist from the early 19 th century. This quote may seem to be unrelated to the topic of a foreign body (FB) aspiration; however, aspiration of a medicinal pill represents a distinct clinical entity that is often overlooked. It requires a high degree of suspicion for its precise diagnosis in a timely fashion. Occasionally, serious complications involving the airways can occur as a result of a delay in its recognition. The purpose of our editorial is to increase the awareness of this entity among the pulmonologists.

Medicinal pills are prescribed over 3.7 billion times annually in the United States. It is considered as one of the most common forms of retail medical product in the country. [1] It is estimated that roughly 7% of all FB aspirated in the airways are medicinal pills. The pill aspiration in the airways, however, is under-recognized and the literature may not reflect the true incidence of this important entity. In addition, there are only limited numbers of articles that describe the unique reactions of each pill when aspirated into the tracheobronchial tree.

The diagnosis of pill aspiration is challenging. Although the patient may have a clear history of the nature and the timing of the pill aspiration, most pills are radiolucent on chest imaging and the pill itself may no longer be present at the time of bronchoscopic examination. It needs to be highlighted that if the aspirated pill dissolves in the tracheobronchial tree, the diagnosis of FB aspiration has to be established in the absence of the actual FB! Thus, in many of the instances, diagnosis of the pill aspiration is not even suspected. It remains unrecognized that aspiration of several types of pills can lead to significant inflammation and stenosis of the air passages as well as death. [2]

Küpeli et al. recently reviewed the clinical presentation, mechanism of injury, diagnosis and management of pill aspiration. [3] It pointed out that there are two major mechanisms of airway involvement with pill aspiration: Inflammation and obstruction. The former is based on the chemical nature of the pill, with FeSO 4 and KCl being the most common culprits. If the pill dissolved in the airway secretions, in selected cases diagnosis is established by either the endobronchial biopsy or by the bronchoalveolar lavage. Certain medications can also involve airways through their systemic side-effects without actual aspiration (e.g., Amiodarone and Clopidogrel).

Lastly, the air passages have been used as a novel route of drug delivery. Many of these medications can cause specific reactions to the airways [Table 1] and [Table 2]. An example of one such medication is inhaled corticosteroid (ICS). There are several articles demonstrating an increased risk of mycobacterial infection (both tuberculosis and non-tuberculosis) among ICS users. [4],[5] These studies raise a possibility of the adverse effect of ICS and suggest that the dose of ICS should be reduced at the earliest opportunity.
Table 1: Pills causing airway inflammation*

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Table 2: Airway involvement with medicinal pills (other mechanisms)

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An early bronchoscopic examination in a patient with clear history of pill aspiration may mitigate the detrimental effects of a partially dissolved pill. An extraction of the aspirated pill can be attempted with bronchoscopic tools such as forceps, baskets, snares and balloon catheters. Most of the case reports of pill aspiration highlight the importance of early bronchoscopic surveillance and intervention to promptly identify the extension of airway injury. Once the airway injury has taken place, frequent bronchoscopic interventions with balloon dilatation, cryotherapy, argon plasma coagulation, mitomycin C application and stent placement may be required to maintain airway patency. Ultimately, some of the patients with pill aspiration may require surgical interventions (lobectomy and/or pneumonectomy) for refractory stenosis and occlusion.

The most important issue to avoid the airway complications from pill aspiration is its prevention. In elderly patients with or without prior history of swallowing disorders, caregivers need to be extremely cautious while administering medications via the oral route. In high-risk patients, especially among infants and those with swallowing disorders, as far as possible medicinal pills should be avoided. Otherwise, the pill should be administered one at a time making sure that the patient has completely swallowed each pill before receiving the next pill.

Pulmonologists must be fully cognizant regarding the urgency of management in patients with aspiration of foreign body, especially the pill aspiration. The syndrome of "pill aspiration" is underrecognized, which should be included in the differential diagnosis of unexplained endobronchial findings. Diagnosis of the pill is often made in the absence of the actual foreign object. Flexible bronchoscopy is the best method in an evaluation of pill aspiration as most of the medicinal pills are radiolucent. Airways are also increasingly being used to deliver medications, which place the airways at a higher risk of localized complications. The long-term side-effects of aerosolized medication and metered dose inhaler remain unrecognized.

 
   References Top

1.United States: Prescription drugs. The Henry J Kaiser Family Foundation website. Available from: http://kff.org/other/state-indicator/total-retail-rx-drugs/ [Last accessed on 2013 Nov 5].  Back to cited text no. 1
    
2.Lee P, Culver DA, Farver C, Mehta AC. Syndrome of iron pill aspiration. Chest 2002;121:1355-7.  Back to cited text no. 2
[PUBMED]    
3.Kupali E, Khemasuwan D, Lee P, Mehta AC. Pills and air passage. Chest 2013;144:651-60.  Back to cited text no. 3
    
4.Andréjak C, Nielsen R, Thomsen VØ, Duhaut P, Sørensen HT, Thomsen RW. Chronic respiratory disease, inhaled corticosteroids and risk of non-tuberculous mycobacteriosis. Thorax 2013;68:256-62.  Back to cited text no. 4
    
5.Kim JH, Park JS, Kim KH, et al. Inhaled corticosteroid is associated with an increased risk of TB in patients with COPD. Chest 2013;143:1018-24.  Back to cited text no. 5
[PUBMED]    



 
 
    Tables

  [Table 1], [Table 2]

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