I
ntubation of critically ill patients and subsequent care of the airway, including suctioning through tracheostomy and endotracheal tubes, are common procedures performed in intensive care units. Fortunately, foreign body aspiration directly related to these procedures is n~e.'-~Two pl.eviously unreported cases of airway foreign bodies resulting directly from respiratory care procedures are described.
A patient suffered a C-6 spinal cord injury after a motor vehicle accident and subsequently developed respiratory failure due to right upper lobe pneumonia and atelectasis of the left lung. The patient was treated with antibiotics, bronchodilators, and vigorous suctioning while on a ventilator. This treatment allowed reexpansion ofthe left lung, and the patient was weaned from the ventilator and the left lung remained expanded.
Four days later, the patient again developed atelectasis of the I& lung and respiratory distress which required reinstitution of mechanical ventilation. Conservative measures were again utilized to improve bronchial hygiene; however, the atelectasis remained. Bronchoscopy was performed which demonstrated a small white rubber washer (Fig 1) in the left mainstem bronchus which was easily removed with the bmnchoscope biopsy forceps. Removal of the washer allowed reexpansion of the lung, and the patient no longer required ventilator support.
h extensive search of all respiratory equipment resulted in the discovery that the washer was a component part of the Ballard closed system catheter which is commonly used in respiratory intensive care units ( F i g 1). The catheter and sleeve are attached to a clear plastic ' T ' adaptor by a "luerlock" type plastic hub. This plastic hub houses the washer which s u m d s the catheter. The washer remains secure within the hub as long as the system remains closed. If the ' T ' adapter is removed from the hub, the washer is then free to slide &the end ofthe suction catheter. While suctioning the above described patient, the adapter was removed from the hub, and the patient was then manually suctioned thrwgh the hacheostomy, using the free end of the catheter. This allowed the unsecured washer to slide down the end of the catheter and directly enter the airway.
A patient with a pulmonary embolus was undergoing intubation for respiratory failure. The respiratory therapist used an Armstrong FIGURE 1. Aspirated washer.
FIGURE 2. Armstrong Medical Industries stylet.
Medical Industries 8801 (Fig 2) intubating stylet to assist in the intubation. The stylet itself is a brass rod about 43 cm long with a small ball soldered on one end and a laqger ball soldered on the other end. The intubation was Wcult, and the patient constantly bit down on the endotracheal tube while the stylet was advanced inside the endotracheal tube. The stylet was subsequently withdrawn, apparently with force, and it was noted that the brass ball at the end of the stylet was absent. Subsequent chest roentgenogram confirmed the location of the metallic ball in the I& lower lobe bronchus.
Flexible bronchoscopy was unsuccessful at retrieval of the metallic ball, due to its small size and peripheral location. Further attempts at retrieval, including possible thoracotomy, were not performed due to the patient's underlying condition. Although the patient had no acute respiratory compromise due to this event, subsequent long-term follow-up regarding her clinical condition is not available.
These two cases demonstrate unusual episodes of aspiration of component parts from respiratory care equipment, which at least in one case, caused immediate compromise to the patient's respiratory status. The Ballard closed system suction catheter 2U)5 is commonly used in respiratory intensive care units throughout the country. It is important to emphasize the potential hazard which exists when the unit is taken apart so as not to remwe the catheter from the "T." A strong argument can be made that the "luer-lock" fitting should be made solid, so a violation of its integrity will not occur. In addition, the washer should at least be radiopaque so that if it falls into the airway, it can be seen roentgenographically. We urge the instruction of nursing staff and respiratory personnel in this rare but potential complication which exists when this commonly employed suction catheter is used improperly.
Caution is also urged in the use of the Armstrong Medical Industries model 8801 intubating stylet. Although this isolated event likely occurred due to forceful remwal of the stylet while the patient was biting, it nonetheless is a complication which should not have occurred. Clearly, this stylet has the potential to "shear o f f the ball end, and it is not unreasonable to expect that under similar circumstances, this adverse event could occur again. A 57-yea~old man had a histologically proven giant blood cyst in the left ventricle. An encapsulated mobile cystic tumor (3 x 3 x 4 em), which was attached to the antemlateral papillary muscle by a stalk, was successfully resected by a t r d c valve approach for preserving cardiac function.
(Chcst 1993; 103:MS-HS)
A blood cyst in the heart is a rare clinical state and it is necessary to differentiate this from primary cystic tumors such as hemangioma and rnyx0ma.l Previous descriptions have stated that a blood cyst is usually small, is found on the endocardium (especially the valvular endocardium) in newborn infants, and is thought to have no clinical signifi~ance.~ We report herein an adult case of left ventricular giant cyst that was diagnosed as a blood cyst by a postoperative histologic study.
CASE REPORT
An asymptomatic 57-yearold man was admitted to the Second Department of Internal Medicine, Sapporo Medical College, for further examination of an abnormal heart sound. Physical examination revealed no abnormal finding except a midsystolic prop sound and a late crescendc-systolic munnur graded W6 at the apex.
His pulse rate was 80 beatshin and blood pressure was 126/74 mm Hg. Laboratory examinations disclosed no abnormal findings of special note. The electrocardiogram and the chest roentgenogram did not demonstrate any sign of abnormality. Cardiac catheterization showed n o d values in the inhacavital pressures, cardiac index (3.96 Wmin/mml), and left ventricular ejection fraction (52 percent). Echocardiography (Fig 1. a) demonstrated a giant "snowman" shaped mass attached to the apical side of the antemlateral papillary muscle. The surface of the mass rarealed a partiaUy high-echoic density, although most of the tumor mass showed homogenous echolucent characteristics and was clearly differentiated from the myocardial tissue. On 

{'paper_id': '11072082', 'title': 'Iatrogenic Aspiration of Components of Respiratory Care Equipment', 's2_url': 'https://api.semanticscholar.org/CorpusID:11072082', 'source': 'S2ORC'}