Eight Years With an Airway Foreign Body: Asthma or Aspiration?

Foreign body aspiration (FBA) is most commonly observed in children under the age of three and typically presents acutely with respiratory distress. In adolescents, FBA is less frequent and often results from behavioral incidents or accidental inhalation. Chronic retained airway foreign bodies are rare and often present with nonspecific or misleading symptoms, making timely diagnosis challenging. This case highlights the unusual presentation and anesthetic considerations in managing a delayed diagnosis of FBA in a 15-year-old male with a history of mild intermittent asthma who presented with new-onset hemoptysis, hematemesis, and a chronic, malodorous cough for a duration of eight months. Symptoms were followed by a coughing episode that produced blood-streaked sputum and post-tussive emesis. Imaging revealed left lower lobe bronchiectasis and mucus-impacted airways. Notably, at age seven, the patient choked on a pen cap and sought medical attention but was discharged after a negative nasolaryngoscopy and was instructed to observe for passage of the pen cap in their stool. Bronchoscopy was planned, given the patient's history, presentation, and new CT findings. Under anesthesia with preserved spontaneous ventilation via a supraglottic airway, flexible bronchoscopy identified a pen cap lodged in the distal left lower lobe. Subsequent rigid bronchoscopy was performed due to the depth of the object and associated airway changes. The foreign body was successfully retrieved, and postoperatively, the patient's respiratory symptoms markedly improved. They recovered after a course of antibiotics and airway clearance therapy. This case underscores the importance of maintaining clinical suspicion for FBA in patients with chronic respiratory symptoms with relevant history, regardless of time elapsed. It also highlights key anesthetic considerations in managing airway access, ventilation, and procedural coordination during rigid bronchoscopy. The successful outcome illustrates the necessity of interdisciplinary collaboration and individualized anesthetic planning in complex airway foreign body retrieval.