Beware the Stick: A Case of a Fractured Nasopharyngeal COVID-19 Screening Swab Lost to a Patient’s Distal Airways

Patient selection

A 57-year-old woman was initially admitted to hospital four months prior with a right temporal infarct with hemorrhagic transformation, complicated by venous sinus thrombosis. She required repeated craniotomies and a ventriculoperitoneal shunt. Supportive management involved placement of a feeding jejunostomy for nutritional support and a tracheostomy (TRACOE®twist Tracheostomy Tube), from which weaning off oxygen was unsuccessful. She was also found to have bilateral lung nodules, with a clinical diagnosis of lung cancer and recommendation of best supportive care in view of her comorbidities.

Whilst being rehabilitated in a Brain Injuries Unit amidst the COVID-19 pandemic, she displayed signs and symptoms of a lower respiratory tract infection: an indication for SARS-CoV-2 testing. During swabbing through the tracheostomy tube, the plastic swab-stick snapped in half, and the distal end was lost into the airway.

A noticeable decrease in oxygenation saturations and increased respiratory effort were escalated to the on-call emergency team. Further cross-sectional imaging revealed a linear focus of high density within the right lower lobe bronchus. Visualization of the broken plastic swab stick at flexible bronchoscopy through the tracheostomy tube confirmed the presence of the swab stick at this site. However, it was not possible to be safely retrieved at this time. She was subsequently transferred to the care of thoracic surgery for management.

The case was complicated by her aforementioned extensive past medical history, baseline Glasgow Coma Score (GCS) of 6, and anticoagulated state (International Normalised Ratio (INR) of 3.0 on transfer). Following careful assessment of all risks and benefits, the decision was made for the patient to undergo a repeat attempt at awake bronchoscopy, following intravenous reversal of warfarin anticoagulation using vitamin K.

Operative steps

The surgical team wore full personal protective equipment (PPE) as per local trust policy for all aerosol generating procedures. The technique involved flexible bronchoscopy using a large (5.8 mm) Ambu® aScopeTM (AMBU® ASCOPETM 4 BRONCHO LARGE (5.8/2.8) with a 2.8 mm working port, via the existing size 7 tracheostomy tube with its inner tube removed. Twenty mL of 1% lidocaine was inserted through the bronchoscope to aid comfort. 

Uncomplicated removal of the foreign object that was again identified in the right lower lobe bronchus was performed using standard biopsy forceps (OLYMPUS® EndoJaw DISPOSABLE BIOPSY FORCEPS).

An opportunistic bronchoalveolar lavage was sent for microscopy, culture, and sensitivity (MC&S) and SARS-CoV-2 testing, together with the original broken microbiology swab.

Postprocedural plain imaging confirmed no new or residual pathology, and the patient was successfully transferred back to the care of her neurology team that same day, to continue her rehabilitation.

Tips and pitfalls

This case outlines the inadvertent events that can arise from SARS-CoV-2, or indeed any respiratory swab testing. Current advice on caring for patients with tracheostomies during COVID-19 primarily focus on PPE and techniques to minimize infection transmission. Swabbing through tracheostomy tubes requires thoughtful consideration in view of current equipment limitations. Care and vigilance must be maintained when adapting routine practice to meet the needs of special patient groups in these uncertain times.

References 

1. Public Health England. COVID-19: guidance for taking swab samples. [Online]. Available from: https://www.gov.uk/government/publications/covid-19-guidance-for-taking-swab-samples [Accessed 2 November 2020].
2. The New England Journal of Medicine. How to Obtain a Nasopharyngeal Swab Specimen. [Online]. Available from: https://www.nejm.org/doi/full/10.1056/NEJMvcm2010260 [Accessed 2 November 2020].
3. ENT UK. Tracheostomy guidance during the COVID-19 Pandemic. [Online]. Available from: https://www.entuk.org/tracheostomy-guidance-during-covid-19-pandemic [Accessed 2 November 2020].
4. Assessurgery gmbh. The Clavien-Dindo Classification. [Online]. Available from: https://www.assessurgery.com/clavien-dindo-classification/ [Accessed 2 November 2020].
5. University Hospitals of Leicester Trust. COVID-19 Clinical Management UHL RRCV Guideline (Trust ref B14/2020). Leicester; England. 2020 [Accessed 2 November 2020].

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