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Am Fam Physician. 2002;66(8):1401

to the editor: Asthma and chronic obstructive pulmonary disease (COPD) are significant health problems in the United States, affecting over 20 million Americans.1,2 Reactive airways disease is treated with the use of inhaled bronchodilators and steroids, which are most commonly administered via hand-held metered-dose inhalers (MDIs).1 MDIs are designed with a mouthpiece that maximizes deposition of the medication in the small airways when used properly. We report two cases of serious aspiration of foreign bodies that had been inadvertently entrapped within the mouthpiece of the inhaler.

One case occurred in a 46-year-old woman who experienced an acute asthma exacerbation while driving. She used the inhaler, which was in her purse, in the standard manner; however, she accidentally inhaled a golf ball marker that was entrapped within the mouthpiece of the inhaler. She coughed violently, dislodging the foreign body from the lungs, but then swallowed it. She required emergency upper endoscopy to retrieve the marker from the distal esophagus.

The other case occurred in a 58-year-old man with a COPD exacerbation while walking. He used his inhaler, which was in his pants pocket. The patient continued to have dyspnea over the next two weeks. Chest radiographs revealed a foreign body in the left mainstream bronchus. Subsequent bronchoscopy revealed a corroded coin (a dime) that was intermittently obstructing the bronchus.

Given the serious nature of these two cases, we believe standard MDIs should be modified to prevent entrapment of foreign bodies within the mouthpiece. External caps can be effective if patients consistently use them. Newer delivery technologies using propellants, disks, and spacers may minimize this risk. Patients, physicians, and pharmaceutical companies need to be informed of the risk of foreign-body inhalation with MDIs. We suggest that the mouthpiece be modified with a mesh screen that would allow for inhalation of the drug while preventing the entrapment of foreign bodies. This minor modification may prevent life-threatening complications caused by MDI-induced foreign-body inhalation.

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This series is coordinated by Kenny Lin, MD, MPH, deputy editor.

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