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Pulmonary puzzle

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From the question on page 802.

Two small opacities are seen in the nasopharynx.

Using fluoroscopy, an ENT surgeon was able to identify the presence of a nasal clip (fig 1) which was removed without difficulty, hence allowing NIV to continue. The patient had been using the device at night to keep his nasal flares patent to help alleviate snoring; he had nasally inhaled the clip with the added positive pressure of his ventilator. The presence of a foreign body either in the upper or lower respiratory tract must always be eliminated when signs of respiratory distress are observed. Assessment is particularly difficult in patients with limited communication such as those with bulbar disease of whatever cause.

Figure 1 Nasal clip device after its removal.

Snoring is a extremely common condition that can cause significant difficulties in relationships and home life. Despite very limited evidence, there are numerous commercially available mechanical aids that attempt to keep the nasal air passages clear. When initiating non-invasive ventilation or continuous positive airways pressures therapy, one should check with the patient that these aids are not being used at night due to the risk of aspiration with added positive pressure.

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