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images in clinical medicine

Barium Aspiration

Mazen Albeldawi, M.D.

Rohit Makkar, M.D.
Cleveland Clinic
Cleveland, OH

79-year-old man was evaluated for unintentional weight loss

and dysphagia. He underwent a modified barium swallow. During the rapiddrinking phase, the patient aspirated a large amount of barium (which did not
elicit a cough reflex), which resulted in hypoxemic respiratory failure and subsequent
intubation. He was admitted to the intensive care unit, and a chest film was obtained.
The film showed barium in both the right and left main stem bronchi, outlining
the bronchus intermedius, all four lower-lobe basal bronchi, and the segmental bronchi
in the left upper and lower lobes. The barium also spread into the smaller airways,
producing a tree-in-bud appearance (arrow). The patient underwent bronchoscopy,
which confirmed the presence of barium in the right and left lower lobes and lingula.
The barium was suctioned extensively. Circulatory shock developed, and the patient
had severe anoxic brain injury after cardiac arrest. Despite fluid resuscitation and
treatment with inotropic agents and antibiotics, his clinical condition deteriorated,
and his family opted for conservative care. He died shortly thereafter.

Copyright 2012 Massachusetts Medical Society.

1038

n engl j med 366;11

nejm.org

march 15, 2012

The New England Journal of Medicine

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Copyright 2012 Massachusetts Medical Society. All rights reserved.