Managing Live Fish Aspiration (Video)

Live foreign body aspiration is a life-threatening emergency that presents unique challenges to clinicians. In an article in Chest, Atul Mehta, MBBS, Vice Chairman of the Department of Pulmonary Medicine and Medical Director of Lung Transplantation at Cleveland Clinic, and his colleague Syed Rizwan Ali, MBBS, at Bombay Hospital in India, describe several cases of fish, leech and roundworm infestation and aspiration. The below images focus on fish aspiration.

*All images and videos are republished with permission from Wolters Kluwer and/or Elsevier.

Drs. Mehta and Rizwan found 75 references to fish aspiration in the medical literature, usually resulting from fishing accidents. Nineteen of these cases involved the lower airways, including the above photo and below video of a live fish in the trachea with the cephalic end in the left main stem bronchus. Doctors removed the fish with a rigid bronchoscope. (Adapted with permission from Raju and Jhawar.)

Biting a fish behind the eyes to kill it and holding a fish between the teeth are common but dangerous fishing practices. Frequently, the fish slips into the mouth and flaps quickly in an inverted anatomic position into the aerodigestive tract. This risky practice proves fatal when impaction leads to sudden asphyxiation if the fish lodges in one of several areas, including at the tracheal bifurcation (below). The images show necroscopy findings after live fish aspiration. The fish was impacted at the carina and obstructed both mainstem bronchi. (Adapted with permission from A. Appiah-Thompson et al and Aissaoui et al.)

Cases of live fish aspiration should be approached as acute airway obstructions. Once an airway is established, pain management and removal of the fish can be considered. Grabbing the fish by the tail actually obstructs removal due to the retrograde movement of spiny fins when impacted in the throat.

Piecemeal extraction is recommended to remove a supraglottic impaction, and tracheostomy or needle cricothyroidotomy may be required. Removal of the fish tail occurs first, then the body is hollowed with a rongeur. Spiny fins should be cut with small scissors to allow space for detangling the fish from surrounding mucosa. At this point, the head should be easy to remove.

Subglottic impaction can be confirmed with flexible bronchoscopy. Depending on the degree of obstruction, a rigid bronchoscope can secure the airway and help to visualize the fish. The fish will decompose rather quickly, so if removal attempts are unsuccessful and an airway is established, watchful waiting should be encouraged.