We read with interest the article by Gómez Hernández et al. published in your journal in May, entitled “Foreign body aspiration during inhaled bronchodilator administration”.1 Last month we encountered in our hospital a patient who had aspirated a coin concealed in the mouthpiece of his salbutamol pressurized inhaler, by the same mechanism described in the above-mentioned article.

Our patient was a 67-year-old British man, former smoker with a history of arterial hypertension and COPD, who was on holiday in Spain. He was receiving regular treatment with hypotensive agents and long-acting bronchodilators, and used salbutamol on demand from a pressurized cartridge. On this occasion, he took a puff of salbutamol on demand for dyspnea. The patient reported that he was carrying the inhaler without the mouthpiece cover in his pocket, where he also had loose change. The patient took out the inhaler and took a quick puff without examining the mouthpiece or shaking the device before use, so he failed to notice the coin. He immediately realized that he had aspirated a foreign body and began to cough persistently, so he attended the emergency department. A chest X-ray revealed a coin lodged in the right main bronchus, and the respiratory medicine and thoracic surgery department was alerted. The patient was informed that a foreign body, in the form of a coin, was lodged in the right main bronchus as a result of his hasty inhalation. The decision was made to extract it in the operating room, using rigid bronchoscopy for greater safety due to the size of the foreign body and the danger of it becoming wedged in the trachea. The coin was removed using forceps. No complications occurred and the patient was discharged the next day after being reminded about the correct use of inhalers.

As in the previously published case, the patient had been carrying the inhaler without the mouthpiece cover in the same pocket in which he was also carrying coins. In our case, it was a 20 euro cent coin, and in the previous authors’ case, it was a LED light bulb.

We fully agree with Gómez Hernández et al. in that the correct handling of the inhaler includes use of the mouthpiece cover and checking for foreign bodies before inhaling, as stipulated in the product information for salbutamol delivered in pressurized cartridges.2 We would just like to add that after checking the device and before inhaling, the inhaler should be shaken in order to properly mix the contents, as recommended in the product information; this step would have prevented aspiration of the foreign body in both cases.

These accidents can be caused by errors in the routine use of inhalers, either due to haste when inhaling, careless techniques, or lack of training in the correct use of the device. It is very important to routinely review inhalation techniques with patients during check-ups in the clinic, to help avoid mistakes and accidents due to incorrect use, as described here.