Respiratory support with venovenous extracorporeal membrane oxygenation during stenting of tracheobronchomalacia

Extracorporeal membrane oxygenation for general thoracic surgery: case series and narrative review

Background and Objective

Extracorporeal membrane oxygenation (ECMO) has historically been utilized as a temporary life support option for patients with severe cardiac and pulmonary dysfunction. Recent advancements have enabled the safe application of ECMO in a wider variety of patients; we present a review of its use in patients undergoing general thoracic procedures supported by a case series at our institution.

Methods

We review current literature focusing on ECMO applications in thoracic surgery outside of the traditional use. Additionally, we offer three cases of ECMO utilization to illustrate success stories and key lessons learned regarding the use of ECMO in general thoracic surgery.

Key Content and Findings

Technologic advancements and enhanced safety profiles have enabled the safe application of ECMO in a wide array of patients far beyond the historic indications of cardiogenic shock and acute respiratory distress syndrome (ARDS). It is now feasible to consider ECMO for management of acute thoracic emergencies, as well as to better facilitate operative safety in complex general thoracic surgical procedures. Both venovenous and venoarterial ECMO can be utilized in carefully selected patients to provide cardiopulmonary support while enabling improved visualization and increased mobilization without concern for respiratory and/or cardiac compromise.

Conclusions

Enthusiasm for the use of ECMO has increased in recent years. What was once considered a salvage therapy in cases of life-threatening cardiopulmonary decompensation now plays an increasingly important role in the safe conduct of complex thoracic surgery procedures, provides much needed time for organ recovery, and offers acute resuscitation options. This shift broadens our ability to deliver life-saving care to patients that previously would have otherwise had limited treatment options.

Innovation in rigid bronchoscopy-past, present, and future

German laryngologist Gustav Killian performed the first "Direkte Bronchoskopie" using a rigid bronchoscope to extract a foreign airway body from the right main bronchus over a hundred years ago, transforming the practice of respiratory medicine. The procedure instantaneously became popular throughout the world. Chevalier Jackson Sr from the United States further advanced the instrument, technique, safety, and application. In the 1960s, Professors Harold H. Hopkins and N.S. Kapany introduced optical rods as well as fiberoptics that led Karl Storz to develop the cold light system improving endoluminal illumination, achievements that ushered in the modern era of flexible endoscopy. Several diagnostic and therapeutic procedures became possible such as transbronchial needle biopsy, transbronchial lung biopsy, airway electrosurgery, or cryotherapy. Dr. Jean-François Dumon from France advanced the use of Nd-YAG laser in the endobronchial tree and created the dedicated Dumon silicone stent introducing the whole new field of interventional pulmonology (IP). This major milestone revitalized interest in rigid bronchoscopy (RB). Now, advancements are being made in stenting, instrumentation, and education. RB robotic technology advancements are currently anticipated and can potentially revolutionize the practice of pulmonary medicine. In this review, we describe some of the most substantial advances related to RB from its beginning to the modern era.

Extracorporeal membrane oxygenation in critical airway interventional therapy: A review

Introduction

Extracorporeal membrane oxygenation (ECMO) is widely used during refractory cardiac or respiratory failure, and some case reports described ECMO utilization in critical airway interventional therapy.

Methods

Eligible reports about patients receiving airway interventional therapy under ECMO were retrieved from Web of Science, Embase, Medline, and Cochrane databases up to 1 August 2022.

Results

Forty-eight publications including 107 patients who underwent ECMO for critical airway problems met the inclusion criteria. The critical airway problem that was reported the most was tumor-associated airway obstruction (n = 66, 61.7%). The second most reported etiology was postoperative airway collapse or stenosis (n = 19, 17.8%). The main interventional therapies applied were airway stent placement or removal (n = 61, 57.0%), mass removal (n = 22, 20.6%), and endotracheal intubation (n = 12, 11.2%) by bronchoscopy. The median ECMO duration was 39.5 hours. Eleven patients had ECMO-associated complications, including seven cases of airway hemorrhage, one case of arteriovenous fistula, one case of vein rupture and hematoma, one case of foot ischemia, and one case of neuropraxia of the cannulation site. In total, 91.6% of the patients survived and were discharged from the hospital.

Conclusion

ECMO appears to be a viable form of life support for patients undergoing interventional therapy for critical airway problems.

Management of life-threatening malignant central airway obstruction: A novel approach of using extracorporeal membrane oxygenation with tumor debulking and stenting

Extracorporeal membrane oxygenation (ECMO) is an artificial lung or heart used to oxygenate and circulate blood. Veno-venous ECMO is most commonly used as an emergency therapy in patients with acute respiratory distress syndrome (ARDS), but it has the potential to be useful in other respiratory-related diseases. We report a case where ECMO successfully allowed for interventional pulmonary procedures in a patient with life-threatening tracheal obstruction secondary to lung cancer, requiring tumor debulking and silicone Y stent placement. The patient was a 44-year-old male who was admitted to the intensive care unit (ICU) for an advanced stage subcarinal tumor invading into the trachea and bilateral main stem bronchi. The tumor was unresectable, and the first attempt to debulk the tumor was terminated due to the risk of complete airway occlusion. With the help of ECMO, the second attempt at tumor debulking was successful, and a Y stent was placed. The patient regained ventilation in both lungs and was transferred out of the ICU on day 2 post-op. The pathology confirmed squamous cell carcinoma, programmed death-ligand 1 (PD-L1) 99%. The patient received immunotherapy after hospital discharge. ECMO has the potential to be useful for patients with severe tracheal obstructions and compromised respiratory systems. For patients with certain types of lung cancer, who are good candidates for novel immunotherapies and targeted therapies, it offers a potential bridging therapy for procedures that would otherwise be too dangerous and should be considered when traditional treatments for these patients fail.

Venovenous extracorporeal membrane oxygenation during high-risk airway interventions

OBJECTIVES

Practice patterns for the use of extracorporeal membrane oxygenation (ECMO) during high-risk airway interventions vary, and data are limited. We aim to characterize our recent experience using ECMO for procedural support during whole-lung lavage (WLL) and high-risk bronchoscopy for central airway obstruction (CAO).

METHODS

We performed a retrospective cohort study of adults who received ECMO during WLL and high-risk bronchoscopy from 1 July 2018 to 30 March 2020. Our primary end point was successful completion of the intervention. Secondary end points included ECMO-associated complications and hospital survival.

RESULTS

Eight patients received venovenous ECMO for respiratory support during 9 interventions; 3 WLLs for pulmonary alveolar proteinosis were performed in 2 patients, and 6 patients underwent 6 bronchoscopic interventions for CAO. We initiated ECMO prior to the intervention in 8 cases and during the intervention in 1 case for respiratory decompensation. All 9 interventions were successfully completed. Median ECMO duration was 17.8 h (interquartile range, 15.9-26.6) for the pulmonary alveolar proteinosis group and 1.9 h (interquartile range, 1.4-8.1) for the CAO group. There was 1 cannula-associated deep vein thrombosis; there were no other ECMO complications. Seven patients (87.5%) and 4 (50.0%) patients survived to discharge and 1 year postintervention, respectively.

CONCLUSIONS

Use of venovenous ECMO to facilitate high-risk airway interventions is safe and feasible. Planned preprocedural ECMO initiation may prevent avoidable respiratory emergencies and extend therapeutic airway interventions to patients otherwise considered too high risk to treat. Guidelines are needed to inform the utilization of ECMO during high-risk bronchoscopy and other airway interventions.

Elective extra corporeal membrane oxygenation for high-risk rigid bronchoscopy

The use of extracorporeal membrane oxygenation for high-risk rigid bronchoscopy has been reported in few urgent cases. We report our experience with this approach which was planned electively in five cases on 202 procedures (2.5%). It was proposed because of the potential inability to ventilate the lungs using conventional techniques due to extensive tracheobronchial lesions or the risk of major intraoperative bleeding related to disease characteristics. There were no intraoperative complications and postoperative course was favourable in all patients. With a maximum follow-up of 3 years and 7 months, all patients are alive with no tracheostomy despite major morbidities.

Clinical Comparison of Airway Stent Placement in Intervention Room and Operating Room

BACKGROUND

Airway stent placement is the effective regimen for central airway obstruction (CAO), while its application scenarios varied. This study aimed to make clinical comparison of airway stent placement in the intervention room and operating room.

METHODS

Patients underwent airway stent placement between 2014 and 2018 were included in this retrospective case-control study. Clinical performance of airway stent placement in intervention room and operating room were compared.

RESULTS

82 patients were included in this study, including 39 in the intervention room and 43 in the operating room. Patients treated in the intervention room had lower Charlson comorbidity index (CCI) (P=0.018) and received less Y-shaped stents (P<0.001). Better clinical response (P=0.026), more stents placed (P<0.001) and longer length of stent (P<0.001) were observed in operating room, while there was no significantly statistical difference of stent-related complications and post-stent survival rate between the two groups. Extracorporeal membrane oxygenation (ECMO) supported airway stent placement procedures were performed in the operating room, which provided definitive safety support for high-risk intervention.

CONCLUSIONS

Patients with CAO could benefit from the operating room scenario, and airway stent placement in the operating room is more suitable for patients with higher CCI scores and receiving more complicated procedures.

Extracorporeal Membrane Oxygenation During Adult Noncardiac Surgery and Perioperative Emergencies: A Narrative Review

Over the last decade, the use of extracorporeal membrane oxygenation (ECMO) has increased significantly. In some centers, ECMO has been deployed to manage perioperative emergencies and plays a role in facilitating high-risk thoracic, airway, and trauma surgery, which may not be feasible without ECMO support. General anesthesiologists who usually manage these cases may not be familiar with the initiation and management of patients on ECMO. This review discusses the use of ECMO in the operating room for thoracic, airway, and trauma surgery, as well as obstetric and perioperative emergencies.

Respiratory support with venovenous extracorporeal membrane oxygenation during stent placement for the palliation of critical airway obstruction: case series analysis

BACKGROUND

Venovenous extracorporeal membrane oxygenation (VV ECMO) is used to support gas transfer of patients suffering from respiratory failure during various procedures. The purpose of this study was to evaluate the technical feasibility and safety of fluoroscopic stent placement under respiratory support with VV ECMO in patients with critical airway obstructions.

METHODS

We reviewed the records of 17 patients (14 male and 3 female; mean age: 63 years; range, 30-82 years) who underwent self-expandable metallic stent (SEMS) placement under VV ECMO respiratory support for critical airway obstruction caused by malignant (n=16) or benign (n=1) etiology.

RESULTS

Fluoroscopic placement of SEMS was successful in all patients (100%) with no procedure-related complications. During a mean follow-up of 83 days (range, 10-367 days), 15 (88.2%) of 17 patients showed improvement of Hugh-Jones grades (from 4.7±0.4 to 3.1±0.9, P<0.001). Removal of the endotracheal tube was possible in 11 (84.6%) of 13 patients. Weaning off ECMO was successful in all patients. The ECMO-related and stent-related complication rates were 11.7% (n=2) and 29.4% (n=5), respectively, all successfully managed by additional interventions. Indications for VV ECMO included failure of mechanical ventilation in 13 (76.5%) patients, and orthopnea in 4 (23.5%) patients.

CONCLUSIONS

Fluoroscopic stent placement under VV ECMO respiratory support can be successfully performed in patients with critical airway obstruction, especially in cases of respiratory distress despite ventilation support and an inability to lie in a supine position. However, further studies will be needed to validate the standardized methods and specific indications.

Extracorporeal support in airway surgery

Extracorporeal life support (ECLS) is increasingly used for major airway surgery. It facilitates complex reconstructions and maintains gas exchange during endoscopic procedures in patients with critical airway obstruction. ECLS offers the advantage of an uncluttered surgical field and eliminates the need for crossing ventilation tubes, thus, making precise surgical dissection easier. ECLS is currently used for hemodynamic and respiratory support in lung transplantation as well as extended tumor resections with an acceptable risk profile. This work reviews the published experience of ECLS in airway surgery both in adults and in pediatric patients. It highlights currently available devices and their indications.

Extracorporeal Lung Support as a Bridge to Airway Stenting and Radiotherapy for Airway-Obstructing Pancoast Tumor

Venovenous (V-V) extracorporeal membrane oxygenation (ECMO) is used for respiratory failure that is suspected to be reversible (bridge to recovery), or as a bridge to lung transplantation. Patients with proximal airway obstruction due to endobronchial malignancy can develop acute respiratory failure, and may benefit from V-V ECMO as a bridge to airway intervention, further treatment, and eventual recovery. We describe a case of a superior sulcus tumor with tracheobronchial and superior vena cava invasion causing both respiratory failure and superior vena cava syndrome. This was treated successfully with V-V ECMO, bronchial stenting, and radiotherapy.