Management of complicated airway foreign body aspiration using extracorporeal membrane oxygenation (ECMO)

Use of extracorporeal membrane oxygenation for bronchoscopic removal of a tracheal foreign body in a child

BACKGROUND

Bronchoscopic removal of a foreign body is a common emergency procedure in paediatric otolaryngology. It is potentially life-threatening, as complete airway obstruction caused by the foreign body can lead to hypoxic cardiac arrest during the manipulation of the object.

CASE REPORT

This paper presents a child who had aspirated a foreign body that could not be extracted conventionally via rigid bronchoscopy in the first instance. Subsequently, it was extracted at repeat bronchoscopy under controlled respiratory conditions maintained by an extracorporeal gas exchange circuit - extracorporeal membrane oxygenation, using a polypropylene hollow fibre oxygenator commonly employed in cardiac surgery (rather than a more expensive polymethyl pentene oxygenator commonly used in extracorporeal membrane oxygenation).

CONCLUSION

Extracorporeal membrane oxygenation use can be considered in exceptional cases of upper airway emergencies, even in resource-poor settings, and can avoid more hazardous thoracotomy and bronchotomy procedures.

Pediatric surgical interventions on ECMO

Extra Corporeal Membrane Oxygenation (ECMO) has historically been reserved for refractory pulmonary and cardiac support in children and adult. Operative intervention on ECMO was traditionally contraindicated due to hemorrhagic complications exacerbated by critical illness and anticoagulation needs. With advancements in ECMO circuitry and anticoagulation strategies operative procedures during ECMO have become feasible with minimal hemorrhagic risks. Here we review anticoagulation and operative intervention considerations in the pediatric population during ECMO cannulation. Pediatric surgical interventions currently described in the literature while on ECMO support include thoracotomy/thoracoscopy, tracheostomy, laparotomy, and injury related procedures i.e. wound debridement. A patient should not be precluded from a surgical intervention while on ECMO, if the surgery is indicated.

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.

Early extracorporeal membrane oxygenation as bridge for central airway obstruction patients caused by neck and chest tumors to emergency surgery

Central airway obstruction caused by neck and chest tumors is a very dangerous oncological emergency with high mortality. Unfortunately, there is few literature to discuss an effective way for this life-threating condition. Providing effective airway managements, adequate ventilation and emergency surgical interventions are very important. However, traditional airway managements and respiratory support has only limited effect. In our center, using extracorporeal membrane oxygenation (ECMO) as a novel approach to manage patient with central airway obstruction caused by neck and chest tumors has been adopted. We aimed to show the feasibility: using early ECMO to manage difficult airway, provide oxygenation and support surgical procedure for patients with critical airway stenosis caused by neck and chest tumors. We designed a single-center, small sample size retrospective study based on real-world. We identified 3 patients with central airway obstruction caused by neck and chest tumors. ECMO was used to ensure adequate ventilation to emergency surgery. Control group cannot be established. Because traditional manner very likely led to death of such patients. Details of clinical characteristics, ECMO, surgery and survival outcomes were recorded. Acute dyspnea and cyanosis were the most frequent symptoms. All patients (3/3) showed descending arterial partial pressure of oxygen (PaO₂). Computed tomography (CT) revealed severe central airway obstruction caused by neck and chest tumors in all cases (3/3). All patients (3/3) had definite difficult airway. All cases (3/3) received ECMO support and emergency surgical procedure. Venovenous ECMO was the common mode for all cases. 3 patients weaned off ECMO successfully without any ECMO-related complications. Mean duration of ECMO was 3 h (range: 1.5-4.5 h). Under ECMO support, difficult airway management and emergency surgical procedure were finished successfully for all cases (3/3). The mean ICU stay was 3.3 days (range: 1-7 days), and the mean general ward stay was 3.3 days (range: 2-4 days). Pathology demonstrated the tumor dignity for 3 patients including 2 malignant cases and 1 benign case. All patients (3/3) were discharged from hospital successfully. We showed that early ECMO initiation was a safe and feasible approach to manage difficult airway for patients with severe central airway obstruction caused by neck and chest tumors. Meanwhile, early ECMO initiation could ensure security for airway surgical procedure.

The intersection of bronchoscopy and extracorporeal membrane oxygenation

Central airway obstruction (CAO), which results from malignant, benign or iatrogenic etiologies, causes significant morbidity and mortality and can be seen in both the pediatric and adult patient population. Patients frequently present to the hospital with dyspnea, stridor, and respiratory distress, indicating impending respiratory failure. Heliox is used to help alleviate symptoms while procedural planning takes place. A multidisciplinary approach to airway management is often needed. Interventional pulmonologists treat CAO with rigid of flexible bronchoscopy in order to deliver therapeutic interventions under general anesthesia. In severe CAO where there is concern for total loss of the airway creating a life-threatening situation for the patient during procedural intervention, short term extracorporeal membrane oxygenation or ECMO has been successfully reported in the literature to provide ventilation and oxygenation support throughout the procedure. Venoarterial ECMO can be used to augment cardiac output in cases of central tumors with cardiac involvement. ECMO can also be used for the removal of tracheal stents when there is a concern that ventilation will be interrupted for a prolonged period of time. ECMO has also been reported as a salvage measure for patients with life threatening hemoptysis until more definitive interventions can be performed. Short term ECMO cannulation can be used with limited associated morbidity and a heparin-free approach can be pursued when there is a concern for bleeding. We will briefly review the anesthetic considerations in CAO as well as review cases of CAO where ECMO was employed to safely alleviate the airway compromise.

Cardiopulmonary bypass as a bridge for bronchial foreign body removal in a child with pulmonary artery sling: A case report

RATIONALE

Successful removal of an airway foreign body (FB) in some intractable cases can be very challenging, because of tracheal anomalies, unstable respiratory status of the patients, and the location of FB. The use of cardiopulmonary bypass (CPB) support for the treatment of a FB is extremely rare.

PATIENT CONCERNS

We present a case of a 39-month-old previously healthy girl who was admitted to our hospital for suspected FB aspiration (FBA). Initially, the attempt for removal of the FB by conventional bronchoscopy failed because of hypoxic intolerance.

DIAGNOSES

Bronchoscopy revealed tracheal anomalies and subsequent computed tomography angiography demonstrated the presence of a pulmonary artery sling (PAS), which confirmed the diagnosis of PAS accompanied with FBA.

INTERVENTIONS

With the assistance of CPB, multidisciplinary treatment involving the respiratory, cardiothoracic and anesthetic teams were involved and the bronchial FB was removed by flexible bronchoscopy successfully and then PAS was corrected by surgical intervention.

OUTCOMES

The patient remained asymptomatic, without shortness of breath or wheezing during the 15 months follow-up.

LESSONS

This case highlights that in a complicated case of FBA, bronchoscopy and computed tomography imaging are of great importance to achieve an accurate diagnosis, and a multidisciplinary treatment approach is essential for a satisfactory outcome. If the patient is unstable for bronchoscopy, CPB can be temporarily used in the stabilization of the patient to allow safe removal of the FB.

Extracorporeal Oxygenation Techniques in Adult Critical Airway Obstruction: A Review

Extracorporeal life support has been increasingly utilized in different clinical settings to manage either critical respiratory or heart failure. Complex airway surgery with significant or even total perioperative airway obstruction represents an indication for this technique to prevent/overcome a critical period of severe hypoxaemia, hypoventilation, and/or apnea. This review summarizes the current published scientific evidence on the utility of extracorporeal respiratory support in airway obstruction associated with hypoxaemia, describes the available methods, their clinical indications, and possible limitations. Extracorporeal membrane oxygenation using veno-arterial or veno-venous mode is most commonly employed in such scenarios caused by endoluminal, external, or combined obstruction of the trachea and main bronchi.

Treatment of tracheal stenosis with extracorporeal membrane oxygenation support in infants and newborns

Tracheal stenosis in children is a challenge for the healthcare team, since it is a rare disease. Patients usually have other clinical comorbidities, mainly previous cardiac surgical interventions. This retrospective single-center study included infants with tracheal stenosis (congenital or acquired) operated between 2016 and 2020 on venoarterial extracorporeal membrane oxygenation (VA ECMO). Five patients were operated and the median age of detection of the tracheal disease was 3.7 months, and the median age at the operation was 5 months. All patients had associated cardiac anomalies. Four patients had congenital tracheal stenosis; two with associated pig bronchus. One patient had acquired subglottic stenosis with concomitant stenosis at the carina. After the operation, the patients were referred to ICU on ECMO with an open chest. Minor ECMO-related complications occurred in two patients (hemothorax and wound infection). All patients required endoscopic evaluation during the postoperative care; median of 3.2 procedures. Two patients are currently in follow-up and three have died. Slide tracheoplasty with VA-ECMO can be successfully performed in infants with prior cardiac surgery. Nevertheless, a difficult postoperative course should be anticipated, with possible prolonged ECMO use, readmissions, and higher morbidity and mortality than in children with tracheal stenosis alone.

Extended Indications for Extracorporeal Membrane Oxygenation in the Operating Room

Background:

The use of extracorporeal life support (ECLS) for cardiorespiratory support is increasing. Traditional absolute contraindications are currently deemed relative contraindications. Extracorporeal life support is now considered for a wider cohort of patients on a case-by-case basis.

Method:

We performed a review of the literature and examined current Extracorporeal Life Support Organization guidelines that support the use of ECLS in the operating room, based on the underlying pathology and surgical procedure proposed. We discuss specific surgical populations and different modes of ECLS and cannulation strategies.

Results:

Based on the available literature, veno-venous extracorporeal membrane oxygenation (ECMO) can be used for the management of complex tracheobronchial and lung surgery, both in the elective and in the emergent setting. Elective veno-arterial (V-A) ECMO for cardiocirculatory support should be considered in high-risk patients undergoing ventricular tachycardia ablation. Extracorporeal life support should be considered as a potential life-saving intervention in almost all parturients with severe respiratory failure or refractory cardiogenic shock. V-A ECMO should be considered in unanticipated intraoperative cardiac arrest in patients without preexisting end-organ failure.

Conclusion:

As the number of indications for ECLS in the operating room is growing, anesthesiology and surgical staff should become familiar with the perioperative management of patients on ECLS.

The Use of Extracorporeal Membrane Oxygenation in Life-Threatening Foreign Body Aspiration: Case Series, Review of Extracorporeal Life Support Organization Registry Data, and Systematic Literature Review

BACKGROUND

Foreign body aspiration (FBA) is a common cause of morbidity and mortality in children < 3 years of age. Guidelines recommend performing a bronchoscopy in any suspected or confirmed FBA. Extracorporeal membrane oxygenation (ECMO) can be used as a rescue mode of support in children with life-threatening FBA for stabilization before, during, and after removal.

CASE REPORT

We present a series of children with life-threatening FBA who were placed on ECMO for stabilization before or after FB removal and a review of the literature and the Extracorporeal Life Support Organization database. Foreign bodies were removed without complications, and all patients survived ECMO support and were promptly discharged home. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: ECMO can be safely used in the stabilization of children with life-threatening FBA before, during, and after bronchoscopic removal. ECMO should be considered in the stabilization of children presenting with FBA to facilitate removal.

Intraoperative Venovenous Extracorporeal Membrane Oxygenation as Rescue for a Patient With an Inhalational Burn and Iatrogenic Upper Airway Injury: A Case Report

Venovenous extracorporeal membrane oxygenation (VV-ECMO) is a well-established alternative oxygenation method for critically ill patients. A 58-year-old male was transferred to our level 1 trauma and burn center after sustaining an inhalational injury from a carburetor explosion, with subsequent iatrogenic tracheal injury and emergent cricothyrotomy before arrival. During attempted surgical airway stabilization, our ability to ventilate and oxygenate was compromised. Intraoperative VV-ECMO enabled rescue from severe hypoxemia and subsequent recovery without lasting neurologic sequelae. This case highlights the utility of VV-ECMO for acute intraoperative rescue.

Favorable outcome with early initiation of VV-ECMO for unilateral lung disease in children

Unilateral lung diseases such as unilateral pneumonia, trauma or pulmonary hemorrhage can cause profound hypoxemic respiratory failure necessitating mechanical ventilation. These disorders are characterized by marked asymmetry in lung mechanics, with the affected lung having a lower compliance compared to the healthier lung, and management involves complex strategies such as simultaneous independent lung ventilation. However, such strategies can be challenging in pediatric populations due to technical limitations, and also lead to ventilator induced lung injury. We report two unique cases that support the use of venovenous extracorporeal membrane oxygenation as an alternative strategy for management of unilateral lung disease in children.

Principles and indications of extracorporeal life support in general thoracic surgery

The role of extracorporeal life support (ECLS) has expanded rapidly over the past 15 years to become an important tool in advanced general thoracic surgery practice. Intra-operative and in some cases continued post-operative ECLS is redefining the scope of complex surgical care. ECLS encompasses a spectrum of temporary mechanical support that may remove CO₂, oxygenate or provide hemodynamic support or a combination thereof. The most common modalities used in general thoracic surgery include extracorporeal membrane oxygenation (ECMO), interventional lung assist device (iLA^® Novalung^®, Heilbronn, Germany), and extracorporeal CO₂ removal (ECCO₂R). The ECMO and Novalung^® devices can be used in different modes for the short term or long-term support depending on the situation. In this review, the principles and current applications of ECLS in general thoracic surgery are presented.

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.

Regional dietary characteristics and bronchial foreign body: a repeated misdiagnosis caused by a red pepper

Bronchial foreign body is a common health problem worldwide, types of bronchial foreign bodies are variegated, depending on patient age and cultural background including religious beliefs as well as alimentary habits. However, misdiagnoses caused by regional dietary correlation factors were rarely concerned. In this case, a 52-year-old woman with aggravated cough and hemosputum took thoracic CT scan twice and flexible fiberoptic bronchoscopy 5 times, which all revealed the chronic pulmonary inflammation. Furthermore, the biopsies showed bronchial granulation nodule formation. With the highly suspicion of tumor, lung lobe resection was conducted. However, from the resected specimen, we belatedly found a red pepper inserted in the bronchus, without tumor cell in postoperative pathological analysis. We reviewed the case, analyzed the potential factors that may led to repeated misdiagnoses, and concluded that regional dietary characteristics and higher clinical suspicion should be seriously under consideration in the process of diagnosis.