Use of venovenous extracorporeal membrane oxygenation in central airway obstruction to facilitate interventions leading to definitive airway security

The application of extracorporeal membrane oxygenation in emergent airway management - a single-center retrospective study

BACKGROUND

Emergent airway occurrences pose a significant threat to patient life. Extracorporeal membrane oxygenation (ECMO) has been proven to be an effective method for managing emergent airways.

METHODS

A retrospective analysis was conducted on all patients receiving ECMO as an adjunct for emergent airway management from January 2018 to December 2022 at the People's Hospital of Zhongshan City. We collected the basic information of the patients, their blood gas data before and after ECMO, the related parameters of ECMO, and the outcome and then analyzed and summarized these data.

RESULTS

Six patients, with an average age of 51.0(28-66) years, received veno-venous (VV)- ECMO as an adjunct due to emergent airway issues. The average ECMO support duration was 30.5(11-48) hours. All six patients were successfully weaned off ECMO support, with five (83.3%) being successfully discharged after a hospital stay of 15.5(7-55) days. All six patients underwent VV-ECMO through femoral-internal jugular vein cannulation. Among these, five patients, whose airway obstruction was due to hemorrhage, underwent a non-anticoagulant ECMO strategy with no recorded thrombotic events.

CONCLUSIONS

The rapid establishment of ECMO support is aided by the establishment of a standardized ECMO initiation protocol and the formation of a multidisciplinary rapid-response ECMO team, which is particularly crucial for emergent airway management. When airway obstruction results from hemorrhagic factors, the early adoption of a non-anticoagulant ECMO strategy can be considered when implementing VV-ECMO.

Left Main Bronchus Obstruction in a Patient with Small-cell Lung Cancer Successfully Treated with Venovenous Extracorporeal Membrane Oxygenation

Lung cancer can cause fatal central airway obstruction. Rapid airway clearance is necessary in some cases, but ventilator management may be insufficient to maintain oxygenation levels. Venovenous extracorporeal membrane oxygenation (VV-ECMO) may be an effective rescue therapy for respiratory failure, but its efficacy in treating tumor-related airway obstruction is unknown. We herein report a case of central airway obstruction and severe acute respiratory failure due to small-cell lung cancer successfully treated with VV-ECMO, bronchoscopic airway intervention, and chemotherapy. VV-ECMO can be an effective option for the treatment of central airway obstruction with acute respiratory failure due to lung cancer.

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.

Successful extracorporeal membrane oxygenation in a patient with central airway obstruction due to an endotracheal mass

Extracorporeal membrane oxygenation (ECMO) assists blood circulation and gas exchange via a heart–lung machine. ECMO is used mainly in intensive care units as bridging therapy until heart and respiratory failure can be addressed or until transplantation can be performed. ECMO is sometimes used during surgery under general anaesthesia, depending on the patient’s underlying diseases and the nature of the operation. If the oxygen supply and carbon dioxide removal capacity are limited, venovenous (VV)-ECMO can be helpful. Here, we describe the use of VV-ECMO for surgical resection of an endotracheal mass through rigid bronchoscopy in a patient who developed decompensating dyspnoea due to central airway obstruction (CAO).

Intervention to severe lower trachea obstruction supported by extracorporeal membrane oxygenation in a human immunodeficiency virus patient: A case report and literature review

Here we reported a case, male, 33 years old, diagnosed with human immunodeficiency virus (HIV) infection 5 months ago, but he didn’t take antiretroviral drugs regularly. He was admitted to intensive care unit emergently due to hypoxemia, hypercapnia, and hypotension. CT showed severe lower trachea obstruction caused by soft tissue. After rapid bedside assessment, the patient was considered to need endotracheal operation, but he couldn‘t tolerate intubation and mechanical ventilation. Extracorporeal membrane oxygenation (ECMO) was used. Hemodynamics improved significantly along with rehydration and low-dose vasoactive drugs. Subsequently, the patient underwent rigid bronchoscopy, airway tumor resection and Y-type silicone stent implantation. Postoperatively protective endotracheal intubation and mechanical ventilation was followed. ECMO was weaned off after the operation, and endotracheal cannula was removed 6 h later. The pathological examination of excisional tissue showed lung squamous cell carcinoma. Finally, the patient was discharged safely and went to local hospital for further treatment. From this case, we conclude that ECMO could play a key role for those who need endotracheal surgery while cannot endure conventional intubation and mechanical ventilation.

Anesthetic Management of Upper Tracheal Cancer Resection and Reconstruction: A Case Report

Tracheal tumor resection and reconstruction is the primary treatment for tracheal tumors. The trachea is the surgical site as well as an important channel to ensure ventilation and maintain oxygenation during surgery. In this report, we describe the successful management of an upper tracheal tumor in a 50-year-old patient. The tumor was situated approximately 2–3 cm below the vocal cords, occluding the tracheal lumen by 80%. Conventional orotracheal intubation was expected to be impossible, and the patient was managed with an I-Gel supraglottic airway for mechanical ventilation with the assistance of venovenous extracorporeal membrane oxygenation (VV ECMO). After securing tracheal intubation via the tracheostomy site, VV ECMO was weaned off, and mechanical ventilation was changed to tracheal intubation. Eventually, tracheal tumor resection and reconstruction were successfully performed under general anesthesia. No specific events occurred during anesthetic management. Careful preoperative planning and good teamwork made the procedure possible without complications.

Malignant Central Airway Obstruction: What's New?

Malignant central airway obstruction (MCAO) is a debilitating and life-limiting complication that occurs in an unfortunately large number of individuals with advanced intrathoracic cancer. Although the management of MCAO is multimodal and interdisciplinary, the task of providing patients with prompt palliation falls increasingly on the shoulders of interventional pulmonologists. While a variety of tools and techniques are available for the management of malignant obstructive lesions, advancements and evolution in this therapeutic venue have been somewhat sluggish and limited when compared with other branches of interventional pulmonary medicine (e.g., the early diagnosis of peripheral lung nodules). Indeed, one pragmatic, albeit somewhat uncharitable, reading of this article's title might suggest a wry smile and shug of the shoulders as to imply that relatively little has changed in recent years. That said, the spectrum of interventions for MCAO continues to expand, even if at a less impressive clip. Herein, we present on MCAO and its endoscopic and nonendoscopic management-that which is old, that which is new, and that which is still on the horizon.

Tracheobronchoplasty and Diaphragmatic Plication under VV ECMO for Combined ECAC and Diaphragmatic Paralysis

The coexistence of expiratory central airway collapse and diaphragmatic paralysis presents a diagnostic and treatment challenge. Both entities are underrecognized causes of dyspnea, cough, sputum production, and orthopnea. Optimal treatment must be individualized and is best achieved by a multidisciplinary team. We present a case of a patient with profound functional impairment from dyspnea and hypoxemia due to expiratory central airway collapse, complicated by bronchiectasis from recurrent respiratory infections, and diaphragmatic paralysis.

Awake nasotracheal intubation under bronchoscopic guidance and anesthetic management in a patient undergoing excision of an endotracheal mass: A case report

RATIONALE

The main challenge facing anesthesiologists during endotracheal mass resection is securing effective airway management during surgery. It is important to select an airway intubation and airway maintenance method according to the patient's condition and the characteristics of the mass.

PATIENT CONCERNS

A 74-year-old woman with aggravated dyspnea for 1 year was scheduled to undergo endotracheal mass excision under general anesthesia.

DIAGNOSIS

The mass was 4 × 3 × 3 cm ovoid-shaped, and located 4 cm above the carina, occupying 41% of the tracheal lumen in a preoperative chest computed tomography and bronchoscopy.

INTERVENTIONS

After preparing extracorporeal membrane oxygenation in case of the inability to ventilate and intubate, we attempted awake bronchoscopy-guided nasotracheal intubation using a reinforced endotracheal tube with an inner diameter of 5.5 mm and outer diameter of 7.8 mm after a translaryngeal block. The tube was passed around the mass without resistance and placed right above the carina. With the tube pulled back above the mass, another tube was introduced from the opened trachea below the mass to the right main bronchus. Following the resection of the tracheal portion containing the mass, the posterior wall of the remaining trachea was reconstructed. The tube placed in the right main bronchus was removed and the tube in the upper trachea was introduced right above the carina. The patient's head was kept flexed once the anastomosis of the trachea was completed, and the surgery ended uneventfully.

OUTCOMES

The mass was confirmed as schwannoma by histopathological finding. The patient was discharged from the hospital on the 6th postoperative day without complication.

LESSONS

Awake bronchoscopy-guided intubation is a safe airway management method in patients with an endotracheal mass. Close cooperation between anesthesiologist and surgeon, and preparation for airway management before surgery is essential. It is necessary to establish alternative plans that can be implemented in the case that intubation and ventilation are not possible.

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.

Defining and understanding the "extra-corporeal membrane oxygenation gap" in the veno-venous configuration: Timing and causes of death

In‐hospital mortality of adult veno‐venous extracorporeal membrane oxygenation (V‐V ECMO) patients remains invariably high. However, little is known regarding timing and causes of in‐hospital death, either on‐ECMO or after weaning. The current review aims to investigate the timing and causes of death of adult patients during hospital admittance for V‐V ECMO, and to define the V‐V ECMO gap, which is represented by the patients that are successfully weaned of ECMO but still die during hospital stay. A systematic search was performed using electronic MEDLINE and EMBASE databases through PubMed. Studies reporting on adult V‐V ECMO patients from January 2006 to December 2020 were screened. Studies that did not report on at least on‐ECMO mortality and discharge rate were excluded from analysis as they could not provide the required information regarding the proposed V‐V ECMO‐gap. Mortality rates on‐ECMO and after weaning, as well as weaning and discharge rates, were analyzed as primary outcomes. Secondary outcomes were the causes of death and complications. Initially, 35 studies were finally included in this review. Merely 24 of these studies (comprising 975 patients) reported on prespecified V‐V ECMO outcomes (on‐ECMO mortality and discharge rate). Mortality on V‐V ECMO support was 27.8% (95% confidence interval (CI) 22.5%‐33.2%), whereas mortality after successful weaning was 12.7% (95% CI 8.8%‐16.6%, defining the V‐V ECMO gap). 72.2% of patients (95% CI 66.8%‐77.5%) were weaned successfully from support and 56.8% (95% CI 49.9%‐63.8%) of patients were discharged from hospital. The most common causes of death on ECMO were multiple organ failure, bleeding, and sepsis. Most common causes of death after weaning were multiorgan failure and sepsis. Although the majority of patients are weaned successfully from V‐V ECMO support, a significant proportion of subjects still die during hospital stay, defining the V‐V ECMO gap. Overall, timing and causes of death are poorly reported in current literature. Future studies on V‐V ECMO should describe morbidity and mortality outcomes in more detail in relation to the timing of the events, to improve patient management, due to enhanced understanding of the clinical course.

Pre-emptive veno-venous ECMO in advanced tracheal malignancy prior to tracheal stenting

Extracorporeal membrane oxygenation (ECMO) is helpful in providing ventilatory support when other conventional methods of ventilation fail. We report a case of successful management of advanced tracheal malignancy with impeding airway obstruction where veno-venous ECMO (VV-ECMO) was instituted prior to performing critical endotracheal procedure. After securing the VV-ECMO through right jugular vein and left femoral vein under local anaesthesia, the tracheal stent placement was conducted under flexible bronchoscope and fluoroscope control. Oxygenation and carbon dioxide levels were maintained by the ECMO. VV-ECMO is a useful adjunct in the management of subglottic difficult airway obstruction due to complex tracheal pathology where conventional ventilation may not be possible or adequate.

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.

Venovenous Extracorporeal Membrane Oxygenation to Facilitate Removal of Endobronchial Tumors

Short-term extracorporeal membrane oxygenation is a useful adjunct to thoracic procedures. We report the cases of 2 middle-aged men who were supported with venovenous extracorporeal membrane oxygenation to facilitate tumor debulking and recanalization of the carina and mainstem bronchi. Neither patient had major complications or adverse events. These cases suggest that short-term extracorporeal membrane oxygenation is safe in patients undergoing complex resection or debulking of endobronchial lesions.

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.

Endobronchial Tumor With Ball Valve Mechanism: A Real Airway Emergency

Central airway obstruction due to the tumor can present as near-complete tracheal obstruction. The results can be life-threatening requiring emergent intervention. Rigid bronchoscopy has been preferred for the management of central airway obstruction. However, there are relatively few studies comparing rigid bronchoscopy and flexible bronchoscopy in treating these cases. We describe a 61-year-old woman with a lower trachea tumor with ball valve occlusion of the left mainstem bronchus and complete occlusion of the right mainstem bronchus successfully managed with flexible bronchoscopy and iCAST^® stent. We herein highlight the role of therapeutic flexible bronchoscopy with airway stenting as an efficacious treatment modality for the management of malignant central airway obstruction. 

Utility of extracorporeal membrane oxygenation (ECMO) in the management of traumatic tracheobronchial injuries: case series

Tracheobronchial injury is a rare, but potentially life-threatening condition, and in most cases requires urgent treatment to restore normal respiratory physiology. Over the past decades, extracorporeal membrane oxygenation (ECMO) has evolved as an important adjunct in airway surgery. We presented three cases of traumatic tracheobronchial injury managed with ECMO support at a level-1 trauma center and emphasized the benefits of anticipation and early institution of ECMO support perioperatively, in these high-risk cases. The management of traumatic tracheobronchial injuries requires early measures to guarantee adequate ventilation. Anticipation and early institution of ECMO in these patients may support respiratory physiology, facilitate repair and improve survival. The time factor and multidisciplinary communication and plan prior to intervention should be considered. ECMO support, whenever available, plays important role in the management of complicated tracheobronchial surgical procedure and thereby reduces risk of mortality.

Bronchotracheal Stenting Management by Rigid Bronchoscopy under Extracorporeal Membrane Oxygenation (ECMO) Support: 10 Years of Experience in a Tertiary Center

Purpose

Airway stenting offers good palliation and improves the quality of life in patients with inoperable bronchotracheal stenosis. However, in some cases, the management of stenting can be life-threatening. Hence, a strategy for maintaining oxygenation and hemodynamic stability should be anticipated to avoid critical situations. Herein, we report the use of extracorporeal membrane oxygenation (ECMO) in bronchotracheal stenting management to secure oxygenation and facilitate interventions.

Methods

We retrospectively reviewed all patients who underwent rigid bronchoscopy under ECMO support for the management of bronchotracheal stenting at CHU UCL Namur hospital (Belgium), between January 2009 and December 2019.

Results

We included 14 bronchoscopy cases performed on 11 patients (3 patients underwent 2 bronchoscopies) in this study; 12 were performed on males and 2 on females. The median age was 54 years. There were 11 benign and 3 malignant etiologies for the central airway obstruction/stenosis. Eight cases were supported by venovenous ECMO and six by venoarterial ECMO. The median ECMO time was 267 minutes. The weaning of ECMO support was successful in all cases. In most cases, the procedures were performed effectively and safely. Only two local complications caused by the cannulation of ECMO were reported, and anticoagulation was adapted to avoid bleeding at the operating site and clot formation in the system.

Conclusion

Elective ECMO support was helpful and safe for the high-risk management of bronchotracheal stenting with rigid bronchoscopy and was not associated with any additional significant complications.

Multivariate Analysis of Risk Factor for Mortality and Feasibility of Extracorporeal Membrane Oxygenation in High-Risk Thoracic Surgery

Background: Extracorporeal membrane oxygenation (ECMO) as intraoperative cardiorespiratory support during lung transplantation is well known, but use for other types of surgery are limited. To assess risk factor for mortality after high-risk thoracic surgery and feasibility of ECMO, we reviewed.

Methods: This study was an observational study. Between January 2011 and October 2018, 63 patients underwent thoracic surgery with ECMO for severe airway disease, pulmonary insufficiency requiring lung surgery, and other conditions.

Results: In all, 46 patients remained alive at 30 days after surgery. The mean patient age was 50.38 ± 16.16 years. ECMO was most commonly used to prevent a lethal event (34 [73.9%]) in the Survival (S) group and rescue intervention (13 [76.5%]) in the Non-survival (N) group. In all, 11 patients experienced arrest during surgery (S vs N: 2 [4.3%] vs 9 [52.9%], p ≤0.001). The multivariate analysis revealed that arrest during surgery (odds ratio [OR], 24.44; 95% confidence interval [CI], 1.82–327.60; p = 0.016) and age (OR, 7.47; 95% CI, 1.17–47.85; p = 0.034) were independently associated with mortality.

Conclusions: ECMO provides a safe environment during thoracic surgery, and its complication rate is acceptable except for extracorporeal cardiopulmonary resuscitation (ECPR).

[Extracorporeal Lung Support in Thoracic Surgery: Basics and Pathophysiology]

Extracorporeal lung support (ECLS) is of increasing importance in general thoracic surgery. Different modes of ECLS may be applied in several situations throughout the perioperative phase and are adapted to the individual patient's needs and the planned surgical procedures. ECLS is not a static procedure and should be always evaluated according to the present condition of the patient. Therefore, it is essential to understand the pathophysiology of the disease and the different ECLS modes, as well as the different cannulation options, in order to be able to use the different escalation and de-escalation techniques in accordance with the clinical situation.

Use of venovenous extracorporeal membrane oxygenation for resection of a large paratracheal mass causing critical tracheal stenosis: A case report

Critical airway stenosis is challenging for surgeons and anesthesiologists to secure a reliable airway for ventilation. The use of venovenous (VV)-extracorporeal membrane oxygenation (ECMO) has been described as a strategy to provide adequate gas exchange in such instances. We present a case of a young female with a complex paratracheal mass significantly compressing the trachea; a planned intraoperative VV-ECMO was instituted to allow safe orotracheal intubation of a double-lumen endotracheal tube for lung isolation and tumor resection.

Continuous infusion chemotherapy, radiotherapy, and FDG-PET are feasible during extracorporeal membrane oxygenation

Extracorporeal membrane oxygenation (ECMO) may be used in extreme circumstances for patients with a mediastinal mass and respiratory failure. We report on a young man with primary mediastinal B-cell lymphoma invading into the trachea, requiring a 40-day ECMO run who underwent fluorodeoxyglucose positron emission tomography (FDG-PET) imaging and treatment with concurrent mediastinal irradiation and continuous infusion chemotherapy while on this life-saving technology. This case illustrates that oncology patients may be managed by multidisciplinary teams for extended periods in extraordinary circumstances using multimodality therapies. Additionally, to our knowledge this is the first case to demonstrate the feasibility of FDG-PET imaging while on ECMO.

Successful use of extracorporeal membrane oxygenation for airway-obstructing lung adenocarcinoma

Endobronchial‐invasive lung cancers are generally diagnosed at advanced stages and may require emergency treatment for airway obstruction. Stent implantation is a common intervention for such obstructed airways but certain subsets of patients cannot receive adequate treatment without respiratory support. Veno‐venous extracorporeal membrane oxygenation (ECMO) is a salvage therapy for respiratory failure but its usefulness in managing patients with advanced lung cancer remains unclear given the poor prognosis. In recent years, molecular targeted agents for patients with driver mutations offer rapid responses and may be administered even while under critical care. In this report, we describe the case of 39‐year‐old female who presented to our emergency department with severe respiratory distress. A computed tomography scan revealed a large mediastinal tumor invading the tracheal carina causing severe stenosis of the left main bronchus and right main pulmonary artery. ECMO support was required as the respiratory condition remained unstable despite high pressure ventilation. Under ECMO support, the patient underwent bronchial stent implantation and was successfully weaned off ECMO. The tumor was histologically diagnosed as pulmonary adenocarcinoma with anaplastic lymphoma kinase gene rearrangement. Treatment with a tyrosine kinase inhibitor, alectinib, induced a marked tumor reduction within a short period. The patient recovered well and is now in remission one year later. This case indicates that intensive respiratory support with ECMO may become a bridge through the critical period for selected patients with respiratory failure secondary to advanced lung cancer.

Key points

Significant findings of this study

ECMO was important to maintain oxygenation during airway intervention for acute respiratory failure due to critical lung adenocarcinoma with ALK gene rearrangement.

What this study adds

With the development of targeted therapies and the improvement in therapeutic bronchoscopy, intensive respiratory support with ECMO may be helpful especially in selected lung cancer patients with oncogenic driver mutations.

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.

Case Report of Acute Airway Obstruction Caused by Transglottic Squamous Carcinoma (Stage IV) During the Coronavirus Pandemic Cured by ECMO-Assisted Tracheostomy

Acute airway obstruction caused by invasive laryngeal cancer can make surgeons reluctant to perform a high-risk tracheostomy, which is life-saving for such patients. In the setting of the current COVID19 pandemic, we present a case of severe transglottic stenosis due to stage IV laryngeal carcinoma, in which gaseous exchange was facilitated by venovenous (VV) extracorporeal membrane oxygenation prior to emergent tracheostomy. The VV technique can ensure adequate oxygenation and CO₂ removal. Venovenous extracorporeal membrane oxygenation provided sufficient time for surgical planning and preparation. It reduced the formation of aerosol, lowered the risk associated with life-saving tracheostomy, and protected the patient from ischemia.

Preemptive veno-venous ECMO support in a patient with anticipated difficult airway: A case report

This report presents a case of endotracheal metastasis in which elective veno-venous extracorporeal membrane oxygenation (VV ECMO) was used to undergo tracheal laser-surgery prior to establishment of a definitive airway. Specifically, we describe the respiratory and airway management in an adult patient from the preclinical phase throughout elective preoperative ECMO implantation to postoperative ECMO weaning and decannulation in the Intensive Care Unit. This case report lends further supports to the idea that the extracorporeal membrane oxygenation could be electively used to provide safe environment for surgery in situations where the standard maneuvers of sustaining adequate gas exchange are anticipated to fail.

Tracheal Reconstruction Surgery Supported by Extracorporeal Membrane Oxygenation for Patients with Traumatic Post-Tracheotomy Tracheal Stenosis

PURPOSES

Patients who require surgeries for traumatic post-tracheotomy tracheal stenosis (PTTS) often cannot be supported using conventional airway management approaches. This study documents the use of extracorporeal membrane oxygenation (ECMO) in patients with PTTS.

METHODS

Patient characteristics, procedure, and outcome of patients who required tracheal reconstruction surgery for PTTS supported by ECMO were retrieved and analyzed.

RESULTS

Four patients (mean age 28 years; range 17-48 years) with traumatic PTTS underwent tracheal reconstruction surgery supported by ECMO. The mean time from removal of tracheotomy tube to admission was 3.2 months (range: 1-9 months). The mean diameter of the stenotic segment was 5 mm (range: 4-6 mm). One patient underwent tracheoplasty and semi-tracheostomy with venoarterial ECMO urgently. Three patients underwent tracheal resection and end-to-end anastomosis (TRE) with venovenous ECMO empirically. Intervention success was achieved in 100% (4/4) of patients. The mean duration of ECMO was 35.3 hours (range: 16-53 hours). The overall survival rate was 100% (4/4) within a mean follow-up of 26 months (range: 7-57 months).

CONCLUSIONS

ECMO is a safe and feasible method to support oxygenation for patients with critical traumatic PTTS during tracheal reconstruction surgery.

Usefulness of extracorporeal membrane oxygenation in status asthmaticus with severe tracheal stenosis

Extracorporeal membrane oxygenation, traditionally used to treat refractory hypoxemic respiratory failure due to acute respiratory distress syndrome, is being used to treat other etiologies of severe respiratory failure refractory to conventional mechanical ventilation. We present a 30-year-old woman with concomitant life-threatening airway obstruction due to severe tracheal stenosis and status asthmaticus treated effectively with veno-venous extracorporeal membrane oxygenation.

Pre-Intubation Veno-Venous Extracorporeal Membrane Oxygenation in Patients at Risk for Respiratory Decompensation

Veno-venous extracorporeal membrane oxygenation (VV-ECMO) has emerged as a potential life-saving treatment for patients with acute respiratory failure. Given the accumulating literature supporting the use of VV-ECMO without therapeutic levels of anticoagulation, it might be feasible to use it for planned intubation before surgical procedures. Here, we report consecutive series of patients who underwent planned initiation of VV-ECMO, without anticoagulation, before induction of general anesthesia for anticipated difficult airways or respiratory decompensation. We describe the approach to safely initiate VV-ECMO in an awake patient. We retrospectively identified patients in a prospectively maintained database who underwent planned initiation of VV-ECMO before intubation. Standard statistical methods were used to determine post-procedure outcomes. Patients included were three men and one woman, with a mean age of 34.3 ± 10.4 years. Indications included mediastinal lymphoma, foreign body obstruction, hemoptysis, and tracheo-esophageal fistula. VV-ECMO was initiated electively for all patients, and no anticoagulation was used. The median duration of VV-ECMO support was 2.5 days (1-11 days), the median length of ventilator dependence and intensive care unit stay was 1 day (1-23 days) and 5 days (4-31 days), respectively. The median length of stay was 18.5 days (8-39 days). There were no thrombotic complications and no mortality at 30 days. Initiation of awake VV-ECMO is feasible and is safe before intubation and induction of anesthesia in patients at high risk for respiratory decompensation.

Bronchoscopy-guided intervention therapy with extracorporeal membrane oxygenation support for advanced cancer metastasis to the central airway: A case report

INTRODUCTION

Dyspnea due to tracheal invasion by malignant tumors is a common oncological emergency that is difficult to manage, and a common cause of death among patients with advanced cancer. Bronchoscopy-guided intervention therapy under conventional ventilation is very risky for patients with severe central airway stenosis. Extracorporeal membrane oxygenation (ECMO) provides strong cardiopulmonary support, but is rarely used in bronchoscopy-guided interventional therapy.

PATIENT CONCERNS

The patient had advanced esophageal cancer with metastases to the trachea and left and right main bronchi. Despite several sessions of radiotherapy, chemotherapy, and bronchoscopy-guided intervention therapy, the tumor in the airway became enlarged, the lumen was severely narrow, and the patient experienced respiratory distress.

DIAGNOSIS

A thoracic computed tomography scan performed at our hospital revealed invasion of the trachea and opening of the left and right main bronchi by the esophageal cancer, blockage of the stent by the tumor, and severe luminal narrowing. An emergency bronchoscopy showed slit-like stenosis of the middle and lower part of the trachea and the left and right main bronchi, and the tumor was highly vascular.

INTERVENTIONS

To reduce the risk of major airway bleeding and asphyxia during bronchoscopy under conventional ventilation, we finally performed argon plasma coagulation with a high frequency electric knife and cryotherapy with ECMO support.

OUTCOMES

We successfully cleared the tumor tissue in the airway under ECMO support. The trachea and left and right main bronchi recovered smoothly, and the patient was soon discharged.

CONCLUSION

ECMO can meet the oxygenation needs during bronchoscopy-guided intervention therapy. For patients with severe central airway obstruction due to malignant tumors, ECMO should be considered if conventional respiratory support cannot guarantee the safety of surgery.

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.

[Use of extracorporeal membrane oxygenation for pulmonary haemorrhage after pulmonary endarterectomy]

Pulmonary haemorrhage is one of the most severe complications of pulmonary endarterectomy. To the most effective methods of combating this potentially fatal complication belongs extracorporeal membrane oxygenation (ECMO). In this article we describe a clinical case report regarding intraoperative use of central veno-arterial ECMO for pulmonary haemorrhage following thromboendarterectomy from the pulmonary arteries. According to the data of some authors, long-term ECMO support (for more than 4 days) may lead to such severe consequences as rethrombosis of pulmonary arteries and impairment of cerebral circulation. In our case we managed to avoid such complications, taking into consideration that the duration of ECMO amounted to 21 days. Resulting from the carried out comprehensive therapeutic measures by the time of discharge from hospital, a significant decrease in pulmonary artery pressure was achieved, with events of residual pulmonary hypertension.

Central Airway Obstruction due to Mediastinal Malignant Lymphoma Requiring Venovenous-Extracorporeal Membrane Oxygenation

Extracorporeal membrane oxygenation (ECMO) therapy might be controversial when patients with advanced malignant disease develop heart or lung failure refractory to conventional management. Especially as for the hematological malignancy patients, the induction of ECMO therapy must be considered carefully, since it is often associated with bleeding complications or infectious diseases. Here, we report a case of life-threatening airway obstruction requiring ECMO. The trachea of the patient was narrowed by an anterior mediastinal tumor too highly to ventilate both lungs, so she had to be connected to venovenous-ECMO (VV-ECMO) before pathological examination and radical treatment were planned. During the intensive care with ECMO, she was diagnosed with malignant lymphoma and the chemotherapy was started. The chemotherapy brought such an immediate result that the trachea regained its patency and ECMO was disconnected 9 days after the initiation of the chemotherapy. Then, the patient was able to leave the intensive care unit with no sequelae. Central airway obstruction is a life-threatening situation, in which prompt decisions are essential. On the other hand, if the airway is impaired by hematological malignancy, it might be generally challenging to consider ECMO as a bridge until the chemotherapy takes an effect. The prognosis of hematological malignancy differs according to its subtype or stage, so it may be reasonable to take ECMO therapy into consideration for some population.

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.

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.

New trends in interventional pulmonology

PURPOSE OF REVIEW

As the field of interventional pulmonology continues to expand and develop at a rapid pace, anesthesiologists are increasingly called upon to provide well tolerated anesthetic care during these procedures. These patients may not be candidates for surgical treatment and often have multiple comorbidities. It is important for anesthesiologists to familiarize themselves with these procedures and their associated risks and complications.

RECENT FINDINGS

The scope of the interventional pulmonologist's practice is varied and includes both diagnostic and therapeutic procedures. Bronchial thermoplasty is now offered as endoscopic treatment of severe asthma. Endobronchial lung volume reduction procedures are currently undergoing clinical trials and may become more commonplace. Interventional pulmonologists are performing medical thoracoscopy for the treatment and diagnosis of pleural disorders. Interventional radiologists are performing complex pulmonary procedures, often requiring anesthesia.

SUMMARY

The review summarizes the procedures now commonly performed by interventional pulmonologists and interventional radiologists. It discusses the anesthetic considerations for and common complications of these procedures to prepare anesthesiologists to safely care for these patients. Investigational techniques are also described.

Extracorporeal lung support

PURPOSE OF REVIEW

The applications for extracorporeal membrane oxygenation for lung support are constantly evolving. This review highlights fundamental concepts in extracorporeal lung support and describes directions for future research.

RECENT FINDINGS

Since the 1950s, extracorporeal lung support has experienced continuous advancements in circuit design and safety in acute respiratory distress syndrome, chronic obstructive pulmonary disease exacerbations, as a bridge to transplantation, intraoperative cardiopulmonary support, and for transportation to referral centers. Patients on extracorporeal membrane oxygenation are now capable of being awake, extubated, and ambulatory for accelerated recovery or optimization for transplantation.

SUMMARY

Extracorporeal lung support is a safe and an easily implemented intervention for refractory respiratory failure. Recent advances have extended its use beyond acute illnesses and the developments for chronic support will facilitate the development of durable devices and possible artificial lung development.