Elective extra corporeal membrane oxygenation for high-risk rigid bronchoscopy

ECMO support for endoscopic resection of postpneumonectomy critical central airway obstruction

A 73-year-old woman was admitted to our hospital with severe respiratory distress due to postpneumonectomy neoplastic central airway obstruction. An emergency recanalization with rigid bronchoscopy (RB) was planned. Controlled and jet ventilation are routinely used to assure ventilation during RB, but the risk of inadequate oxygenation and removal of carbon dioxide was prohibitively high in this case due to the presence of a single lung. The use of venovenous extracorporeal membrane oxygenation was decided by multidisciplinary team to support ventilation during RB. Complete airway recanalization was successfully achieved without any complications. The patient was discharged 2 days later. Pathology revealed metastatic adenocarcinoma, and the patient was reviewed for oncologic treatment.

[Tracheobronchial involvement in relapsing polychondritis and differential diagnoses]

Relapsing polychondritis is a systemic auto-immune disease that mainly affects cartilage structures, progressing through inflammatory flare-ups between phases of remission and ultimately leading to deformation of the cartilages involved. In addition to characteristic damage of auricular or nasal cartilage, tracheobronchial and cardiac involvement are particularly severe, and can seriously alter the prognosis. Tracheobronchial lesions are assessed by means of a multimodal approach, including dynamic thoracic imaging, measurement of pulmonary function (with recent emphasis on pulse oscillometry), and mapping of tracheal lesions through flexible bronchoscopy. Diagnosis can be difficult in the absence of specific diagnostic tools, especially as there may exist a large number of differential diagnoses, particularly as regards inflammatory diseases. The prognosis has improved, due largely to upgraded interventional bronchoscopy techniques and the development of immunosuppressant drugs and targeted therapies, offering patients a number of treatment options.

Case Report: Laryngotracheal Post-Intubation/Tracheostomy Stenosis in COVID-19 Patients

Introduction

The novel Coronavirus disease 2019 (COVID-19), which is caused by severe acute respiratory syndrome coronavirus 2 (SARSCoV-2), has spread rapidly to become a major global public health emergency since March 2020. Laryngotracheal stenosis (LTS) has been observed more frequently since the onset of the COVID-19 pandemic.

Methods

All patients referred to our 24/7 Airway Diseases Center for laryngotracheal post-intubation/tracheostomy stenosis from May 2020 to May 2021were evaluated retrospectively. Patient data on comorbidities, diagnosis, type of procedures, lengths of ICU stay and invasive mechanical ventilation, medical treatment, and the severity of illness were recorded.

Results

This case series included nine patients (five women and four men), with a mean age of 52.9 years, most with a BMI >30, all with a severe illness revealed by the Simplified Acute Physiology Score (SAPS) II >31. From May 2020 to May 2021, 21 procedures were performed on seven patients, consisting of bronchoscopic rigid interventions, T-tube Montgomery tracheostomy, and one cricotracheal resection with end-to-end anastomosis. Histologic examination of tracheal biopsies showed an inflammatory state of the airway mucosa. Two patients only had medical therapy.

Discussion and Conclusions

Pneumonia caused by SARSCoV-2 can lead to severe acute respiratory distress syndrome (ARDS) requiring invasive mechanical ventilation. The time of intubation, the drugs used, the prone position, comorbidities (diabetes, obesity), and the inflammatory state of the upper airways linked to the viral infection, predispose to an increased tendency to stenosis and its recurrence. A conservative approach with medical and endoscopic treatment should be preferred in case of persistence of local airways inflammation. Further studies with a larger sample of patients will help to a better understanding of the disease, reduce the prevalence, and improve its treatment.

Venovenous extracorporeal membrane oxygenation-assisted tracheobronchial surgery: a retrospective analysis and literature review

Background

Airway management in tracheobronchial surgeries, especially carinal resection and reconstruction, remains one of the greatest challenges to thoracic surgeons. This study investigated the safety and effectiveness of venovenous extracorporeal membrane oxygenation (VV-ECMO) for respiratory support during tracheobronchial surgeries.

Methods

The data of patients who underwent VV-ECMO-assisted tracheobronchial surgeries at the Shanghai Chest Hospital from August 2006 to August 2021 were retrospectively reviewed. The clinicopathological, perioperative, and follow-up outcomes were analyzed.

Results

A total of 7 patients (4 males and 3 females) with a median age of 56 years (range, 11–70 years) were included in the study. The following tracheobronchial surgeries were conducted: carinal resection and reconstruction with complete pulmonary parenchyma preservation (n=4), left main bronchus and hemi-carinal sleeve resection (n=1), right upper sleeve lobectomy and hemi-carinal resection (n=1), and tracheal resection and reconstruction (n=1). The mean time on VV-ECMO was 167.7±65.8 min, and the mean operative time was 192.4±55.0 min. The average estimated blood loss was 271.4±125.4 mL. No perioperative death or reimplantation of VV-ECMO occurred. Postoperative complications were observed in 2 patients, including 1 case of respiratory failure due to preoperative severe chronic obstructive pulmonary disease (COPD) and 1 case of chylothorax. The median hospital stay was 11 days (range, 7–46 days). The median follow-up time was 30 months (range, 21–33 months). All the patients remained alive, and no postoperative readmission occurred during the follow-up period.

Conclusions

VV-ECMO is a safe and feasible ventilation mode when intraoperative oxygen saturation cannot be well maintained during tracheobronchial surgery.

Percutaneous dilation tracheostomy in a patient with tracheal stent

We reported the case of a patient with obstruction of tracheal stent, deployed previously for anaplastic thyroid carcinoma. The extension of malignant stricture above and below the stent and close to the vocal folds made unfeasible the stent recanalization and/or its replacement with another longer. Thus, tracheostomy was the only option to assure ventilation. After partial air-way recanalization with rigid bronchoscope, tracheostomy cannula was inserted through the stenosis using percutaneous dilatation tracheostomy technique.