ACUTE ON COPD

Abstract

SESSION TITLE: Wednesday Medical Student/Resident Case Report Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: 10/23/2019 09:45 AM - 10:45 AM INTRODUCTION: Central Airway Obstruction (CAO) is pathologic obstruction of air flow in the trachea and main stem bronchi. The most common cause of CAO is non-small cell lung cancer, but other common causes are tracheobronchomalacia, tracheal strictures, and other malignancies. Less commonly, primary tumors of the trachea and metastatic cancers can also cause central airway obstruction. CASE PRESENTATION: A 68 year old female with a prior medical history of hypertension, hyperlipidemia, past alcohol dependence, and COPD due to a 45 pack year smoking history presented to the emergency department via EMS. She was intubated for acute hypoxic and hypercapnic respiratory failure and was admitted to the ICU where she underwent treatment for COPD exacerbation, community-acquired pneumonia, and urinary tract infection with azithromycin, methylprednisolone, and ceftriaxone. A review of the patient’s chart showed a screening CT had been completed two days prior to admission and showed a paratracheal mass with invasion into the trachea and right main bronchus. Given the patient’s lack of response to maximal medical therapy, bronchoscopic evaluation was pursued. During bronchoscopy, a mass was found protruding from the right main stem bronchus, occluding 80-90% of the trachea. The bronchoscope could not be passed around the mass, however biopsies were taken before the procedure was aborted. Interventional Pulmonology was consulted with plans for further evaluation and management. The patient underwent a second bronchoscopic evaluation, which showed near occlusion of the trachea due to tumor in the left main stem bronchus. Debulking provided rapid improvement in oxygen saturation. Further debulking of the trachea and right main stem bronchus were completed with rigid bronchoscopy and a stent was placed at the entrance of the right main stem to prevent further airway collapse. The following day, the patient was successfully extubated without further respiratory difficulties. She was transferred from the ICU to the general medical floor and ultimately to a rehabilitation facility with Oncology follow up. The patient has quit smoking, follows at UW medicine for her sarcoma, and is handling her symptoms well. DISCUSSION: Pathology on the specimens obtained showed poorly differentiated synovial sarcoma. Synovial sarcoma most commonly affects children and young adults. It routinely affects the knees and ankles but can involve other joints. It is normally found proximal to tendons and bursae without invasion of surrounding tissues, joint space, or synovial membranes. Case reports have described synovial sarcoma in almost all anatomical locations despite its predilection for synovial joints. CONCLUSIONS: Obstructive lung disease can have multiple causes, therefore it is important to consider that respiratory failure may be secondary to more than just a patient’s known underlying lung pathology. Reference #1: Herth, Felix JF. (2018). Clinical Presentation, diagnostic Evaluation, and management of central airway obstruction in adults. G. Finlay (Ed.), UpToDate. Retrieved March 10, 2019, from https://www.uptodate.com/contents/clinical-presentation-diagnostic-evaluation-and-management-of-central-airway-obstruction-in-adults Reference #2: Goldblum, John R. Rosai and Ackerman’s Surgical Pathology, 11th ed. Elsevier Inc. C2018. Chapter 41, Soft Tissues; p. 1810-1914. Reference #3: David Feller-Kopman, Atul C. Mehta and Momen M. Wahidi. Murray and Nadel's Textbook of Respiratory Medicine. 6th ed. Saunders. c2016. Chapter 23, Therapeutic Bronchoscopy; p. 383-392. DISCLOSURES: no disclosure on file for Jonathan Danaraj; No relevant relationships by Matthew Strohmeyer, source=Web Response