Hemorrhagic Tracheobronchial Obstruction

Abstract

To the Editor: In the last 5 years we twice encountered a major complication after tracheostomy: a hemorrhagic obstruction of the tracheobronchial tree. In both situations a rigid bronchoscope was not available. CASE 1 (NON–UNIVERSITY SETTING) This patient had septic multiple organ system failure (multiple organ dysfunction score 13). After tracheostomy, excessive bleeding from the operative site required surgical reexploration and a return to orotracheal intubation. Increasing ventilation problems demanded flexible bronchoscopy. A subtotal obstruction of the tracheobronchial tree was seen. It took more than 3 hours to remove the blood clots through a flexible bronchoscope with the help of a Fogarty catheter and a biopsy forceps. CASE 2 (UNIVERSITY SETTING) This patient had cerebral sinus thrombosis. Post-tracheostomy the patient's hemodynamic status deteriorated and she developed septic shock (multiple organ dysfunction score 11). Nevertheless, full-dose heparin was restarted 4 hours postoperatively. Another 6 hours later the gas exchange deteriorated rapidly to a Pao2/Fio2 of 51 mm Hg with a Paco2 of 55 mm Hg and a right-to-left shunt of 55%. The intracranial pressure rose from 20 to 30 mm Hg; the patient was again hemodynamically unstable. Flexible bronchoscopy revealed massive bleeding into the tracheobronchial tree. The right bronchus was fully occluded and the left bronchus partially occluded. At this time anticoagulation was stopped. A rigid bronchoscopy was considered but rejected owing to the critical hemodynamic and neurologic condition of the patient, which excluded transport to the operation theatre. It took nearly 6 hours to remove the blood clots by flexible bronchoscopy—again with the help of a Fogarty catheter and a biopsy forceps. Thereafter the Pao2/Fio2 went to ≥300 mm Hg, the Paco2 decreased to 35 mm Hg, the right-to-left-shunt to 14%, and the intracranial pressure to 20 mmHg. A bleeding source could not be identified. We will not question that rigid bronchoscopy is the method of choice in the setting of tracheobronchial bleeding. However, this method is not always available, or it may be rejected owing to the clinical situation. Especially in critically ill patients, as our two cases were, the intervention should be as fast and compatible as possible. We are interested if anyone knows better tools that can be used during flexible bronchoscopy for the removal of clots or foreign bodies from the tracheobronchial tree. W. Schummer, M.D., D.E.A.A. C. Schummer, M.D.