POST-PNEUMONECTOMY CENTRAL AIRWAY OBSTRUCTION: MANAGEMENT CHALLENGES

Abstract

SESSION TITLE: Fellows Procedures Posters SESSION TYPE: Fellow Case Report Posters PRESENTED ON: October 18-21, 2020 INTRODUCTION: Management of central airway obstruction (CAO) is challenging post-pneumonectomy due to limited respiratory reserve and the potential for life-threatening intraprocedural complications. We present a case of malignant CAO in a patient with a single lung that has been treated bronchoscopically with success for 3 years. CASE PRESENTATION: A 73-year-old man with pT2bN1M0 squamous cell carcinoma of the right lung 6 years ago s/p chemotherapy, radiation, and right pneumonectomy presented to the hospital for one week of exertional dyspnea and blood-tinged sputum. He was in no acute distress but had stridor. Computed tomography showed thickening of the tracheal mucosa and narrowing of the tracheal lumen. Fiberoptic bronchoscopy revealed friable, polypoid lesions extending the length of the trachea narrowing the lumen to 4 mm in the most affected region. Rigid bronchoscopy was performed with jet ventilation. The endotracheal tumor was devitalized using neodymium-doped yttrium aluminum garnet (Nd:YAG) laser. Pathology revealed squamous cell carcinoma consistent with metastatic disease from the former right lung. The patient completed radiation and chemotherapy but had recurrent dyspnea from CAO. 12 rigid bronchoscopies with laser tumor destruction have been performed to-date over 3 years. The patient continues to walk 30 minutes per day and maintains an active lifestyle. DISCUSSION: Bronchoscopic management of CAO with laser resection can improve quality of life, functional status, and prolong survival (1). The Nd:YAG laser is particularly advantageous because of its deep penetration, superior coagulation characteristics, resecting ability, and versatility to be utilized through a flexible or rigid bronchscope (1). We chose rigid bronchoscopy for airway security, the ability to tamponade a hemorrhage, and superior oxygenation with jet ventilation. Laser therapy is useful for lesions in the trachea or mainstem bronchi that are polypoid, less than 4 cm, and have a visible distal airway lumen with functional lung (1). Complications include perforation of the mediastinum, vascular structures, or esophagus which is why lesions that obliterate anatomical boundaries are not usually amenable to laser therapy. Essential elements of tumor debulking in complex cases like this one include the following: deep sedation and muscle relaxation, proper estimation of bronchoscope size, atraumatic rigid intubation, use of the Nd:YAG laser conforming to established technical standards (2) with intermittent exposures (0.5 to 1 second) not higher than 45 Watts (3), use of hemostatic agents such as Surgicel and cottonoids, and an anesthesia team experienced in jet ventilation. CONCLUSIONS: Endotracheal tumor resection can be safely performed in single lung patients. The Nd:YAG laser is especially advantageous for tumor debulking and hemostasis with the ability to improve quality of life and extend survival. Reference #1: Angel LF, Levine DJ. Basic Therapeutic Techniques. In: Introduction to Bronchoscopy. Ernst A, Herth FJF, editors. Cambridge: Cambridge University Press; 2017. pp. 184. Reference #2: Hoag JB. Use of Medical Lasers for Airway Disease. In: Principles and Practice of Interventional Pulmonology. Ernst A, Herth FJF, editors. Berlin: Springer; 2013. pp.364. Reference #3: Dumon JF, Shapshay S, Bourcereau J, et al. Principles for safety in application of neodymium-YAG laser in bronchology. Chest. 1984;86(2):163-168. DISCLOSURES: No relevant relationships by Brian Cody Adkinson, source=Web Response No relevant relationships by Sisir Akkineni, source=Web Response No relevant relationships by Sixto Arias, source=Web Response