RIGID BRONCHOSCOPY AND DEBULKING IN CASE OF CENTRAL AIRWAY OBSTRUCTION BY METASTATIC ESOPHAGEAL TUMOR RESCUED BY ECMO

Abstract

TOPIC: Lung Cancer TYPE: Medical Student/Resident Case Reports INTRODUCTION: Veno-venous extracorporeal membrane oxygenation( ECMO) has been used to provide the ventilatory support in patients with refractory hypoxia that does not respond to traditional methods of ventilation. Its use to support the ventilation while the patient undergoes life saving central airway procedures has been increasing. We present a rare case of metastatic esophageal tumor obstructing the central airway where VV-ECMO was used to provide the ventilation to the patient while undergoing rigid bronchoscopy and debulking of the tumor. CASE PRESENTATION: A 44-year-old male with a past medical history of chronic tobacco use, alcoholic dependence was transferred from an outside hospital for further workup of 4.7x6.5cm subcarinal mass centered on the esophagus with invasion to the trachea and complete occlusion of the right main stem and about 80% occlusion of the left main stem. He was saturating 95% on room air and hemodynamically stable. Physical examination revealed diminished breath sounds on the left lung, and coarse breath sounds on the right lung. Given the concern for near-complete tracheal obstruction with impending respiratory failure, urgent rigid bronchoscopy and debulking were planned. However, the tumor was found to be friable and started to bleed on flexible bronchoscopy. The procedure was aborted in the middle due to a friable tumor and high risk of complete tracheal obstruction . Subsequently, patient was put on the VV ECMO circuit. Debulking was done on both sides of the tumor using CO2 laser, cryoablation, coring through 11 mm rigid bronchoscope. Further, wire stents were placed with a tracheal length of 5 cm, left length of 4.5, and the right length of 2.5 cm. The post-procedure course was unremarkable. DISCUSSION: Recent exploration of ECMO use has led physicians to utilize it for interventional procedures with high risk of complications that can lead to cardiopulmonary failure. Yu et al intervened on a patient with advanced esophageal cancer with metastasis to trachea under ECMO support, a case similar to ours, and reported a successful resection of the mass using high-frequency electric knife and cryotherapy. 1 The literature published thus far is encouraging for the use of ECMO in cases of central airway interventions especially in malignant masses that otherwise would have been impossible to resect due to risks of severe bleeding and complete airway obstruction.2 CONCLUSIONS: It is essential to realize the high risk of complete airway obstruction and impending respiratory failure in case of tumors obstructing the trachea. Further, interventional pulmonologists should be prepared for an alternate ventilation method like VV ECMO in such cases. REFERENCE #1: Yu W, Zhou P, Chen K, Tang W, Xia Q, Ma J. Bronchoscopy-guided intervention therapy with extracorporeal membrane oxygenation support for advanced cancer metastasis to the central airway: A case report. Medicine (Baltimore). 2020;99(11):e19488. doi:10.1097/MD.0000000000019488 REFERENCE #2: Hong Y, Jo KW, Lyu J, Huh JW, Hong SB, Jung SH, Kim JH, Choi CM. Use of venovenous extracorporeal membrane oxygenation in central airway obstruction to facilitate interventions leading to definitive airway security. J Crit Care. 2013 Oct;28(5):669-74. doi: 10.1016/j.jcrc.2013.05.020. Epub 2013 Jul 8. PMID: 23845793. DISCLOSURES: No relevant relationships by Fernando Figueroa Rodriguez, source=Web Response No relevant relationships by Samiksha Gupta, source=Web Response no disclosure on file for Taha Khan; No relevant relationships by Miloni Parmar, source=Web Response No relevant relationships by Mukund Tiwari, source=Web Response