SUCCESSFUL EXTRACORPOREAL CPR OF A PATIENT WITH A BULKY MEDIASTINAL MASS AND ACUTE AIRWAY COMPROMISE

Abstract

SESSION TITLE: Wednesday Fellows Case Report Posters SESSION TYPE: Fellow Case Report Posters PRESENTED ON: 10/23/2019 09:45 AM - 10:45 AM INTRODUCTION: The applications of extracorporeal membrane oxygenation (ECMO) continue to evolve. Its role in cases of critical airway compression and acute airway emergencies deserve better recognition. CASE PRESENTATION: An 18-year-old male presented with cough and orthopnea. Chest imaging revealed a massive anterior mediastinal mass with significant compression of the distal trachea and mainstem bronchi causing central airway compromise. An endobronchial ultrasound-guided transbronchial biopsy diagnosed a primary mediastinal B-cell lymphoma (PMBCL). A covered metal stent was deployed in the distal trachea and left main stem to negotiate the obstruction and decrease airway resistance and inflation pressures on the ventilator. On day 9 of hospital admission, a rigid bronchoscopy was performed revealing coarse granulation tissue emeshed within the stent, the manipulation of which resulted in uncontrolled airway bleeding and severe respiratory failure refractory to conventional mechanical ventilation requiring emergent initiation of venovenous (VV) ECMO. Midway during the procedure the patient suffered a respiratory arrest requiring cardiopulmonary resuscitation. A hybrid configuration (veno-arterio-venous or VAV) ECMO was deployed to support the embarrassed cardio-pulmonary apparatus. The cardiac function recovered promptly without residual neurological deficit and arterial limb decannulation was performed the following day. VV-ECMO support was continued with concomitant radio- and chemotherapy until day 49. On day 89, bronchoscopy was performed showing significant improvement in airway patency. DISCUSSION: ECMO has traditionally been utilized as a bridge to definitive therapy. As such, it has rarely been used in patients with central airway obstruction or acute airway emergencies [1,2]. In the few case reports of ECMO deployment for central airway obstruction, the definitive therapy was airway stenting or tumor debulking. PMBCL is chemosensitive and we show that ECMO can allow time for chemotherapy to reduce the tumor burden and relieve airway compression. Finally, we show that VV-ECMO can be used as a rescue modality in acute airway emergencies when traditional approaches to airway management have failed. CONCLUSIONS: ECMO can be used as bridge to chemotherapy in PMBCL causing airway compression and as a rescue modality in acute airway emergencies. Reference #1: Hong Y, Jo KW, Lyu J et al. 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. Reference #2: Willms DC, Mendez R, Norman V et al. Emergency bedside extracorporeal membrane oxygenation for rescue of acute tracheal obstruction. Respir Care. 2012 Apr;57(4):646-9. DISCLOSURES: No relevant relationships by Francisco Almeida, source=Web Response No relevant relationships by Balaram Anandamurthy, source=Web Response No relevant relationships by Shailesh Balasubramanian, source=Web Response No relevant relationships by Alejandro Bribriesco, source=Web Response No relevant relationships by Abhijit Duggal, source=Web Response No relevant relationships by Sudhir Krishnan, source=Web Response No relevant relationships by Mani Latifi, source=Web Response No relevant relationships by Eduardo Mireles-Cabodevila, source=Web Response No relevant relationships by Guramrinder Thind, source=Web Response No relevant relationships by Leslie Tolle, source=Web Response No relevant relationships by James Yun, source=Web Response