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Pulmonary Stents And Hemoptysis

Pulmonary Stents And Hemoptysis. Scott Farquharson M.D. Dec 9 th 2010 With thanks to Dr. Alain Tremblay and Dr. David Jungen. Case - 57 Y/O woman with Hemoptysis. Rockyview Hospital 00: 12 – EMS patch 57 y/o female with gross hemoptysis, has endobronchial stent and “difficult airway”

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Pulmonary Stents And Hemoptysis

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  1. Pulmonary Stents And Hemoptysis Scott Farquharson M.D. Dec 9th 2010 With thanks to Dr. Alain Tremblay and Dr. David Jungen

  2. Case - 57 Y/O woman with Hemoptysis • Rockyview Hospital • 00: 12 – EMS patch • 57 y/o female with gross hemoptysis, has endobronchial stent and “difficult airway” • Awake, alert, sats 98% on NRB, other vitals OK • How would you prepare?

  3. Preparation for difficult airway • Code room • RT, Nursing • Prepare for awake intubation • DAM cart, Glidescope • Topical Lidocaine • Ketamine • Big Bertha • Notify other Ed physician re possible triple set up

  4. Who is aware that there is an Interventional Pulmonologist on call?

  5. Objectives of Talk • Review indications for calling Interventional Pulmonologist • Discuss pulmonary stent use and complications that could be seen in the ED • Discuss airway management of life threatening hemoptysis in the ED

  6. Case • 00:29 – Pt arrives • T 35.9, P 150, BP 189/90, RR 40, Sats 96% NRB • Drying blood in mouth, on face, hands and front of clothing. No active hemoptysis. • Stridor • Able to speak 1-2 words at a time • Indrawing

  7. History - EMS • Oral Ca 2002 with curative resection and subsequent reconstruction • Lung Ca 2006 in remission post chemo/radiation – radiation scarring of lungs • Has stent in L mainstem bronchus • Had balloon bronchoplasty of R mainstem 5 days ago • R1 as no active cancer

  8. Stent Card

  9. IPM • IPM – Interventional Pulmonary Medicine • Only 3 MDs in call group • Practice out of FMC but will go to other sites for unstable patients • All things bronchoscopic

  10. Indications for calling IPM • Pulmonary Stent patients with respiratory difficulty or stent obstruction • Pleural catheter patients • Blocked catheters • Respiratory difficulty • Subglotic airway obstruction • CA • FB • Massive or life threatening hemoptysis

  11. Pulmonary Stents • Extrinsic compression • Malacia • Barrier effect • Intrinsic tumor growth • Tracheo-esophageal fistula • Support Effect

  12. Malignant Tracheoesophageal Fistula • Double Stenting C-H Marquette

  13. Endobronchial Stents Dumon Interventional bronchoscopy. ProgRespir Res. Basel, Karger, 2000, vol 30, pp 171-186 • 2 basic types • Silicone • Non radio opaque • Metal • Radio opaque • Stent card • Type of stent • Placement site • IPM number Ultraflex Dumon Y Rüsch Y

  14. Stents – Complications • Tumor growth causing obstruction

  15. Stents – Complications Granulation tissue obstructing stent

  16. Stents – Complications • Secretions blocking stent

  17. Stents – Complications • Stent migration causing obstruction

  18. Stents - Complications • Hemoptysis • Stent erosion • Underlying lesion could cause hemoptysis • Infection

  19. Stents – Complications • Intubation • OK with mainstem stents or more distal stents • Fiberoptic intubation preferred with tracheal stents • IPM will be needed to clear any stent obstruction • Discuss with on call Pulmonary if Pt stable not in respiratory distress

  20. Code Level • 80% of pulmonary stent placement in Calgary area are for palliative purposes • Pt’s may agree to short term intubation for clearing of obstruction as palliation • Intubation could be done after discussion with Pt and on cal IPM

  21. Case • 00:58 • Pt had been given Nebulized EPI with slight improvement • Able to speak short sentences, agrees to intubation • VBG – pH 7.29, Hgb 135

  22. Physical Exam • P 117, RR 38, BP 150/75, Sats 100% NRB • Still some insp. stridor • OP – dried blood, anatomy distorted, restricted mouth opening, no active hemoptysis • Chest – diffuse harsh wheezes and upper air way stridor, indrawing • Abd – soft with peg tube

  23. Chest X-ray

  24. Case • 01:02 • Discussed case with ICU attending and Fellow • Plan – intubate with urgent bronchoscopy • Triple set up – Dr. Harji present • Nebulized and topical Lidocaine • Ketamine titrated

  25. Case • 00:16 – 01:33 • Attempt X 3 Dr. Farquharson awake intubation • Glidescope – unable to visualize epiglottis • Direct laryngoscopy with bougie – unable to pass bougie • Fiberoptic scope – airway visualized unable to pass 7.5 tube • Attempt X 1 Dr. Harji awake intubation • Fiberoptic intubating stylet – airway visualized unable to pass 6.5 tube

  26. Case • 01:33 – 02:12 • Anesthesia paged • Airway attempt X 2 Dr. Soska, Dr. Topher (Anesthesia) • Glide scope • Bougie • Requested fiber optic scope – taken by RT to be cleaned!! • Airway attempt X 1 Dr. Harji • FIS with 40 mg Succ – unable to see cords • Attempt X 1 Dr. Soska – Success !!! • Lightwand and 40 cc of Succ – 6.0 tube passes

  27. Case • 02:23 • Called back to Code room as Pt increasingly difficult to bag • Poor BS bilaterally • Nothing with suctioning • Tube pulled back 1-2 cm with no change • Port CXR done • No hemoptysis noted

  28. CXR

  29. Case • 02:32 - 02:48 • Sats drop to 59% • PEA arrest • Tube pulled, Bagged, CPR started • Very difficult to bag • Return of circulation with atropine, epi • Sats in 40s • Anesthesia called back • Crich done by Dr. Harji while pt being bagged

  30. Case • 02:49 – 03:25 • Only able to ventilate pt by occluding mouth and nose, bagging very difficult • Now apparent there is a distal obstruction • Sats 50-75 then drop to 35% • 2nd PEA arrest • Responds to Epi • IV ventolin started • Stomach decompressed through PEG tube

  31. Case • 03:26 – 04:11 • bagging slightly easier, mouth and nose still have to be occluded • Sats to 91% • Dr. Tremblay arrives (called by ICU) • Bronchoscopy reveals clots obstructing both mainstem bronchi • 7.0 ET tube placed, crich removed • Clots cleared with bronchoscope • Pt now easy to bag – taken to ICU

  32. Massive Hemoptysis • Greater than 600 cc of blood in 24 hrs • Not very useful definition in ED setting (although Pt’s regularly stay more than 24hrs) • Gross hemoptysis • Gross hemoptysis with respiratory distress • Gross hemoptysis with respiratory distress and hemodynamic instability

  33. Massive Hemoptysis • Literature reports a Mortality of 25-65% with massive hemoptysis 1 • Majority die of respiratory failure from blood contaminating upper airways and alveoli 2 • 2 sources of bleeding in lungs possible • Pulmonary circulation • Bronchial circulation • Majority from bronchial circulation 3

  34. Massive Hemoptysis • Causes tend to be unilateral 4 • Trauma • Cancer • Intervention • infection • Systemic illness rarely a cause of massive hemoptysis 5

  35. Management Strategy • Localize the bleeding • Advanced airway management • Simple intubation may not be enough to protect uncontaminated lung from blood • Early mobilization of other specialties to control bleeding • Anesthesia • IPM • Interventional radiology - Embolization • Thoracic Surgery

  36. Airway Management • Selective ventilation of one lung • No special equipment • Protects 1 lung • Can only ventilate one lung • If R lung intubated will occlude RUL • No tamponade • Have to reposition tube to use FB

  37. Selective Lung Ventilation

  38. Airway Management • Double Lumen ET Tube • Can ventilate each lung independently • Most commonly placed • Can be placed blind • Provides protection of non bleeding lung • No direct tamponade • Allows only small FB • Sizes French • 35-37 women • 39-41 men

  39. Double Lumen ET Tube

  40. Airway Management- Bronchial Blockers • Fogarty Catheter • Passed beside ET tube • Placed with FB • Allows large FB • Can place in lobar bronchi • Balloon can migrate or leak

  41. Fogarty Catheter

  42. Airway Management- Bronchial Blockers • Univent tube • Combined ET tube and bronchial blocker • Can ventilate while placing blocker • Large diameter tube > 8.0 • Blocker placed with FB or blind • Allows large FB • Can place in lobar bronchi • Tube can migrate or leak

  43. Univent Tube

  44. Airway Management- Bronchial Blockers • Arndt wire guided endobronchial blocker • Can be added to regular ET tube • Multiport adapter allows for simultaneous ventilation, bronchoscopy and Blocker placement • Can place in lobar bronchi • Tube can migrate or leak

  45. Airway Management • All methods are temporizing • Definitive hemostasis • FB • Embolization by Interventional Radiology • Thoracic Surgery • High failure rate in inexperienced hands

  46. Case • Next 48 hrs • Pt showed evidence of anoxic brain injury • Seized • Had 2nd massive pulmonary bleed • Family decided no further interventions • Died

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