Respiratory support with venovenous extracorporeal membrane oxygenation during stent placement for the palliation of critical airway obstruction: case series analysis

Airway Stenting Under Venoarterial Extracorporeal Membrane Oxygenation (V-A ECMO) Support With Multimodal Sedation Including Remimazolam in a Patient With Central Airway Stenosis: A Case Report

The perioperative anesthetic management of patients with severe airway obstruction due to advanced lung cancer poses significant challenges, and no standardized protocols have been established. A 49-year-old man with severe tracheal stenosis due to extrinsic tumor compression underwent successful airway stenting supported by venoarterial extracorporeal membrane oxygenation (V-A ECMO). Due to the high risk of airway collapse, we initiated ECMO under dexmedetomidine sedation while preserving spontaneous breathing. In addition to dexmedetomidine, remimazolam then allowed safe, awake intubation and smooth induction of general anesthesia, facilitating controlled mechanical ventilation. V-A ECMO stabilizes the respiratory and circulatory functions, enabling safe, rigid bronchoscopy-guided airway stent placement. This case highlights the feasibility of combining V-A ECMO and remimazolam for high-risk airway management, demonstrating the potential benefits for patients in whom traditional induction techniques are contraindicated. Although limited to a single case, it suggests a potential role of this approach in the perioperative management of difficult airways.

Extracorporeal membrane oxygenation as life-saving bridge for patients with airway obstruction caused by neck and chest tumors to salvage procedure: an in-depth review

Narrowed or stenotic airways are frequently encountered in emergency practice. Neck and chest tumors-caused airway obstruction usually follow a severe clinical course, necessitating urgent ventilation as a bridge to perform emergency operations. In certain cases, traditional ventilation methods may not safely address complicated airway conditions. In such instances, special cardiopulmonary support becomes necessary to manage both hemodynamics and ventilation for patients. Extracorporeal membrane oxygenation (ECMO) is considered a last resort treatment for respiratory failure. When dealing with emergency difficult airway situations, ECMO offers certain advantages over conventional ventilation. However, its effectiveness in managing airway obstruction due to solid tumors located in the neck or chest is not well-established due to limited clinical practice. Published articles about this topic are still limited and primarily rely on case series and reports. As a result, they offer insufficient data and illustrations to fully elucidate emergency issues. In the present article, the authors summarize the existing literature concerning ECMO utility in managing patients with airway obstruction due to solid tumor located in the neck or chest based on PubMed, Web of Science, and other medical databases, to conduct an in-depth review. The authors conducted an analysis of 27 studies, including a total of 54 patients with airway obstruction caused by tumors. All patients underwent surgical relief of airway obstruction with ECMO as ventilatory support. Postoperatively, 87% of the patients (47/54) survived. 7.4% of the patients (4/54) died due to postoperative disease progression, unrelated to ECMO complications. The prognosis of 5.6% of the patients (3/54) could not be obtained. Additionally, the authors present an interesting case series (n=5) based on a real-world research to demonstrate the different outcomes among airway-obstructed patients due to neck and chest masses. In this series, four patients supported by ECMO were successfully discharged postoperatively, while one patient on conventional ventilation died due to respiratory collapse before surgery. Meanwhile, the authors share novel illustrations and clinical figures to supplement the understanding of this condition. The findings presented in this article provide a basis for further studies and can be used to improve management of the patients.

Left Main Bronchus Obstruction in a Patient with Small-cell Lung Cancer Successfully Treated with Venovenous Extracorporeal Membrane Oxygenation

Lung cancer can cause fatal central airway obstruction. Rapid airway clearance is necessary in some cases, but ventilator management may be insufficient to maintain oxygenation levels. Venovenous extracorporeal membrane oxygenation (VV-ECMO) may be an effective rescue therapy for respiratory failure, but its efficacy in treating tumor-related airway obstruction is unknown. We herein report a case of central airway obstruction and severe acute respiratory failure due to small-cell lung cancer successfully treated with VV-ECMO, bronchoscopic airway intervention, and chemotherapy. VV-ECMO can be an effective option for the treatment of central airway obstruction with acute respiratory failure due to lung cancer.

Extracorporeal membrane oxygenation in critical airway interventional therapy: A review

Introduction

Extracorporeal membrane oxygenation (ECMO) is widely used during refractory cardiac or respiratory failure, and some case reports described ECMO utilization in critical airway interventional therapy.

Methods

Eligible reports about patients receiving airway interventional therapy under ECMO were retrieved from Web of Science, Embase, Medline, and Cochrane databases up to 1 August 2022.

Results

Forty-eight publications including 107 patients who underwent ECMO for critical airway problems met the inclusion criteria. The critical airway problem that was reported the most was tumor-associated airway obstruction (n = 66, 61.7%). The second most reported etiology was postoperative airway collapse or stenosis (n = 19, 17.8%). The main interventional therapies applied were airway stent placement or removal (n = 61, 57.0%), mass removal (n = 22, 20.6%), and endotracheal intubation (n = 12, 11.2%) by bronchoscopy. The median ECMO duration was 39.5 hours. Eleven patients had ECMO-associated complications, including seven cases of airway hemorrhage, one case of arteriovenous fistula, one case of vein rupture and hematoma, one case of foot ischemia, and one case of neuropraxia of the cannulation site. In total, 91.6% of the patients survived and were discharged from the hospital.

Conclusion

ECMO appears to be a viable form of life support for patients undergoing interventional therapy for critical airway problems.

Early extracorporeal membrane oxygenation as bridge for central airway obstruction patients caused by neck and chest tumors to emergency surgery

Central airway obstruction caused by neck and chest tumors is a very dangerous oncological emergency with high mortality. Unfortunately, there is few literature to discuss an effective way for this life-threating condition. Providing effective airway managements, adequate ventilation and emergency surgical interventions are very important. However, traditional airway managements and respiratory support has only limited effect. In our center, using extracorporeal membrane oxygenation (ECMO) as a novel approach to manage patient with central airway obstruction caused by neck and chest tumors has been adopted. We aimed to show the feasibility: using early ECMO to manage difficult airway, provide oxygenation and support surgical procedure for patients with critical airway stenosis caused by neck and chest tumors. We designed a single-center, small sample size retrospective study based on real-world. We identified 3 patients with central airway obstruction caused by neck and chest tumors. ECMO was used to ensure adequate ventilation to emergency surgery. Control group cannot be established. Because traditional manner very likely led to death of such patients. Details of clinical characteristics, ECMO, surgery and survival outcomes were recorded. Acute dyspnea and cyanosis were the most frequent symptoms. All patients (3/3) showed descending arterial partial pressure of oxygen (PaO₂). Computed tomography (CT) revealed severe central airway obstruction caused by neck and chest tumors in all cases (3/3). All patients (3/3) had definite difficult airway. All cases (3/3) received ECMO support and emergency surgical procedure. Venovenous ECMO was the common mode for all cases. 3 patients weaned off ECMO successfully without any ECMO-related complications. Mean duration of ECMO was 3 h (range: 1.5-4.5 h). Under ECMO support, difficult airway management and emergency surgical procedure were finished successfully for all cases (3/3). The mean ICU stay was 3.3 days (range: 1-7 days), and the mean general ward stay was 3.3 days (range: 2-4 days). Pathology demonstrated the tumor dignity for 3 patients including 2 malignant cases and 1 benign case. All patients (3/3) were discharged from hospital successfully. We showed that early ECMO initiation was a safe and feasible approach to manage difficult airway for patients with severe central airway obstruction caused by neck and chest tumors. Meanwhile, early ECMO initiation could ensure security for airway surgical procedure.

Malignant Central Airway Obstruction: What's New?

Malignant central airway obstruction (MCAO) is a debilitating and life-limiting complication that occurs in an unfortunately large number of individuals with advanced intrathoracic cancer. Although the management of MCAO is multimodal and interdisciplinary, the task of providing patients with prompt palliation falls increasingly on the shoulders of interventional pulmonologists. While a variety of tools and techniques are available for the management of malignant obstructive lesions, advancements and evolution in this therapeutic venue have been somewhat sluggish and limited when compared with other branches of interventional pulmonary medicine (e.g., the early diagnosis of peripheral lung nodules). Indeed, one pragmatic, albeit somewhat uncharitable, reading of this article's title might suggest a wry smile and shug of the shoulders as to imply that relatively little has changed in recent years. That said, the spectrum of interventions for MCAO continues to expand, even if at a less impressive clip. Herein, we present on MCAO and its endoscopic and nonendoscopic management-that which is old, that which is new, and that which is still on the horizon.

The intersection of bronchoscopy and extracorporeal membrane oxygenation

Central airway obstruction (CAO), which results from malignant, benign or iatrogenic etiologies, causes significant morbidity and mortality and can be seen in both the pediatric and adult patient population. Patients frequently present to the hospital with dyspnea, stridor, and respiratory distress, indicating impending respiratory failure. Heliox is used to help alleviate symptoms while procedural planning takes place. A multidisciplinary approach to airway management is often needed. Interventional pulmonologists treat CAO with rigid of flexible bronchoscopy in order to deliver therapeutic interventions under general anesthesia. In severe CAO where there is concern for total loss of the airway creating a life-threatening situation for the patient during procedural intervention, short term extracorporeal membrane oxygenation or ECMO has been successfully reported in the literature to provide ventilation and oxygenation support throughout the procedure. Venoarterial ECMO can be used to augment cardiac output in cases of central tumors with cardiac involvement. ECMO can also be used for the removal of tracheal stents when there is a concern that ventilation will be interrupted for a prolonged period of time. ECMO has also been reported as a salvage measure for patients with life threatening hemoptysis until more definitive interventions can be performed. Short term ECMO cannulation can be used with limited associated morbidity and a heparin-free approach can be pursued when there is a concern for bleeding. We will briefly review the anesthetic considerations in CAO as well as review cases of CAO where ECMO was employed to safely alleviate the airway compromise.

Pre-emptive extracorporeal membrane oxygenation to support endobronchial stenting for severe airway obstruction

Tracheobronchial stent insertion is a common palliative intervention for the management of dynamic airway collapse due to severe tracheobronchomalacia or tracheal compression due to mass effect [1]. Airway stents are usually placed bronchoscopically with or without fluoroscopy. In more complex cases, airway stents are placed using a rigid bronchoscope under general anaesthesia with conventional or jet ventilation. In patients where advancement of a rigid bronchoscope into the distal airway or ventilation through a rigid bronchoscope may be difficult, pre-emptive awake veno-venous extracorporeal membrane oxygenation should be considered. This report is the first publication to describe a novel technique in a series of patients being treated for critical airway obstruction who would otherwise be at risk of respiratory arrest at the induction of anaesthesia.

Central airway obstruction treated with initial support by venovenous extracorporeal membrane oxygenation

A 24-year-old man with Down syndrome and congenital tracheal stenosis, who had undergone cartilage patch tracheoplasty twice in infancy, was transferred from a local hospital to manage an airway emergency. On arrival, the patient was in severe respiratory distress. Increased airway pressure following endotracheal intubation complicated the administration of mechanical ventilation. CT of the chest showed widespread consolidation and tracheal stenosis 3 cm above the carina distal to the tip of the endotracheal tube. The diagnosis was tracheal stenosis with type A influenza infection. The patient was transferred to another hospital for initiating venovenous extracorporeal membrane oxygenation (VV-ECMO). Intubation with a 6.0 mm spiral tube was successful after intraluminal balloon dilatation of the tracheal stenosis. The patient was admitted to the intensive care unit and was weaned off VV-ECMO on day 3 due to improvement in respiratory status. A tracheotomy was performed on day 28 and the tracheal tube was removed on day 41.

Use of venovenous extracorporeal membrane oxygenation for resection of a large paratracheal mass causing critical tracheal stenosis: A case report

Critical airway stenosis is challenging for surgeons and anesthesiologists to secure a reliable airway for ventilation. The use of venovenous (VV)-extracorporeal membrane oxygenation (ECMO) has been described as a strategy to provide adequate gas exchange in such instances. We present a case of a young female with a complex paratracheal mass significantly compressing the trachea; a planned intraoperative VV-ECMO was instituted to allow safe orotracheal intubation of a double-lumen endotracheal tube for lung isolation and tumor resection.

Successful use of extracorporeal membrane oxygenation for airway-obstructing lung adenocarcinoma

Endobronchial‐invasive lung cancers are generally diagnosed at advanced stages and may require emergency treatment for airway obstruction. Stent implantation is a common intervention for such obstructed airways but certain subsets of patients cannot receive adequate treatment without respiratory support. Veno‐venous extracorporeal membrane oxygenation (ECMO) is a salvage therapy for respiratory failure but its usefulness in managing patients with advanced lung cancer remains unclear given the poor prognosis. In recent years, molecular targeted agents for patients with driver mutations offer rapid responses and may be administered even while under critical care. In this report, we describe the case of 39‐year‐old female who presented to our emergency department with severe respiratory distress. A computed tomography scan revealed a large mediastinal tumor invading the tracheal carina causing severe stenosis of the left main bronchus and right main pulmonary artery. ECMO support was required as the respiratory condition remained unstable despite high pressure ventilation. Under ECMO support, the patient underwent bronchial stent implantation and was successfully weaned off ECMO. The tumor was histologically diagnosed as pulmonary adenocarcinoma with anaplastic lymphoma kinase gene rearrangement. Treatment with a tyrosine kinase inhibitor, alectinib, induced a marked tumor reduction within a short period. The patient recovered well and is now in remission one year later. This case indicates that intensive respiratory support with ECMO may become a bridge through the critical period for selected patients with respiratory failure secondary to advanced lung cancer.

Key points

Significant findings of this study

ECMO was important to maintain oxygenation during airway intervention for acute respiratory failure due to critical lung adenocarcinoma with ALK gene rearrangement.

What this study adds

With the development of targeted therapies and the improvement in therapeutic bronchoscopy, intensive respiratory support with ECMO may be helpful especially in selected lung cancer patients with oncogenic driver mutations.

Clinical Outcomes of Complications Following Self-Expandable Metallic Stent Insertion for Benign Tracheobronchial Stenosis

Background and Objectives: The use of metallic stents in benign TBS is controversial. Here, we report the clinical outcomes of patients who developed complications due to self-expandable metallic stent (SEMS) insertion for benign TBS. Materials and Methods: Our institution, which is the largest and most active referral hospital for airway stenosis in South Korea, only uses silicone stents. We conducted a retrospective review of 20 patients referred after the insertion of SEMS for benign TBS from 2006 to 2015. Results: All 20 patients underwent rigid bronchoscopy for SEMS removal due to airway obstruction from granulation tissue overgrowth. All but one (95%) experienced successful removal of the SEMS. During a median follow-up period of 40 months, a median of seven rigid bronchoscopies per patient was needed to maintain airway patency. Three (15%) patients suffered acute complications during SEMS removal (bleeding (10%) and fistula (5%)). All patients suffered chronic complications (granulation tissue (80%), stent migration (58%), mucostasis (55%), and restenosis (43%)). Eventually, 15 patients (75%) needed airway prostheses (silicone stent (75%) and tracheostomy (25%)). Conclusion: Our findings indicate that SEMS should be avoided until positive results are consistently reported by high-quality studies in patients with benign TBS.

Clinical Comparison of Airway Stent Placement in Intervention Room and Operating Room

BACKGROUND

Airway stent placement is the effective regimen for central airway obstruction (CAO), while its application scenarios varied. This study aimed to make clinical comparison of airway stent placement in the intervention room and operating room.

METHODS

Patients underwent airway stent placement between 2014 and 2018 were included in this retrospective case-control study. Clinical performance of airway stent placement in intervention room and operating room were compared.

RESULTS

82 patients were included in this study, including 39 in the intervention room and 43 in the operating room. Patients treated in the intervention room had lower Charlson comorbidity index (CCI) (P=0.018) and received less Y-shaped stents (P<0.001). Better clinical response (P=0.026), more stents placed (P<0.001) and longer length of stent (P<0.001) were observed in operating room, while there was no significantly statistical difference of stent-related complications and post-stent survival rate between the two groups. Extracorporeal membrane oxygenation (ECMO) supported airway stent placement procedures were performed in the operating room, which provided definitive safety support for high-risk intervention.

CONCLUSIONS

Patients with CAO could benefit from the operating room scenario, and airway stent placement in the operating room is more suitable for patients with higher CCI scores and receiving more complicated procedures.

Usefulness of extracorporeal membrane oxygenation in status asthmaticus with severe tracheal stenosis

Extracorporeal membrane oxygenation, traditionally used to treat refractory hypoxemic respiratory failure due to acute respiratory distress syndrome, is being used to treat other etiologies of severe respiratory failure refractory to conventional mechanical ventilation. We present a 30-year-old woman with concomitant life-threatening airway obstruction due to severe tracheal stenosis and status asthmaticus treated effectively with veno-venous extracorporeal membrane oxygenation.