Pulmonary Stents And Hemoptysis
Scott Farquharson M.D.Dec 9th 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”• Awake, alert, sats 98% on NRB, other vitals
OK• How would you prepare?
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
Who is aware that there is an Interventional
Pulmonologist on call?
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
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
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
Stent Card
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
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
Pulmonary Stents• Support Effect
– Extrinsic compression
– Malacia• Barrier effect– Intrinsic tumor growth– Tracheo-esophageal fistula
Malignant Tracheoesophageal Fistula
Double Stenting
C-H Marquette
Endobronchial StentsInterventional bronchoscopy. Prog
Respir 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
Dumon
Ultraflex
Dumon Y
Rüsch Y
Stents – Complications• Tumor growth causing obstruction
Stents – Complications
Granulation tissue obstructing stent
Stents – Complications
• Secretions blocking stent
Stents – Complications
• Stent migration causing obstruction
Stents - Complications • Hemoptysis
• Stent erosion • Underlying lesion could cause hemoptysis• Infection
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
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
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
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
Chest X-ray
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
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
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
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
CXR
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
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
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
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
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
Massive Hemoptysis• Causes tend to be unilateral 4
• Trauma• Cancer• Intervention• infection
• Systemic illness rarely a cause of massive hemoptysis 5
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
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
Selective Lung Ventilation
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
Double Lumen ET Tube
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
Fogarty Catheter
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
Univent Tube
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
Airway Management• All methods are temporizing• Definitive hemostasis
• FB• Embolization by Interventional Radiology • Thoracic Surgery
• High failure rate in inexperienced hands
Case• Next 48 hrs• Pt showed evidence of anoxic brain injury• Seized • Had 2nd massive pulmonary bleed• Family decided no further interventions• Died
Conclusions• IPM is available for appropriate consults• Stent complications will often require FB
intervention• Massive Hemoptysis is difficult to manage –
involve appropriate specialties early
Stents – Complications