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