Pulmonary Stents And Hemoptysis

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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” - PowerPoint PPT Presentation

Transcript of Pulmonary Stents And Hemoptysis

Pulmonary Stents And Heoptysis

Pulmonary Stents And HemoptysisScott Farquharson M.D.Dec 9th 2010 With thanks to Dr. Alain Tremblay and Dr. David JungenCase - 57 Y/O woman with HemoptysisRockyview Hospital00: 12 EMS patch 57 y/o female with gross hemoptysis, has endobronchial stent and difficult airwayAwake, alert, sats 98% on NRB, other vitals OK How would you prepare? Teus AM2Preparation for difficult airwayCode roomRT, NursingPrepare for awake intubationDAM cart, GlidescopeTopical LidocaineKetamineBig BerthaNotify other Ed physician re possible triple set up

Who is aware that there is an Interventional Pulmonologist on call?Objectives of TalkReview indications for calling Interventional PulmonologistDiscuss pulmonary stent use and complications that could be seen in the EDDiscuss airway management of life threatening hemoptysis in the ED

Case00:29 Pt arrivesT 35.9, P 150, BP 189/90, RR 40, Sats 96% NRBDrying blood in mouth, on face, hands and front of clothing. No active hemoptysis.StridorAble to speak 1-2 words at a timeIndrawing 15 minutes after call6History - EMSOral Ca 2002 with curative resection and subsequent reconstructionLung Ca 2006 in remission post chemo/radiation radiation scarring of lungsHas stent in L mainstem bronchus Had balloon bronchoplasty of R mainstem 5 days ago R1 as no active cancer Stent Card

IPMIPM Interventional Pulmonary MedicineOnly 3 MDs in call groupPractice out of FMC but will go to other sites for unstable patientsAll things bronchoscopicIndications for calling IPMPulmonary Stent patients with respiratory difficulty or stent obstructionPleural catheter patients Blocked cathetersRespiratory difficultySubglotic airway obstructionCAFBMassive or life threatening hemoptysis

Pulmonary StentsSupport EffectExtrinsic compression MalaciaBarrier effectIntrinsic tumor growthTracheo-esophageal fistula

Malignant Tracheoesophageal FistulaDouble Stenting C-H MarquetteEndobronchial StentsInterventional bronchoscopy. Prog Respir Res. Basel, Karger, 2000, vol 30, pp 171-1862 basic typesSilicone Non radio opaqueMetalRadio opaqueStent card Type of stentPlacement siteIPM number

DumonUltraflexDumon YRsch YStents ComplicationsTumor growth causing obstruction

Stents ComplicationsGranulation tissue obstructing stent

Stents ComplicationsSecretions blocking stent

Stents ComplicationsStent migration causing obstruction

Stents - Complications HemoptysisStent erosion Underlying lesion could cause hemoptysisInfectionStents ComplicationsIntubation OK with mainstem stents or more distal stentsFiberoptic intubation preferred with tracheal stentsIPM will be needed to clear any stent obstructionDiscuss with on call Pulmonary if Pt stable not in respiratory distressCode Level80% of pulmonary stent placement in Calgary area are for palliative purposesPts may agree to short term intubation for clearing of obstruction as palliationIntubation could be done after discussion with Pt and on cal IPM

Case00:58Pt had been given Nebulized EPI with slight improvementAble to speak short sentences, agrees to intubationVBG pH 7.29, Hgb 135Physical ExamP 117, RR 38, BP 150/75, Sats 100% NRBStill some insp. stridorOP 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

Case01:02Discussed case with ICU attending and FellowPlan intubate with urgent bronchoscopyTriple set up Dr. Harji present Nebulized and topical Lidocaine Ketamine titrated

Case00:16 01:33Attempt X 3 Dr. Farquharson awake intubationGlidescope unable to visualize epiglottisDirect laryngoscopy with bougie unable to pass bougie Fiberoptic scope airway visualized unable to pass 7.5 tubeAttempt X 1 Dr. Harji awake intubation Fiberoptic intubating stylet airway visualized unable to pass 6.5 tube16 minutes25Case01:33 02:12Anesthesia paged Airway attempt X 2 Dr. Soska, Dr. Topher (Anesthesia)Glide scopeBougieRequested 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

40 minutes26Case02:23Called back to Code room as Pt increasingly difficult to bagPoor BS bilaterallyNothing with suctioningTube pulled back 1-2 cm with no changePort CXR doneNo hemoptysis noted10 minutes later27CXR

Case02:32 - 02:48Sats drop to 59%PEA arrestTube pulled, Bagged, CPR startedVery difficult to bagReturn of circulation with atropine, epiSats in 40sAnesthesia called backCrich done by Dr. Harji while pt being bagged16 minutes29Case02:49 03:25Only able to ventilate pt by occluding mouth and nose, bagging very difficultNow apparent there is a distal obstructionSats 50-75 then drop to 35%2nd PEA arrestResponds to EpiIV ventolin startedStomach decompressed through PEG tube 35 minutes30Case03:26 04:11 bagging slightly easier, mouth and nose still have to be occludedSats to 91% Dr. Tremblay arrives (called by ICU)Bronchoscopy reveals clots obstructing both mainstem bronchi7.0 ET tube placed, crich removedClots cleared with bronchoscopePt now easy to bag taken to ICU

Massive HemoptysisGreater than 600 cc of blood in 24 hrsNot very useful definition in ED setting (although Pts regularly stay more than 24hrs)Gross hemoptysisGross hemoptysis with respiratory distressGross hemoptysis with respiratory distress and hemodynamic instability Massive HemoptysisLiterature reports a Mortality of 25-65% with massive hemoptysis 1Majority die of respiratory failure from blood contaminating upper airways and alveoli 22 sources of bleeding in lungs possiblePulmonary circulationBronchial circulationMajority from bronchial circulation 3

Massive HemoptysisCauses tend to be unilateral 4TraumaCancerInterventioninfectionSystemic illness rarely a cause of massive hemoptysis 5

Management StrategyLocalize the bleedingAdvanced airway managementSimple intubation may not be enough to protect uncontaminated lung from bloodEarly mobilization of other specialties to control bleedingAnesthesiaIPMInterventional radiology - EmbolizationThoracic Surgery

Airway ManagementSelective ventilation of one lungNo special equipmentProtects 1 lungCan only ventilate one lungIf R lung intubated will occlude RULNo tamponadeHave to reposition tube to use FB

Selective Lung Ventilation

Airway ManagementDouble Lumen ET TubeCan ventilate each lung independentlyMost commonly placedCan be placed blindProvides protection of non bleeding lungNo direct tamponadeAllows only small FBSizes French35-37 women39-41 men

Double Lumen ET Tube

Airway Management- Bronchial Blockers Fogarty CatheterPassed beside ET tube Placed with FBAllows large FBCan place in lobar bronchiBalloon can migrate or leakFogarty Catheter

Airway Management- Bronchial Blockers Univent tubeCombined ET tube and bronchial blockerCan ventilate while placing blockerLarge diameter tube > 8.0Blocker placed with FB or blindAllows large FBCan place in lobar bronchiTube can migrate or leak

Univent Tube

Airway Management- Bronchial Blockers Arndt wire guided endobronchial blockerCan be added to regular ET tubeMultiport adapter allows for simultaneous ventilation, bronchoscopy and Blocker placementCan place in lobar bronchiTube can migrate or leak

46Airway ManagementAll methods are temporizingDefinitive hemostasisFBEmbolization by Interventional Radiology Thoracic SurgeryHigh failure rate in inexperienced hands

CaseNext 48 hrsPt showed evidence of anoxic brain injurySeized Had 2nd massive pulmonary bleedFamily decided no further interventionsDied ConclusionsIPM is available for appropriate consultsStent complications will often require FB interventionMassive Hemoptysis is difficult to manage involve appropriate specialties early

Stents Complications