Eight of 12 (66.6%) patients could be liberated from MV. This included 7 of 9 (77.7%) with ETTs and 1 of 3 (33.3%) with tracheostomy tubes. Of the 12 patients admitted to ICU, 9 (75%) could be transferred to general ward after median (range) interval of 2 days (range, 1 to 7 d) after the day of intervention (Fig. 1).
Physiologically, median (range) prebronchoscopy and postbronchoscopy PaO2/FiO2 ratio was 102.8 (range, 99.2 to 328) and 180 (range, 129 to 380), respectively, with significant improvement postintervention (P=0.002) (Fig. 2). Radiologically, all 8 patients with lung atelectasis on presentation, experienced complete reexpansion of the lung on the day after the bronchoscopic intervention.
Rising medical intensive care costs with respiratory disease and ventilator support being a large contributor, emphasizes the need to evaluate current ICU practices to identify procedures and practices that optimize use of these resources. Majority of patients in our cohort (75%) with central airway diseases could be promptly (within 2 d postbronchoscopy) transferred out from ICU to general ward after successful discontinuation of MV and extubation after bronchoscopic intervention. These finding support existing literature on the role of bronchoscopy in reduction of the ICU length of stay in this group of patients. Correspondingly, early referral, and bronchoscopic intervention in such patients can help conserve ICU resources.
Three patients were admitted to ICU for respiratory failure from malignant CAO. Numerous studies have demonstrated the role of bronchoscopic intervention in patients with central airways diseases. Colt and Harrell5 described how bronchoscopic intervention allowed the immediate discontinuation of MV in 10 of 19 patients (52.6%) with both benign and malignant disease. Lo et al7 reported successful extubation of 7 patients with major airway obstruction within 48 hours of rigid bronchoscopy with endoscopic techniques. Five patients had malignant airway obstruction in this cohort similar to 3 patients with malignant central airway obstruction in our cohort who were successfully stented. Murgu et al8 reported immediate extubation and discontinuation of MV after bronchoscopic intervention in 9 of 12 (75%) patients with central airway obstruction from inoperable/unresectable lung cancer. The outcomes of patients in our cohort with malignant central airway obstruction are consistent with these findings. Three ICU patients with malignant CAO and indwelling ETT before intervention were successfully extubated, and discharged to general ward shortly after the intervention (Fig. 3).
Five patients were admitted to ICU for bleeding and clot formation in the central airways causing respiratory failure (Fig. 4). Airway obstruction secondary to a blood clot has been reported to complicate several pulmonary diseases, including bronchiectasis, tuberculosis, bronchial carcinoma, and pulmonary arterial venous malformations.9–11 Such blood clots can also arise iatrogenically as a result of damage to the mucosa from the use of a suction catheter, bronchoalveolar lavage, transbronchial biopsy, and tracheostomy placement.12–14 Arney et al15 reported 3 cases of airway obstruction arising from blood clots, by a comprehensive literature review. They suggested observation in a patient with adequate gas exchange and stable hemodynamics. Intervention, if necessary, should involve flexible bronchoscopic evaluation with suctioning, saline lavage, and clot removal using flexible biopsy forceps, either en bloc or piecemeal. If this fails, rigid bronchoscopy can be attempted as it allows greater access for suctioning and forceps extraction, and also offers superior airway management in an event of significant bleeding. In 3 of the 5 such ICU patients, clots were successfully removed leading to reversal of respiratory failure, extubation, and transfer out from ICU. One patient passed away, and the other refused intervention beyond change of tracheostomy tube to that with longer vertical limb to by-pass the obstructing granulation tissue in the trachea.
One patient required ICU management for respiratory failure from aspiration pneumonia caused by bronchoesophageal stump fistula (Fig. 5). Malignant tracheoesophageal or bronchoesophageal fistulas can complicate advanced cancer of the esophagus, lung, or mediastinum.16 Patients may present with recurrent pneumonias and acute respiratory failure. The prognosis is poor if the fistula is left untreated. Burt et al17 reported that most patients succumb to respiratory failure within 6 weeks of diagnosis if the fistula is not sealed. Stenting is the management of choice, and this can involve esophageal, tracheobronchial, or parallel (both esophageal and tracheobronchial) stenting.16 Wang et al18 reported a case of failure of 2 esophageal stents to seal off the bronchoesophageal fistula, with dislodgement of 1 into the stomach in a patient with respiratory failure from esophageal cancer. Subsequent placement of the bronchial stent successfully stopped the air leak, allowing weaning from the ventilator in 1 week. One such patient with bronchoesophageal stump fistula in our cohort underwent parallel stenting of the “stomach” pulled up in the mediastinum (after resection of esophagus), and left main bronchus. Although lung infiltrates improved after stenting initially, patient eventually succumbed to aspiration pneumonia and passed away 2 months poststenting.
One patient required ICU management for misdiagnosis of excessive dynamic airway collapse (EDAC) as asthma. EDAC refers to the narrowing of the central airways during expiration as a result of excessive bulging of the posterior membrane into the airway lumen.19 It is more common in patients with obstructive airway diseases (asthma and chronic obstructive pulmonary disease), and obesity, and can present as difficulty in weaning from MV.20 In 1 patient in our cohort, bronchoscopy after failure of second extubation attempt confirmed the presence of EDAC (Fig. 6). She was hence extubated to continuous positive airway pressure the third time and did not require reintubation thereafter. Noninvasive positive pressure ventilation has been used to maintain airway patency in patients with EDAC.20 Lyaker et al21 described a morbidly obese patient who failed repeated attempts at extubation after elective hysterectomy. They suggested that while their patient may have tolerated a significant degree of airway collapse preoperatively, several factors such as reduced functional residual capacity, respiratory muscle dysfunction from a high abdominal incision, atelectasis, edema, secretions, and tracheal reactivity from intubation contributed to an increased work of breathing, shifting the balance toward respiratory failure in the postoperative period.21 Similarly, EDAC in our patient may have been asymptomatic before the stress caused by respiratory infection and prolonged intubation/ICU stay.
Two patients required ICU admission for foreign body (FB) aspiration. FB aspiration is rare in adults. The most common site is right lower lobe and the most common type of FB is peanut in children and food or garden pea in adults.22,23 Patients in our cohort aspirated a green pea and a peanut, respectively. FB was aspirated into the right upper lobe in both the patients and was retrieved successfully using the dormia basket in the one, and rat-tooth forceps in the other (Fig. 7).
Our study is limited by the lack of matched cohort for comparison of ICU length of stay and cost. Although it is conceivable that sparing of ICU resources as a result of prompt extubation and early discharge from ICU will translate into cost savings, our study did not involve true cost effectiveness analysis to support this. However, similarity between our findings and the existing literature strengthens the evidence in favor of the role of bronchoscopy in reduction of ICU length of stay with the potential saving effect on the ICU resources. Our study illustrates a “comprehensive” spectrum of central airway diseases that cause acute respiratory failure resulting in ICU admission and yet, can be reversed promptly by the bronchoscopic intervention.
In conclusion, early discontinuation of MV and extubation in ICU patients carry the potential benefits of reduced risk of ventilator-associated pneumonia, delirium associated with sedation in ventilated patients, and critical care neuropathy. Importantly, there are substantial cost savings and reduction in critical care resource utilization. Patients admitted to ICU for respiratory failure from central airway diseases are amenable to reversal by bronchoscopy. Recognizing this subgroup and carrying out bronchoscopy promptly can modify the course of their illness favorably fulfilling the ultimate goal of ICU, that is timely liberation from MV and extubation, and at the same time free up the scarce ICU resources.
The authors thank Ms Ivy Yu Ling Ling for her valuable contribution in editing the figures and administrative work.
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Keywords:Copyright © 2016 Wolters Kluwer Health, Inc. All rights reserved.
cancer (lung); bronchoscopy; stenting; laser; central airway obstruction