Tracheobronchoplasty and Diaphragmatic Plication under VV ECMO for Combined ECAC and Diaphragmatic Paralysis

The coexistence of expiratory central airway collapse and diaphragmatic paralysis presents a diagnostic and treatment challenge. Both entities are underrecognized causes of dyspnea, cough, sputum production, and orthopnea. Optimal treatment must be individualized and is best achieved by a multidisciplinary team. We present a case of a patient with profound functional impairment from dyspnea and hypoxemia due to expiratory central airway collapse, complicated by bronchiectasis from recurrent respiratory infections, and diaphragmatic paralysis.

Mediastinal Masses, Anesthetic Interventions, and Airway Compression in Adults: A Prospective Observational Study

Background Central airway occlusion is a feared complication of general anesthesia in patients with mediastinal masses. Maintenance of spontaneous ventilation and avoiding neuromuscular blockade are recommended to reduce this risk. Physiologic arguments supporting these recommendations are controversial and direct evidence is lacking. The authors hypothesized that, in adult patients with moderate to severe mediastinal mass–mediated tracheobronchial compression, anesthetic interventions including positive pressure ventilation and neuromuscular blockade could be instituted without compromising central airway patency. Methods Seventeen adult patients with large mediastinal masses requiring general anesthesia underwent awake intubation followed by continuous video bronchoscopy recordings of the compromised portion of the airway during staged induction. Assessments of changes in anterior–posterior airway diameter relative to baseline (awake, spontaneous ventilation) were performed using the following patency scores: unchanged = 0; 25 to 50% larger = +1; more than 50% larger = +2; 25 to 50% smaller = −1; more than 50% smaller = −2. Assessments were made by seven experienced bronchoscopists in side-by-side blinded and scrambled comparisons between (1) baseline awake, spontaneous breathing; (2) anesthetized with spontaneous ventilation; (3) anesthetized with positive pressure ventilation; and (4) anesthetized with positive pressure ventilation and neuromuscular blockade. Tidal volumes, respiratory rate, and inspiratory/expiratory ratio were similar between phases. Results No significant change from baseline was observed in the mean airway patency scores after the induction of general anesthesia (0 [95% CI, 0 to 0]; P = 0.953). The mean airway patency score increased with the addition of positive pressure ventilation (0 [95% CI, 0 to 1]; P = 0.024) and neuromuscular blockade (1 [95% CI, 0 to 1]; P < 0.001). No patient suffered airway collapse or difficult ventilation during any anesthetic phase. Conclusions These observations suggest a need to reassess prevailing assumptions regarding positive pressure ventilation and/or paralysis and mediastinal mass–mediated airway collapse, but do not prove that conventional (nonstaged) inductions are safe for such patients. Editor’s Perspective What We Already Know about This Topic What This Article Tells Us That Is New

Association of the location and initial degree of malignant central airway stenosis with the risk of severe restenosis after interventional bronchoscopy

Background Therapeutic bronchoscopy is one of the effective methods in the treatment and management of malignant central airway stenosis (MCAS). However, restenosis after therapeutic bronchoscopy frequently occurs and severe restenosis (SR) can be life-threatening. Therefore, this study aimed at investigating the risk factors for SR after therapeutic bronchoscopy. Methods The data of 233 consecutive cases with MCAS who were subjected to therapeutic bronchoscopy between 2015 and 2020 at a tertiary hospital were collected. Patients were divided into SR group and non-SR during 6 months after therapeutic bronchoscopy. Multiple logistic regression analysis was performed to determine the risk factors for SR. Results SR during 6 months after therapeutic bronchoscopy occurred in 39.5% (92/233) of patients. The location and the initial degree of MCAS were associated with SR, as assessed by multiple logistic regression analysis (P < 0.05). The risk of SR after therapeutic bronchoscopy in the left main bronchus, right main bronchus, and right intermediate bronchus increased, compared to the risk when of MCAS was located in the trachea (OR (95% CI) of 8.821 (1.850-25.148), 6.583 (1.791–24.189), and 3.350 (0.831–13.511), respectively). In addition, the initial degree of MCAS was positively associated with an increased risk of SR (OR 1.020; 95% CI 1.006–1.035). Conclusions MCAS located in the left main bronchus, right main bronchus and right intermediate bronchus, as well as the higher initial degree of MCAS were independent risk factors for SR during 6 months after therapeutic bronchoscopy.

Ablative Procedures and Additional Anticancer Therapy Prolong the Survival in Patients With Endoluminal or Mixed-type Malignant Central Airway Obstruction: A Single-institution Retrospective Study

BackgroundIn patients with malignant central airway obstruction (MCAO) receiving transbronchial interventions (TBIs), it remains unclear if the prognosis after the intervention might differ according to the bronchoscopic appearance of the airway obstruction. MethodsTBIs were undertaken in MCAO patients with endoluminal obstruction (TM group, n = 19), extraluminal obstruction (EX group, n = 19) and mixed-type obstruction (MX group, n = 23), under moderate sedation and high fractions of inspired oxygen (FiO2). We evaluated the differences in the overall survival period (OS) after the TBIs among the 3 groups. ResultsRegarding the TBIs, the initial procedure was transbronchial microwave ablation (TMA) in the TM group and MX group and stent placement in the EX group. However, 7 patients in the MX group received stent placement as the second-line procedure, after failure of TMA. The OS tended to be longer in the TM/MX group as compared to that in the EX group, both in the subgroups of patients who received post-TBI anticancer therapy (27.2 months/32.9 months vs. 6.0 months, p = 0.011) and in the subgroups of patients who received best supportive care alone (3.2 months/3.1 months vs. 1.4 months, p = 0.072). Multivariate analysis identified adoption of TMA as the initial procedure, successful airway patency restoration following the TBI, and post-TBI anticancer therapy as independent factors associated with a reduced risk of death in patients with MCAO. ConclusionIt is beneficial to administer post-TBI anticancer therapy to MCAO patients with endoluminal or mixed-type obstruction following ablative procedures.

Positive Expiratory Pressure: A Potential Therapy to Mitigate Acute Bronchoconstriction in the Asthma of Obesity

Late-onset non-allergic (LONA) asthma in obesity is characterized by increased peripheral airway closure secondary to abnormally collapsible airways. We hypothesized that positive expiratory pressure (PEP) would mitigate the tendency to airway closure during bronchoconstriction, potentially serving as rescue therapy for LONA asthma of obesity. The PC20 dose of methacholine was determined in 18 obese participants with LONA asthma. At each of 4 subsequent visits, we used oscillometry to measure input respiratory impedance (Zrs) over 8 minutes; participants received their PC20 concentration of methacholine aerosol during the first 4.5 minutes. PEP combinations of either 0 or 10 cmH2O either during and/or after the methacholine delivery were applied, randomized between visits. Parameters characterizing respiratory system mechanics were extracted from the Zrs spectra. In 18 LONA asthma patients (14 females, BMI: 39.6±3.4 kg/m2), 10 cmH2O PEP during methacholine reduced elevations in the central airway resistance, peripheral airway resistance and elastance, and breathing frequency was also reduced. During the 3.5 min following methacholine delivery, PEP of 10 cmH2O reduced Ax and peripheral elastance compared to no PEP. PEP mitigates the onset of airway narrowing brought on by methacholine challenge, and airway closure once it is established. PEP thus might serve as a non-pharmacologic therapy to manage acute airway narrowing for obese LONA asthma.