Interventional bronchoscopy for benign tracheobronchial diseases under cardiopulmonary bypass support: case reports and literature review

Although the use of cardiopulmonary bypass (CPB) is well established for interventions to treat tracheal stenosis in children, its use during bronchoscopy or tracheal procedures has been less frequently reported in adults. Its use as a standby adjunct to bronchoscopy and tracheal stenting has rarely been reported in the UK.

We would like to report an additional use for CPB for support during bronchoscopy and tracheal stenting for non-malignant diseases.

Case 2

A 53 year old female with a longstanding high laryngo-tracheal post-intubation stenosis underwent elective follow-up bronchoscopy. She was fourteen years post-intubation for multitrauma. In February 2005 she underwent tracheostomy for worsening dyspnoea secondary to tracheo-bronchitis after Staphylococcal sepsis. Her past history was significant for right breast cancer, for which she had mastectomy and chemo-radiotherapy, and pneumothorax as a child.

Bronchoscopy showed severe narrowing of the left main bronchus (Figure 1). Stenting was not attempted at that time, as inflamed mucosa was seen to predispose to bleeding which would have made airway management through the tracheostomy difficult.

Her preoperative electrocardiogram and her routine bloods including full blood count, urea and electrolytes, creatinin, cardiac enzymes, liver function tests and coagulation profile were within the normal range. She underwent elective bronchoscopy and stenting with Ultraflex, to the left main bronchus with CPB on standby. As a precautionary measure, just prior to airway intervention, the femoral vessels were exposed for potential cannulation. The bronchoscopic procedure was without complications and therefore CPB was not actually required (Figure 2).

Airway stenting has an important palliative role in malignant disease processes. Its usefulness in benign large airway disorders is less well defined. Non-resectable or systemic diseases with benign aetiology causing airway disruption may require high risk bronchoscopy. Airway procedures in this setting carry potential risks, including desaturation, respiratory failure, airway bleeding, stent dislodgement and inability to intubate or establish a definitive airway. Airway manipulation predisposes to other complications, including restenosis, granulation tissue formation, stent migration, metal fatigue, mucus plugging, and halitosis [3, 4].

Over half a century, CPB has been refined and used for multiple cardiac and various non-cardiac indications [5]. Since then, CPB equipments have enabled surgeons to perform increasingly complex cardiac and other challenging operations [6]. The use of cardiopulmonary bypass to aid surgery for tracheal procedures is more frequently reported in infants and children than in adult population. There are indications that reports in the literature exploring its use in managing tracheal stenosis in adults are on the increase [7]. The use of CPB is potentially associated with postoperative pulmonary insults, ranging from mild dyspnoea to florid adult respiratory distress syndrome (ARDS) in 1–2% of cases, which in itself carries a 50% mortality rate [8].

To our knowledge there are no clinical reviews in the English literature on the use of CPB in airway management in general, or in airway stenting in particular. Furthermore, most of the published case reports or case series were on the use of femoral-femoral CPB or percutaneous cardiopulmonary support (PCPS) in difficult or compromised airways in tumour-related conditions. These case reports advocate the safe use of femoral-femoral CPB and PCPS in the management of airway obstruction [9–12]. A few case reports from Japan, concerning patients who underwent endotracheal stenting for advanced malignancy utilizing PCPS or Extracorporeal Lung Assist (ECLA) perfusion, have been published [13, 14]. The use of PCPS in the palliative surgical management of carcinomatous involvement of the carina to support gas exchange has also been reported from Japan. This allows safe bilateral bronchial dilatation and stenting [15]. Unfortunately, many case reports and case series from Japan are not published in English except for the abstract [16–18].

The cases presented here advocate the safe use of extracorporeal lung support for the treatment of otherwise inoperable tracheal stenoses. Palliative stenting in advanced malignancy is controversial in absence of curative options. In the cases presented here, we found that CPB is safe and useful as a standby during complex stenting procedures for benign tracheo-bronchial conditions with better long term prognosis.

Utilising support of cardiopulmonary bypass during high risk tracheobronchial interventions for benign diseases is controversial but can be safely applied and can be life saving.

Written informed consent was obtained from the patient for publication of this case report and any accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.