Respiratory distress in patients with central airway obstruction

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1 Indian J Thorac Cardiovasc Surg (2010) 26: DOI /s ORIGINAL ARTICLE Respiratory distress in patients with central airway obstruction Mohamed Abdel Hamied Regal & Yasser Ahmed El Ghoneimy & Yasser Maher Aljehani Received: 22 March 2010 /Accepted: 28 April 2010 /Published online: 18 June 2010 # Indian Association of Cardiovascular-Thoracic Surgeons 2010 Abstract Introduction Patients with respiratory distress due to central airway obstruction (Trachea, carina or main bronchi) are critically ill with impending suffocation. This obstruction is caused by a variety of benign and malignant causes that might be intraluminal, extra luminal or combined. Patients and methods This retrospective study conducted between 2002 and 2009, and included 56 patients presented with variable degrees of respiratory distress due to central airway obstruction. There were 37 male and 19 female, aged 3 weeks to 67 years. There were 31 benign causes (55.35%) and 25 malignant causes (44.65%). The site of the obstruction was intra luminal in 20 cases (35.7%), extra luminal in 24cases (42.85%) and combined in 12 cases (21.4%).Urgent bronchoscopic evaluation of the airways was required in all cases. M. A. H. Regal : Y. A. El Ghoneimy Cardiothoracic Surgery Unit, King Faisal University, King Fahd University Hospital, Al Khober, Saudi Arabia Y. A. El Ghoneimy yasser_farag@hotmail.com Y. M. Aljehani Surgery Department, King Faisal University, King Fahd University Hospital, Al Khober, Saudi Arabia altahlawi@hotmail.com M. A. H. Regal : Y. A. El Ghoneimy King Fahd Specialist Hospital, Buridah, Kingdom of Saudi Arabia M. A. H. Regal (*) Department of Surgery, Cardiothoracic Surgery Unit, King Fahd University Hospital, P. O. Box: 40233, Al-Khobar, Saudi Arabia mohamedregal@yahoo.com Results Interventional bronchoscopic procedures were done in 35 cases (62.5%); including removal of foreign bodies, core-out of tumors, suction, dilatation, removal of granulation tissue and stenting. Surgical intervention was required in 36 cases (64.3%). Two patients refused surgical management. There were four (7.14%) mortalities. Conclusion Although the definitive management of central airway obstruction is surgical intervention, which provides the best opportunity, the bronchoscopic management is the first step to provide a diagnosis, stabilize the airways and evaluate resectability. Keywords Respiratory distress. Central airway obstruction. Bronchoscopy Introduction Upper airway obstruction is characterized by progressive dyspnea, wheezes, stridor and cough. Many of these patients may be diagnosed initially as asthma or chronic bronchitis, for long periods prior to proper diagnosis, and subsequently present with acute life threatening upper airway obstruction [1]. Acute obstruction of the airways in the emergent situation results from a wide variety of malignant and benign disease processes, and this obstruction may be due to intra-luminal obstruction, extra-luminal obstruction or combined [2, 3]. In most cases the definitive management is surgical resection and reconstruction, which provides the best opportunity, if possible. However, Bronchoscopic management is the first step to provide a diagnosis, stabilize the airways and evaluate resectability [3].

2 152 Indian J Thorac Cardiovasc Surg (2010) 26: Patients and methods This study is a retrospective one. Review of medical charts & radiological images of 56 patients presented with respiratory distress due to central airway obstruction (trachea, carina& main bronchi) and we have operated upon them during the period of October, 2002 to June, 2009 in two hospitals in the Kingdom of Saudi Arabia; at King Fahd Specialist Hospital (Buridah) and King Fahd University Hospital (Al Khobar).Thirty seven patients (66%) were males and nineteen patients (34%) were females. There ages ranged from 3 weeks to 67 years. The prominent presentations were dyspnea, stridor, Wheezing and cough. Acute onset of the respiratory distress symptoms, in an otherwise normal person, was associated with foreign body inhalation and traumatic tracheal injuries. The other cases had a gradual onset & progressive course. Five of our patients (8.9%) were treated for bronchial asthma in the period before presentation to Cardiothoracic surgery service. Routine blood investigations, Chest X-ray (CXR), Computed Tomography (CT) of the neck & chest were done to all patients. Radiographic images showed a variable degrees of airway compression (Figs. 1 & 2). Pulmonary function tests were not done routinely in patients with acute presentation. Bronchoscopic evaluation of the airways was done to all patients as a diagnostic tool. Both Fiberoptic bronchoscopy (FOB) & Rigid bronchoscopy (RB) were used, but in cases Fig. 2 CT Chest showing severe airway compression by an anterior mediastinal mass with severe respiratory distress or impending suffocation RB was used to maintain adequate ventilation. Results There were various causes of the central airway obstruction in our series (Tables 1 & 2). Bronchoscopic interventional procedures were done to 35 cases (62.5%) of our patients (Table 3). Surgical intervention was required in 36 cases (64.3%) (Table 4). Two patients (3.57%) refused surgical management and were transferred to other hospitals. We had a total of 4 mortalities (7.14%). Group I: benign group It included 31cases (55.35%) Table 1 Etiology of benign lesions Etiology Fig. 1 CT Chest showing tracheal compression by a double aortic arch Foreign Body Inhalation 14 Post Intubation Stenosis 8 Mediastinal Goiter 2 Traumatic Tracheal Injury 2 Vascular Rings 1 Thymic Mass 1 Mediastinal Schwanoma 1 Endobronchial Hamartoma 1 Deep neck space infection 1 Total 31

3 Indian J Thorac Cardiovasc Surg (2010) 26: Table 2 Etiology of malignant lesions Table 4 Surgical interventions Etiology Surgical Interventional Technique Mediastinal Lymphoma 18 Tracheal tumors 3 Thyroid carcinoma infiltrating the airways 3 Bronchial Carcinoid 1 Total 25 Foreign body inhalation There were 14 cases, age ranged from 9 months to 10 years. As the acute onset of the symptoms was suggestive rigid bronchoscope was used in all cases as the definite management to remove inhaled foreign bodies in the airways. There is neither morbidity nor mortality in this group of patients. Post intubation stenosis There were 8 cases in this subgroup. Five of them gave history of recent intubation and admission in the Intensive Care Unit prior to developing symptoms. The other three cases were already intubated with difficult or failure to wean them. Bronchoscopic evaluation of the airways showed either granulation tissue or stricture. Interventional Bronchoscopic techniques included 4 removal of granulation tissue, 12 repeated dilatations of the stenotic areas and 1 removal of granulation tissue and impacted teeth in the bronchus. In 3 cases this was enough and did not require further procedures. In 4 cases resection of the strictured tracheal segment with direct end to end anastomosis was required. There was one mortality in a patient was diffuse tracheobronchial stricture in which repeated bronchoscopic dilatation was done and there was no possible surgical role. Mediastinal goiter Two cases of retrosternal goiter that was significantly compressing the airways and causing respiratory distress. Thyroidectomy was done through a classical neck incision Table 3 Bronchoscopic interventional techniques Interventional Technique Removal of inhaled FB 14 Coring-out of tumors 2 Dilatation of stenotic areas 12 Removal of granulation tissue 5 Stent Placement 2 Total 35 Tracheostomy 4 Open Mediastinal Biopsy 18 Tracheal resection and / or reconstruction 7 Thyroidectomy + tracheal resection & reconstruction 2 Debulking of the tumor 1 Lung resections 2 Drainage of the neck & the mediastinum 1 Thymectomy 1 with a partial sternal split. There was no evidence of tracheomalacia or any other abnormality. Traumatic tracheal injury We had two cases of severe trauma involving the trachea and causing acute severe respiratory distress. One case of direct penetrating injury of the cervical trachea in which the airways was secured by immediate intubation and direct repair was done. The second case of an explosive injury the damaged the cricoid cartilage the upper trachea and caused fracture thyroid cartilage. Airway was secured by urgent tracheostomy as the severe edema caused difficult intubation. Resection of the upper damaged tracheal rings and the anterior plate of the cricoid was done, followed by fixation of the thyroid cartilage and direct anastomosis of the trachea to the thyroid cartilage was done. No morbidity or mortality in this subgroup. Miscellaneous benign causes We had a case of double aortic arch, who was 2 months of age and presented with severe progressive respiratory distress. Initial Bronchoscopic evaluation showed extraluminal obstruction of the trachea with computed tomography scan confirming the diagnosis. Family refused surgical intervention in our hospital and was referred to other center. There was a 5 month old patient who gradually developed severe respiratory distress. Computed tomography showed progressive thymic enlargement, compressing the airways and the lungs. Thymectomy was urgently required and pathologic examination proved to be a true massive thymic hyperplasia [11]. Mediastinal Schwanoma, arising in the neck and extending into the mediastinum and compressing the trachea on its left side, the mass was removed completely through a median sternotomy extending into the neck. Endobronchial hamartoma obstructing the right lower and middle lobes, with repeated massive hemoptysis and 36

4 154 Indian J Thorac Cardiovasc Surg (2010) 26: Table 5 Patients with central airway obstruction and has been treated as bronchial asthma No Diagnosis Period on anti asthma measures before presentation Radiologic findings on routine CXR Response to treatment Final management 1 Tracheal adenoid cystic carcinoma 2 Tracheal undifferentiated carcinoma 3 Carcinoid of the left main bronchus 4 & 5 Post intubation stenosis 4 years Mediastinal mass obstructing trachea No response 1 year Mediastinal shadow, tracheal No stenosis & left sided collapsed lung response 2 years Left total lung collapse No response 4 months Normal lungs, evidence of tracheal Partial stenosis response Debulking of the tumor & tracheal stent Bronchoscopic dilatation, suction of secretions & coring out of the mass. Left sided pneumonectomy Tracheal resection & reanastomosis persistent collapse. Right lower and middle bilobectomies was required. One case of deep neck space infection, in 43 years diabetic male patients, involving both sides of the neck and extending into the mediastinum and causing difficulty of breathing. Tracheostomy was done initially to secure the airways followed by aggressive antibiotics but the pus was increasing in amount and more progressive. Bilateral neck drainage was done in addition to mediastinal drainage. Patient was discharged well after a long course of antibiotics. Group II: malignant cases It included 25 cases (44.65%) Mediastinal lymphoma The majority of the malignant upper airway obstruction (18 cases) had Mediastinal lymphoma. They had a progressive course of respiratory distress. Diagnostic bronchoscopy was negative in all these cases. Computed tomography scan was suggestive of the diagnosis. Airways were secured by intubation and ventilation in 4 cases out of 18, while the other cases did not require intubation. Mediastinal biopsy was urgently done to prove the diagnosis by mediastinoscopy in 3 cases, anterior limited thoracotomy (chamberlain s) in 9cases, and by video assisted thoracoscopic surgery in 6 cases. Tissue elements were sufficient to reach diagnosis and start proper chemotherapy & radiation. Corticosteroids were used in a big dose after obtaining the biopsies in 5 patients with severe respiratory distress. The lymphoma rapidly decreased in size and the obstruction was relieved. We had two in hospital mortality in this group. Tracheal tumors We had three cases of tracheal tumors one of adenoid cystic carcinoma, 1 undifferentiated adenocarcinome and 1 carcinoid. Unfortunately the first two cases were treated as cases Fig. 3 CXR showing clearly a mediastinal mass compressing the airways and the patient unfortunately has been treated for bronchial asthma for 2 years Fig. 4 CXR showing a mass compressing the trachea and the patient has been on Bronchial asthma treatment or 5 years

5 Indian J Thorac Cardiovasc Surg (2010) 26: of bronchial asthma before being referred to cardiothoracic surgery. In the first case exploration was done, but the tumor was found to affect more than 7 cm of the posterior tracheal wall so resection with reconstruction was impossible. Debulking of the mass was done. On the second postoperative day interventional bronchoscopy was done with insertion of an expandable ultraflex tracheal stent which successfully relieved the obstruction. The second case came with total left lung collapse. Airway was secured by urgent intubation and ventilation. Rigid bronchoscope and coring out of the mass was done and radiologically the lung started to expand but unfortunately this patient died on the first day of admission. The third case of tracheal carcinoid was early and resection with end to end anastomosis was done. Thyroid carcinoma We had three cases of thyroid carcinoma proven by the bronchoscopy to be filtrating the trachea. Thyroidectomy was done to all cases. In two cases tracheal resection with direct reanastomosis was done to relieve the obstruction. In the third case a tracheal stent was used to by pass the obstruction. Bronchial carcinoid We had a one young female treated for bronchial asthma although she had a carcinoid tumor of the left main bronchus. The underlying left lung was totally collapsed for a long period and showed severe destruction. Left sided pneumonectomy was done, with no morbidity or mortality. Discussion In this series we report our experience in managing cases of central airway obstruction in two referral hospitals in the Kingdom of Saudi Arabia. We had 56 patients presented with variable degrees of respiratory distress due to a variety of etiologies causing central airway obstruction. Patients with central airway obstruction usually experience respiratory distress with progressive dyspnea, stridor, coughing, and wheezing. A lesion that reduces the diameter of the trachea to 8.0 mm will produce respiratory symptoms with exercise. Any further reduction in tracheal diameter to 5.0 mm will cause inspiratory stridor at rest [4 7]. Most of the lesions causing upper airway obstruction grow slowly and symptoms of obstruction may continue for months or years before developing a life threatening airway impairment [1]. Emergent state results from either a foreign body inhalation or from a small mucus plug or bleeding over a critically stenosed area of the airways [7]. Unfortunately in our series 5 cases have been treated as bronchial asthma for variable periods of time, without any significant improvement, before receiving the proper management (Table 5). In two of these cases there initial radiological studies showed clearly a mediastinal mass & compression of the airways (Figs. 3 & 4). In addition, history taking from these patients they did not give a good response to the anti asthma measures. This problem has been addressed in the literature in many cases [1, 7 10]. Careful evaluation of asthma patients, proper history taking, radiologic examination, pulmonary function test before and after the treatment should be done. Bronchoscopic management is the first step to provide a diagnosis, stabilize the airways and evaluate resectability [3]. Bronchoscopic evaluation of the airways was done to all cases in our series. We have used both the Fiberoptic and the rigid bronchoscopes, but in the critical cases the rigid was preferred to maintain better oxygenation of the patient. As a diagnostic tool the bronchoscopy was important to localize the obstruction as intra luminal, extra luminal or combined and to provide tissues for histopathologic examination. Interventional Bronchoscopic techniques were done in 35 cases (62.5%) in our series. Bronchoscopic management of airway obstruction is almost always palliative and should only be considered when a definitive approach is not feasible. Because it is a palliative procedure, repeated interventions often are required to maintain airway patency [3]. Surgery was required in 36 cases (64.3%).We have used various surgical procedures either to maintain the patency of the airways or to obtain tissues for pathologic examination for diagnosing the cause of obstruction. The benign causes of central airway obstruction have a better outcome than the malignant cases. The overall mortality was 4 cases (7.14%), 1 case in the benign group and 3 cases in the malignant group. In conclusion, interventional bronchoscopic techniques and urgent surgical intervention are successful in maintaining the patency of the airways in central airway obstruction cases. Early diagnosis is important and cases of bronchial asthma should be carefully evaluated to exclude any underlying pathology. 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