中央氣道阻塞 Central airway obstruction

日期：

〈臨床情境〉


檢傷資料

- 病患來診為呼吸短促,血壓或心跳有異於病人之平常數值，但血行動力穩定lmd:後縱膈惡性腫瘤

- Vital signs: T:35.5 P:85 R:22 BP:154/80 SpO2 99% E4V5M6

病史簡述

  • 54歲男性無過去慢性病史，主訴漸進呼吸喘一週，合併端坐呼吸及dyspnea on exertion，外院檢查電腦斷層顯示有縱膈腔腫瘤併氣管壓迫，轉至本院做後續治療。

  • PE: bilateral crackles, no use of accessory muscle

  • Personal history: smoking 2PPD for 30 years

  • LMD CT & CXR: 


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〈初始醫囑〉


檢驗：CBC, WBC/DC, PT, APTT, Sugar, BUN, Cr, Na, K, ALT, CRP, Blood gas, Sputum gram’s stain and culture, Covid-PCR

處置：nasal cannula 5L/min, on IV lock


〈臨床進展〉

  • Lab: 

  • 會診胸腔外科: 建議做支氣管鏡切片確認病理診斷，安排整體評估後續治療；若臨床出現氣管壓迫可再次照會胸腔科進行置放tracheal stent。

  • 來診16 hrs後: sputum impaction feeling, bilateral wheezing, no use of accessory muscle, stable vital sign

🡪 加化痰藥

  • 來診28 hrs後: dyspnea, orthopnea, stridor and wheezing sound, impending respiratory failure 

🡪 Epinephrine inhalation

  • Consult ENT doctor: Suspect trachea lumen stenosis; No evidence of vocal cord palsy; Airway patent till vocal cord

  • Consult CVS doctor: secure airway first

  • Intubation (RSI) with midazolam and rocuronium

  • Midazolam line and cisatracurium line for agitation

  • 來診72 hrs後: intermittent desaturation, cyanosis, CO2 retention under ventilator support

  • High peak inspiratory pressure (40mmHg); low tidal volume (214ml)

  • Arrange bronchoscopy: right main bronchus total obstruction; left main bronchus near total obstruction

  • Consult CVS doctor: tracheal stent insertion; ECMO support during operation

  • Post operation day 1: improved ventilator setting

  • Post operation day 2: treat ventilator associated pneumonia

  • Post operation day 9: Pathology: poorly differentiated adenocarcinoma

  • Post operation day 17: immunotherapy for lung cancer



〈Discussion：central airway obstruction〉


  • Central airway obstruction (CAO): the obstruction of air flow in the trachea and mainstem bronchi

  • May overlap with upper airway obstruction

  • Image

  • Etiology: 


  • Clinical presentation: 

    • Acute: tachypnea, tachycardia, inspiratory stridor, or wheeze

      • Endoluminal diameter <8 mm 🡪 exertional dyspnea

      • Endoluminal diameter <5 mm 🡪 stridor

    • Subacute: dyspnea, cough, hemoptysis, wheeze, weight loss, hoarseness, dysphagia, chest pain

      • 常被誤診為COPD/asthma AE or bronchitis/pneumonia

      • 若bronchodilator, unilateral monophonic wheeze, antibiotics 無效則要想到是CAO

  • Diagnosis: 

  • CT

  • Diagnostic flexible bronchoscopy

  • Pulmonary function test


  • Treatment: 

    • Oxygenation

      • Heliox

    • Securing airway (視阻塞位置而定)

      • Endotracheal intubation 盡可能大號endo (for bronchoscopy), avoid trauma/obstruction

      • Awake intubation may be safer; with Fowler’s position; short-acting medications for rapid control of general anaesthesia to preserve spontaneous ventilation

      • Rigid bronchoscopic intubation (oxygenation + ventilation)

      • ECMO support for bridging to final intervention

    • Bronchoscopy 

      • Immediately (for foreign body or almost complete airway occlusion)

      • Within the first 12 to 24 hours (for high grade occlusion in an otherwise stable, ventilated patient)

  • 注意可能共併SVC syndrome

  • Glucocorticoids

  • Treat underlying disease

  • Secure airway

  • Endovenous recanalization with SVC stent placement

  • Systemic anticoagulation for thrombus


〈Take home message〉

  1. 臨床遇到病患同時出現stridor和wheezing時要懷疑Severe central airway obstruction (CAO)。

  2. 若遇到central airway obstruction的病患合併呼吸衰竭須插管時，awake intubation 或使用短效的鎮靜&肌鬆藥物是相對較安全的做法。

  3. 遇到central airway obstruction的病患應盡早安排支氣管鏡進行診斷兼治療評估。

  4. 若central airway obstruction 病患插管後有ventilation failure 狀況，可考慮ECMO使用。


〈Reference〉

  1. Clinical presentation, diagnostic evaluation, and management of central airway obstruction in adults. Uptodate. Last updated: Sep 23, 2021.

  2. Petersson J, Glenny RW. Gas exchange and ventilation-perfusion relationships in the lung. Eur Respir J. 2014;44(4):1023-1041. doi:10.1183/09031936.00037014

  3. Wood DE. Management of malignant tracheobronchial obstruction. Surg Clin North Am. 2002;82(3):621-642. doi:10.1016/s0039-6109(02)00025-7

  4. Erdös G, Tzanova I. Perioperative anaesthetic management of mediastinal mass in adults. Eur J Anaesthesiol. 2009;26(8):627-632. doi:10.1097/EJA.0b013e328324b7f8

  5. Hartigan PM, Karamnov S, Gill RR, et al. Mediastinal Masses, Anesthetic Interventions, and Airway Compression in Adults: A Prospective Observational Study. Anesthesiology. 2022;136(1):104-114. doi:10.1097/ALN.0000000000004011

  6. Lin J, Frye L. The intersection of bronchoscopy and extracorporeal membrane oxygenation. J Thorac Dis. 2021;13(8):5176-5182. doi:10.21037/jtd-2019-ipicu-08

  7. Abdelmalak B, Marcanthony N, Abdelmalak J, Machuzak MS, Gildea TR, Doyle DJ. Dexmedetomidine for anesthetic management of anterior mediastinal mass. J Anesth. 2010;24(4):607-610. doi:10.1007/s00540-010-0946-x

  8. Williamson JP, Phillips MJ, Hillman DR, Eastwood PR. Managing obstruction of the central airways. Intern Med J. 2010;40(6):399-410. doi:10.1111/j.1445-5994.2009.02113.x

  9. Ernst A, Feller-Kopman D, Becker HD, Mehta AC. Central airway obstruction. Am J Respir Crit Care Med. 2004;169(12):1278-1297. doi:10.1164/rccm.200210-1181SO

  10. Malignancy-related superior vena cava syndrome. Uptodate. Last updated: Mar 23, 2022.





Edited by Ming-Ying, Chiang

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