bi 2 practical approach tracheaobronchial aspergillosis 1 acute tracheobronchial aspergillosis...

BI 2 Practical Approach Tracheaobronchial Aspergillosis

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Acute Tracheobronchial Aspergillosis

► Learning Objectives► To describe airway findings

in acute tracheobronchial aspergillosis

► To discuss timing issues for airway stenting in the setting of tracheal stenosis and concurrent active aspergillus tracheobronchitis

► To review the medical treatment of acute tracheobronchial aspergillosis


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The Practical Approach

Initial Evaluation Procedural Strategies

Techniques and Results

Long term Management

• Examination and, functional status

• Significant comorbidities

• Support system• Patient preferences and

expectations

• Indications, contraindications, and results

• Team experience • Risk-benefits analysis and

therapeutic alternatives• Informed Consent

• Anesthesia and peri-operative care

• Techniques and instrumentation

• Anatomic dangers and other risks

• Results and procedure-related complications

• Outcome assessment• Follow-up tests and

procedures• Referrals• Quality improvement


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Case Description (Practical approach #2)

Initial EvaluationHistory and Physical► BB is a 55-year-old female with the remote

history of pulmonary tuberculosis which was treated with antituberculous drugs for two years 35 years ago.

► Post-TB tracheal stenosis was diagnosed 10 years ago and treated with laser and dilation at outside hospital.

► She was asymptomatic until now. During the last 2 weeks, she had increasing productive cough of yellowish-green sputum, dyspnea, fever with chills, and gradually lost her voice.


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Initial Evaluation

Medications►Patient was unresponsive to a two-week

course of Levaquin and prednisone (40 mg/day with tapering regimen).

► Inhaled fluticasone 100 ug twice daily for several years


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Initial Evaluation

History and physical►She was hospitalized due to

respiratory distress and stridor.►Bronchoscopy revealed central airway

obstruction ►Patient had worsening cough,

dyspnea, (NYHC class IV), and complete loss of her voice.


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Initial Evaluation

Past medical history►Pulmonary TB 35 years ago and

treated with anti-TB medication for 2 years, unclear on what medication she was given.

Family history: noncontributory Social history: separated, travels widely,

no tobacco, drugs, or alcohol; lives alone.

Patient expectation: relief of dyspnea and cough, return to work


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Initial Evaluation

Physical examination►BP 168/86 mmHg, P 110/min, T 36.9,

RR 22, mild distress (sitting position), significant dyspnea with cough, completely lost voice, O2 saturation 95% (room air)

►Lungs: coarse breath sounds, wheezing bilaterally and stridor.

►Otherwise exam was normal.


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Initial Evaluation

Initial laboratory data►CBC: Hgb 13.4 g/dl, Hct 39.3%, WBC

7.6, 91% neutrophils, platelets 388►Blood chemistry: BUN 11, Cr 0.7, AST

21, ALT 14, AP 41, TB 0.5 mg/dl


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Chest CT and 3D CT external rendering

Note tracheal stricture and right upper lobe collapse


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Procedural Strategies

►Flexible bronchoscopy: to evaluate the airway stenosis and collect samples for microbiology, cytology.

►Rigid bronchoscopy was planned to evaluate the potential for laser and/or tracheal dilation to relieve stenosis and possible stent placement.


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Procedural Strategies► No contraindications for the procedures. ► Risk-benefit analysis * With regard to the tracheal stenosis, she had

significant signs of airway narrowing but no hypoxemia.

► Flexible bronchoscopy performed in the ICU. Patient could be endotracheally intubated to stabilize the airway in case of worsening respiratory distress from significant airway collapse during or after the procedure.

► Team with experience.► Consent was obtained including education about

risk and benefits of silicone stents, and therapeutic alternatives including metal stents. Patient told that a metal stent would not be inserted because of risk of granulation tissue formation.


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Procedural Techniques and Results

Anesthesia and perioperative care► Flexible bronchoscopy: included awake

intubation to prevent significant upper airway collapse and loss of airway; only local anesthesia with 1% lidocaine was performed for laryngeal analgesia to prevent laryngospasm and laryngeal reflexes (trismus, bradycardia, tachycardia, hypotension, hypertension)


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► Normal hypopharynx ► Large thick yellow material on

the vocal cords, and subglottis.

► White pseudomembranes covering the posterior membrane of the entire trachea to the carina and extending down the posterior membrane of left main bronchus and on the spur of the left upper and left lower lobe bronchi.


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Types of acute tracheobronchial aspergillosis

► A) Obstructive► B) Ulcerative► C) Pseudomembranous

A B C

Denning DW. Thorax 2005;50:812


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►Circumferential narrowing in the mid trachea narrowed to 7 mm

►Right upper lobe bronchus was closed from fibrosis from old TB


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Anesthesia and perioperative care►Rigid bronchoscopy: general

anesthesia using spontaneous assisted ventilation


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Rigid Bronchoscopy Finding► 12-mm EFER-Dumon rigid

ventilating bronchoscope► White material extending

from subglottis to carina was removed, as well as membranes from left main bronchus and spur of left upper lobe and left lower lobe bronchi and the right main bronchus

► Airway stricture in mid trachea reduced to 7 mm


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►The rigid bronchoscope was used to dilate the stricture to 12 mm and remove the pseudomembranous material.

►Bronchial washing, biopsies were done for microbiology, cytology and histopathology.

►At the end of the procedure, airway patency had been restored.


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► Minimal bleeding was controlled by laser photocoagulation (low power density, total 436 joules, 1 second, 30 watt pulse)

► Silicone stent was not placed at the time of original procedure due to massive airway infection from Aspergillus; the airway patency, however, was established by rigid bronchoscopic dilation.

► No complications. ► Voriconazole and nebulized amphotericin B

were given.


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Pathology

► Bronchial washing and biopsies: branching septate fungal hyphae and necrosis


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Rationale: Treatment for Acute Tracheobronchial Aspergillosis

► Amphotericin B (conventional, nebulized) (IA) Denning DW. Lancet Inf Dis 2003;3:230

► Liposomal amphotericin► Voriconazole (IA) Denning DW. Lancet Inf Dis 2003;3:230

Better efficacy in immunocompromised hosts Herbrecht R. New Engl Med 2002;347:408

► Oral triazole: itraconazole (immunocompetent hosts, adjunctive treatment)

Camuset J. Rev Pneumol Clin 2007;63:155

► Caspofungin (case reports)► + Debridement (in destructive and necrotizing) Berlinger NT. Ann Otol Rhino Laryngol 1989;98:718


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Long-term Management

Outcome► Flexible bronchoscopy 1

week later showed improvement of airway mucosa with residual pseudomembranes in the trachea. Hemiparesis of the left cord was seen.

► Patient’s voice became stronger but not normal.


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Long-term ManagementOutcome► Flexible bronchoscopy

performed 3 weeks after the procedure showed substantial improvement of airway mucosa in the trachea, right main and left main bronchus without distal airway involvement. No evidence of disease was seen on the vocal cords. The vocal cords were mobile.

► Dyspnea improved, voice returned but patient continued to have cough and be off work

Narrow RMB


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Follow-up tests and procedures► Outpatient flexible bronchoscopy to evaluate

improvement in the airways. ► Whole body CT scan to look for malignancies or

abscess formation: Results negative► Complete blood tests for immune deficiencies

including, HIV status, immunoglobulins, complement levels and chronic granulomatous disease: All results negative

► Continue antifungal medications initially for 3 months but based on previous studies and case reports, the treatment duration is likely to be at least six months.

► Consider stent placement if the infection resolved


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Follow-up

► Nine weeks later, she had had mild dyspnea over the last 3 weeks and a sudden episode of acute dyspnea the night before and caused her to come to the emergency room. She denied fever, recent increase in cough.

► On examination, she could not speak in full sentences. The lung examination revealed mild diffuse crackles and some minimal use of accessory respiratory muscles. Otherwise were within normal.


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Follow-up

Flexible bronchoscopy ► No evidence of Aspergillus in the

larynx and vocal cords, trachea or bronchi.

► Complex stricture at mid trachea extending for approximately 2.5 cm and narrowing the airway to 5 mm

► Known absence of RUL bronchus. Known narrowing of Right main bronchus and RML bronchus. Normal-appearing RLL bronchus and left bronchial tree.

Assessment and plan► Rigid bronchoscopy with laser

resection, dilatation and silicone stent insertion for relief of stenosis.


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► Trachea was dilated with 13 mm rigid bronchoscope.

► A large Hood flange stent 35 mm long X16 mm wide was inserted within the mid trachea such that distal aspect of the stent was approximately 2.5 cm above the carina, and the proximal aspect of the stent was 5 cm below the vocal cords.


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► Stent care instructions given

► Stent migration one month later prompted rigid bronchoscopy with stent removal and stent replacement using 14 X 50 mm studded silicone stent.

► Stent well tolerated indefinitely.

To view video, please see Video Archive PA 2


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Bronchoscopy International: Practical Approach©, an Electronic On-Line Multimedia Slide Presentation. http://www.Bronchoscopy.org/PracticalApproach/htm. Published 2009 (Please add “Date Accessed”).

Thank you


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Presentation created with help from Prapaporn Pornsuriyasak, MD (Thailand)


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bi 2 practical approach tracheaobronchial aspergillosis 1 acute tracheobronchial aspergillosis...

Documents

initial evaluation history

significant dyspnea

years inhaled fluticasone

medical history pulmonary

lost voice

work slide

airway findings

airway stenting