Presentation is loading. Please wait.

Presentation is loading. Please wait.

BI 2 Practical Approach Tracheaobronchial Aspergillosis 1 Acute Tracheobronchial Aspergillosis Learning Objectives Learning Objectives To describe airway.

Similar presentations


Presentation on theme: "BI 2 Practical Approach Tracheaobronchial Aspergillosis 1 Acute Tracheobronchial Aspergillosis Learning Objectives Learning Objectives To describe airway."— Presentation transcript:

1 BI 2 Practical Approach Tracheaobronchial Aspergillosis 1 Acute Tracheobronchial Aspergillosis Learning Objectives Learning Objectives To describe airway findings in acute tracheobronchial aspergillosis 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 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 To review the medical treatment of acute tracheobronchial aspergillosis

2 BI 2 Practical Approach Tracheaobronchial Aspergillosis 2 The Practical Approach Initial EvaluationProcedural Strategies Techniques and ResultsLong term Management Examination and, functional status Examination and, functional status Significant comorbidities Significant comorbidities Support system Support system Patient preferences and expectations Patient preferences and expectations Indications, contraindications, and results Indications, contraindications, and results Team experience Team experience Risk-benefits analysis and therapeutic alternatives Risk-benefits analysis and therapeutic alternatives Informed Consent Informed Consent Anesthesia and peri-operative care Anesthesia and peri-operative care Techniques and instrumentation Techniques and instrumentation Anatomic dangers and other risks Anatomic dangers and other risks Results and procedure-related complications Results and procedure-related complications Outcome assessment Outcome assessment Follow-up tests and procedures Follow-up tests and procedures Referrals Referrals Quality improvement Quality improvement

3 BI 2 Practical Approach Tracheaobronchial Aspergillosis 3 Case Description (Practical approach #2) Initial Evaluation History 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. 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. 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. 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.

4 BI 2 Practical Approach Tracheaobronchial Aspergillosis 4 Initial Evaluation Medications Patient was unresponsive to a two-week course of Levaquin and prednisone (40 mg/day with tapering regimen). 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 Inhaled fluticasone 100 ug twice daily for several years

5 BI 2 Practical Approach Tracheaobronchial Aspergillosis 5 Initial Evaluation History and physical She was hospitalized due to respiratory distress and stridor. She was hospitalized due to respiratory distress and stridor. Bronchoscopy revealed central airway obstruction Bronchoscopy revealed central airway obstruction Patient had worsening cough, dyspnea, (NYHC class IV), and complete loss of her voice. Patient had worsening cough, dyspnea, (NYHC class IV), and complete loss of her voice.

6 BI 2 Practical Approach Tracheaobronchial Aspergillosis 6 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. 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

7 BI 2 Practical Approach Tracheaobronchial Aspergillosis 7 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) 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. Lungs: coarse breath sounds, wheezing bilaterally and stridor. Otherwise exam was normal. Otherwise exam was normal.

8 BI 2 Practical Approach Tracheaobronchial Aspergillosis 8 Initial Evaluation Initial laboratory data CBC: Hgb 13.4 g/dl, Hct 39.3%, WBC 7.6, 91% neutrophils, platelets 388 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 Blood chemistry: BUN 11, Cr 0.7, AST 21, ALT 14, AP 41, TB 0.5 mg/dl

9 BI 2 Practical Approach Tracheaobronchial Aspergillosis 9 Chest CT and 3D CT external rendering Chest CT and 3D CT external rendering Note tracheal stricture and right upper lobe collapse

10 BI 2 Practical Approach Tracheaobronchial Aspergillosis 10 Procedural Strategies Flexible bronchoscopy: to evaluate the airway stenosis and collect samples for microbiology, cytology. 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. Rigid bronchoscopy was planned to evaluate the potential for laser and/or tracheal dilation to relieve stenosis and possible stent placement.

11 BI 2 Practical Approach Tracheaobronchial Aspergillosis 11 Procedural Strategies No contraindications for the procedures. No contraindications for the procedures. Risk-benefit analysis Risk-benefit analysis * With regard to the tracheal stenosis, she had significant signs of airway narrowing but no hypoxemia. * 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. 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. 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. 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.

12 BI 2 Practical Approach Tracheaobronchial Aspergillosis 12 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) 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)

13 BI 2 Practical Approach Tracheaobronchial Aspergillosis 13 Procedural Techniques and Results Normal hypopharynx Normal hypopharynx Large thick yellow material on the vocal cords, and subglottis. 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. 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.

14 BI 2 Practical Approach Tracheaobronchial Aspergillosis 14 Types of acute tracheobronchial aspergillosis A) Obstructive A) Obstructive B) Ulcerative B) Ulcerative C) Pseudomembranous C) Pseudomembranous AB C Denning DW. Thorax 2005;50:812

15 BI 2 Practical Approach Tracheaobronchial Aspergillosis 15 Procedural Techniques and Results Circumferential narrowing in the mid trachea narrowed to 7 mm Circumferential narrowing in the mid trachea narrowed to 7 mm Right upper lobe bronchus was closed from fibrosis from old TB Right upper lobe bronchus was closed from fibrosis from old TB

16 BI 2 Practical Approach Tracheaobronchial Aspergillosis 16 Procedural Techniques and Results Anesthesia and perioperative care Rigid bronchoscopy: general anesthesia using spontaneous assisted ventilation Rigid bronchoscopy: general anesthesia using spontaneous assisted ventilation

17 BI 2 Practical Approach Tracheaobronchial Aspergillosis 17 Procedural Techniques and Results Rigid Bronchoscopy Finding 12-mm EFER-Dumon rigid ventilating bronchoscope 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 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 Airway stricture in mid trachea reduced to 7 mm

18 BI 2 Practical Approach Tracheaobronchial Aspergillosis 18 Procedural Techniques and Results The rigid bronchoscope was used to dilate the stricture to 12 mm and remove the pseudomembranous material. 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. Bronchial washing, biopsies were done for microbiology, cytology and histopathology. At the end of the procedure, airway patency had been restored. At the end of the procedure, airway patency had been restored.

19 BI 2 Practical Approach Tracheaobronchial Aspergillosis 19 Procedural Techniques and Results Minimal bleeding was controlled by laser photocoagulation (low power density, total 436 joules, 1 second, 30 watt pulse) 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. 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. No complications. Voriconazole and nebulized amphotericin B were given. Voriconazole and nebulized amphotericin B were given.

20 BI 2 Practical Approach Tracheaobronchial Aspergillosis 20 Pathology Bronchial washing and biopsies: branching septate fungal hyphae and necrosis Bronchial washing and biopsies: branching septate fungal hyphae and necrosis

21 BI 2 Practical Approach Tracheaobronchial Aspergillosis 21 Rationale: Treatment for Acute Tracheobronchial Aspergillosis Amphotericin B (conventional, nebulized) (IA) Amphotericin B (conventional, nebulized) (IA) Denning DW. Lancet Inf Dis 2003;3:230 Denning DW. Lancet Inf Dis 2003;3:230 Liposomal amphotericin Liposomal amphotericin Voriconazole (IA) Voriconazole (IA) Denning DW. Lancet Inf Dis 2003;3:230 Denning DW. Lancet Inf Dis 2003;3:230 Better efficacy in immunocompromised hosts Better efficacy in immunocompromised hosts Herbrecht R. New Engl Med 2002;347:408 Herbrecht R. New Engl Med 2002;347:408 Oral triazole: itraconazole (immunocompetent hosts, adjunctive treatment) Oral triazole: itraconazole (immunocompetent hosts, adjunctive treatment) Camuset J. Rev Pneumol Clin 2007;63:155 Camuset J. Rev Pneumol Clin 2007;63:155 Caspofungin (case reports) Caspofungin (case reports) + Debridement (in destructive and necrotizing) + Debridement (in destructive and necrotizing) Berlinger NT. Ann Otol Rhino Laryngol 1989;98:718 Berlinger NT. Ann Otol Rhino Laryngol 1989;98:718

22 BI 2 Practical Approach Tracheaobronchial Aspergillosis 22 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. Flexible bronchoscopy 1 week later showed improvement of airway mucosa with residual pseudomembranes in the trachea. Hemiparesis of the left cord was seen. Patients voice became stronger but not normal. Patients voice became stronger but not normal.

23 BI 2 Practical Approach Tracheaobronchial Aspergillosis 23 Long-term Management Outcome 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. 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 Dyspnea improved, voice returned but patient continued to have cough and be off work Narrow RMB

24 BI 2 Practical Approach Tracheaobronchial Aspergillosis 24 Long-term Management Follow-up tests and procedures Outpatient flexible bronchoscopy to evaluate improvement in the airways. Outpatient flexible bronchoscopy to evaluate improvement in the airways. Whole body CT scan to look for malignancies or abscess formation: Results negative 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 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. 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 Consider stent placement if the infection resolved

25 BI 2 Practical Approach Tracheaobronchial Aspergillosis 25 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. 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. 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.

26 BI 2 Practical Approach Tracheaobronchial Aspergillosis 26 Follow-up Flexible bronchoscopy No evidence of Aspergillus in the larynx and vocal cords, trachea or bronchi. 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 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. 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. Rigid bronchoscopy with laser resection, dilatation and silicone stent insertion for relief of stenosis.

27 BI 2 Practical Approach Tracheaobronchial Aspergillosis 27 Procedural Techniques and Results Trachea was dilated with 13 mm rigid bronchoscope. 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. 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.

28 BI 2 Practical Approach Tracheaobronchial Aspergillosis 28 Long-term Management Stent care instructions given 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 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. Stent well tolerated indefinitely. To view video, please see Video Archive PA 2

29 BI 2 Practical Approach Tracheaobronchial Aspergillosis 29 All efforts are made by Bronchoscopy International to maintain currency of online information. All published multimedia slide shows, streaming videos, and essays can be cited for reference as: 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

30 BI 2 Practical Approach Tracheaobronchial Aspergillosis 30 Presentation created with help from Prapaporn Pornsuriyasak, MD (Thailand)

31 BI 2 Practical Approach Tracheaobronchial Aspergillosis 31 Thank you www.bronchoscopy.org


Download ppt "BI 2 Practical Approach Tracheaobronchial Aspergillosis 1 Acute Tracheobronchial Aspergillosis Learning Objectives Learning Objectives To describe airway."

Similar presentations


Ads by Google