Chest
Volume 112, Issue 1, July 1997, Pages 202-206
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Clinical Investigations in Critical Care: Articles
Therapeutic Rigid Bronchoscopy Allows Level of Care Changes in Patients With Acute Respiratory Failure From Central Airways Obstruction

https://doi.org/10.1378/chest.112.1.202Get rights and content

Objective

To determine whether emergency rigid bronchoscopic intervention, including Nd-YAG laser resection or stenting, immediately affected the need for continued mechanical ventilation or intensive care level of support in critically ill patients with acute respiratory failure from malignant or benign central airways obstruction.

Design

Retrospective review of medical records of all patients with acute respiratory failure and malignant or benign tracheobronchial obstruction necessitating intubation, mechanical ventilation, or hospitalization in the ICU prior to referral for therapeutic bronchoscopy.

Setting

University of California San Diego, a tertiary care institution specialized in airway management.

Patients

Medical records of 32 patients with malignant or benign central airways obstruction requiring admission to the ICU prior to rigid bronchoscopic intervention between January 1994 and April 1996.

Interventions

Emergent rigid bronchoscopy with dilatation, Nd-YAG laser resection, or silicone stent insertion performed in the operating room under general anesthesia.

Results

Thirty-two patients with central airways obstruction requiring emergent hospitalization in the ICU were referred for therapeutic rigid bronchoscopy. Airway strictures were caused by benign disease in 18 patients, and by primary bronchogenic lung cancer in 14. Of the 19 patients who were mechanically ventilated, bronchoscopic intervention allowed immediate discontinuation of mechanical ventilation in 10 (52.6%). Twenty-five patients had indwelling artificial airways (12 endotracheal tubes, 13 tracheotomy tubes). Two, however, were considered tracheotomy-dependent because of neuromuscular disease. Of the remaining 23 patients, immediate extubation or decannulation was possible in seven (30.4%). Of seven patients with no indwelling airway, five (71.4%) were immediately transferred to a lower level of care after intervention. Of the 32 total patients, 20 (62.5%) were immediately transferred to a lower level of care immediately after intervention.

Conclusions

Emergency laser resection or stent insertion can favorably affect health-care utilization in patients with acute respiratory distress from central airways obstruction. Treatment may be lifesaving and allows successful withdrawal from mechanical ventilation, hospitalization in a lower level of care environment, relief of symptoms, and extended survival in critically ill patients. In patients with regionally advanced cancer, the palliative nature of this procedure postpones death by respiratory distress and may prompt consideration for institution of conservative comfort measures to reduce patient suffering.

Section snippets

Materials and Methods

The medical records of all patients emergently admitted to the ICU of the University of California Medical Center for rigid bronchoscopic intervention between January 1994 and April 1996 were reviewed. All patients had acute onset of respiratory failure from benign or malignant tracheobronchial obstruction, and had been referred to our Pulmonary Special Procedures and Nd-YAG Laser Unit for bronchoscopic management of central airways obstruction. Hospital records and procedure notes were

Results

Between January 1994 and April 1996, a total of 278 individuals were referred to the Pulmonary Special Procedures and Nd-YAG Laser Unit for rigid bronchoscopic intervention. Of this group, 32 critically ill patients (13 male, 19 female) were emergently admitted to the ICU with acute respiratory failure and bronchoscopic evidence of near total or complete central airway obstruction. Thirty patients were directly transferred from other institutions and two were admitted into the ICU from the

Discussion

Concerns for increased health-care expenditures oblige us to repeatedly evaluate the impact of new technologies and procedures on health-care utilization, particularly for patients with life-threatening illnesses. Although the efficacy of therapeutic rigid bronchoscopy, laser resection, and stenting is well recognized for palliation of dyspnea, cough, or hemoptysis, few investigators have attempted to evaluate the impact of these procedures on hospitalization costs or medical management

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revision accepted December 27.

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