Transcript Acute tracheobronchial Aspergillus

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
►
BI 2 Practical Approach Tracheaobronchial
Aspergillosis
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The Practical Approach
Initial Evaluation
Procedural Strategies
• 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
Techniques and Results
Long term Management
• Anesthesia and peri-operative
• Outcome assessment
care
• Follow-up tests and procedures
• Techniques and
• Referrals
instrumentation
• Quality improvement
• Anatomic dangers and other
risks
• Results and procedure-related
BI 2 Practical Approach Tracheaobronchial
complications
Aspergillosis
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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.
► 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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Aspergillosis
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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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Aspergillosis
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Procedural Techniques and Results
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
BI 2 Practical Approach Tracheaobronchial
Aspergillosis
Denning DW. Thorax 2005;50:812
C
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Procedural Techniques and Results
► 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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Procedural Techniques and Results
Anesthesia and perioperative care
► Rigid bronchoscopy: general anesthesia
using spontaneous assisted ventilation
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Procedural Techniques and Results
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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Procedural Techniques and Results
► 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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Procedural Techniques and Results
► 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
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Amphotericin B (conventional, nebulized) (IA)
Denning DW. Lancet Inf Dis 2003;3:230
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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
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Oral triazole: itraconazole (immunocompetent hosts,
adjunctive treatment)
Camuset J. Rev Pneumol Clin 2007;63:155
►
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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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Aspergillosis
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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 Narrow
cords were mobile.
RMB
► Dyspnea improved, voice
returned but patient continued
to have cough and be off work
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Long-term Management
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. Normalappearing 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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Procedural Techniques and Results
►
►
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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Long-term Management
► 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.
BI 2 Practical Approach Tracheaobronchial
Aspergillosis
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Aspergillosis
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Presentation created with help from Prapaporn
Pornsuriyasak, MD (Thailand)
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Aspergillosis
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Aspergillosis
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