Airway emergencies in oncology

Airway Emergencies in Oncology

Venugopalan P.PDA,DNB,MNAMS

Chief ,Emergency Medicine ,MIMS,CLT,IndiaSite Director ,Masters program in EM ,GWU ,USA

Executive Director ,ANGELS

EMCON 2011 at Kolkatha, India 16 to 20 November 2011

Objectives

• Explore the causes of airway emergency in malignancies.

• Review pathophysiologic considerations

• Special issues in airway management

• Specific management skills.• Recent advances and ethical issues EMCON 2011 at Kolkatha, India 16 to 20 November 2011

Oncology Airway Proximal

Distal


Proximal Airways

•Hypopharynx• Larynx •Trachea up to the carina


Distal Airway •Mainstem

•Lobar bronchi •Distal radicals.


Airway

“Upper airway - part above the mid-trachea & Lower airway - distal to the mid trachea”


Oncology Head and neck cancer Larynx, pharynx and oral cavity dominant cancers in males and third in overall incidence in females

Causes


Oncology • Primary or metastatic tumors• Head, neck, lung or mediastinum • Obstruction at larynx, trachea or bronchi

Causes


Oncology Airway

Standard airway management strategies may fail or become inappropriate

Issues & challenges

Oncology Airway • Proximal upper

airway obstruction can be bypassed by tracheostomy• Lower airway

obstruction may not be bypassed

Issues & challenges


Oncologic Airway

Clinical differentiation between upper and lower airway obstructions may not be always possible

Issues & challenges


Oncologic Airway

Cough DyspneaWheezingInfection Atelectasis Respiratory

failureDeath.

Obstructive lesions


Oncologic Airway

Level & Degree of obstruction

Symptoms

•Minimal stridor •Complete airway obstruction


Oncologic Airway

• Primary pathology • Secondary

causes InflammationEdema Bleeding

Worsened


Oncologic Airway Airway

obstruction• Impairs airflow • Increase the work

of breathing • Alters

cardiopulmonary interactions

Signs & symptoms


Airway obstruction

Pitfalls • Patients are often

misdiagnosed as asthma before the correct diagnosis is made.

Intra luminal

External compression


Oncology

Airway

• Superior vena cava syndrome• Recurrent

laryngeal nerve palsy

More issues & challenges


Oncology Airway

• EPs to manage airway in uncontrolled environment

• Manage airway crises at suboptimal conditions.

Additional issues & challenges in E R


Oncology Airway • Poor general

conditions• Suboptimal

physiologic reserve

• Cost factors • Ethical issues of

aggressive resuscitation efforts

Additional issues & challenges in E R


WHAT SHOULD BE THE MANAGEMENT GOAL?

Oncology Airway

Oncology Airway

Provide prompt relief of airway obstruction with low morbidity and mortality

Rapid and accurate diagnosis with proper management can be life-saving. EMCON 2011 at Kolkatha, India 16 to 20 November 2011

Oncology Airway

• It should not interfere with future definitive therapy.

• Economical • Minimize

hospitalization.

What should be the management goal?


IDENTIFY THE LIFE THREATS!!

Rapid actions….

Emergent “Restless, diaphoretic, tachycardic, unable to lie down, using accessory muscles and cyanotic”

Stridor

Sign of severe laryngeal or tracheal obstruction


SevereObstruction

Emergent ... • Paradoxical breathing • Intercostal

retractions. • Silent chest • Prolonged

inspiratory and expiratory phase

• Inspiratory and expiratory wheeze

Total or Near total obstruction


Emergent ...

“As the asphyxiation becomes worse , the patients appear cyanotic and obtunded and develop bradycardia”

Every second ….

Counts in terms of life


Caution Rapid evaluation

to rule out foreign body or blood clot as a cause

Acute life-threatening upper airway obstruction


Urgent Unable to

tolerate supine position and more comfortable in sitting or leaning forward position.

Mediastinal tumors & associated airway obstruction


Urgent • Unilateral wheezing

• Persistent unilateral wheezing should always prompt the investigation of focal airway obstruction.

Airway obstruction distal to the carina.


Urgent• Nonspecific

symptoms like positional wheezing

• Shortness of breath

and wheezing are typically unresponsive to bronchodilators

Anatomically fixed obstruction


EVALUATION AND DIAGNOSIS

Oncology Airway

Oncology airway

• ABG ,Spirometry & CXR – Not much value

• CT Scan – Standard • Three dimensional

reconstruction with internal (virtual bronchoscopy) and external images

Support ABC


Oncology airway

• Direct visualization• Level, Degree and

Extend of obstruction• Diagnostic - Biopsy• Curative - Excision• Palliative – Stents/

Debulking

Bronchoscopy

•Rigid •FlexibleEMCON 2011 at Kolkatha, India 16 to 20 November 2011

Caution • Can act as a double-edged sword.

• May further

precipitate the obstruction, making the patient hypoxic.

Bronchoscopy

Moderate to severe airway obstruction


Caution• Access to a team

equipped for advanced airway management

• Access to equipment for emergency airway control

Bronchoscopy

Moderate to severe airway obstruction


TREATMENT STRATEGIES TO SECURE THE AIRWAY

Oncology Airway


Proximal airway obstruction

• Emergency Physician• Chest radiologists• Anesthesiologists• Medical oncologists• Head and neck and

Thoracic surgeons • Intensivist.

Knowledge • Etiology• Physiology• Diagnostic• Treatment



• Establish airway most efficiently • Controlled

environment like Operation Theatre• Position of

comfort • Supplemental

oxygen.

Immediate goal

Acute airway obstruction


Caution • Keep patient breathing spontaneously • Avoid any

procedure that will precipitate total airway obstruction.


Proximal airway obstruction • Tracheotomy

• Cricothyrotomy. • Endotracheal intubation- smaller size tubes should be ready

Malignancies

Surgical airway

EMCON 2011 a Kolkatha, India 16 to 20 November 2011

Proximal airway obstruction • Avoid long acting

sedatives, respiratory depressants and muscle relaxants .

• Fibreoptic intubation- very limited role if tumor is bleeding.

Caution



The patient is uncooperative or in severe respiratory distress - Surgical airway

Caution

Proximal airway obstruction • Attempting

intubation Can be disastrous

• Competent surgeon to establish surgical airway.

Frag

iletu

mor

s

Cau

tion



• Bleed uncontrollably, making the situation worse

• Need very gentle handling

• Distorted anatomy make identification and visualization of glottic aperture difficult

Fragile hypopharyngeal tumors

Caution EMCON 2011 at Kolkatha, India 16 to 20 November 2011


• No role of emergency laryngectomy

• No survival benefit.• Tracheostomy • Elective surgery at a

later date

Emergency laryngectomy?



• Life-saving

Stab - cricothyrotomy

• Tracheostomy later

•Very combative patients in severe distress?

•When patient can not even lie still for tracheostomy!



• Endotracheal intubation is preferred even in an emergency situation.

• Tracheostomy should be avoided as far as possible as it can spread distally .

Pedi

atric

Lary

ngea

l

papi

llom

as


Distal airway obstruction

• Rigid therapeutic bronchoscopy

• Intubation & tracheotomy may not be of much use to alleviate the symptoms.

Central airways obstruction



• Critical airway obstruction

• Helium-oxygen combination (80-20%) has been used effectively to tide over the crisis

Heliox



• Steroids & definite chemotherapy - after proper diagnosis

• Sitting or left lateral positions

• Ventilation with face mask oxygen

• Non invasive PEEP.

Mediastinal mass

CT-guided core needle biopsy EMCON 2011 at Kolkatha, India 16 to 20 November 2011

Distal airway obstruction • Prone position

Ventilation• Radiation +

corticosteroids • Empiric

chemotherapy [Cyclophosphamide + Anthracycline or Vincristine]

Anterior Mediastinal mass

Acute emergencies


Treatment options • Femoro-femoral

cardiopulmonary bypass+ definitive therapy

• Endobronchial debulking of tumor

• Stenting + simultaneous chemotherapy.

• Veno-venous extracorporeal membrane

Extreme life-threatening airway obstruction not relieved by any means


Extrinsic airway obstruction

1.Avoid airway manipulation, muscle paralysis & general anesthesia.

2.Lateral, prone or sitting positions

3.Positive pressure support via facemask

4.Intravenous steroids 5.Awake fibreoptic

bronchoscopic intubation

Mediastinal masses


Extrinsic airway obstruction

6.Rigid bronchoscopy for endobronchial stenting

7.Standby ECMO 8.Urgent diagnosis +

specific therapy Surgery,

Chemotherapy, Radiotherapy and Palliative stenting.

Mediastinal masses


DEFINITIVE THERAPYOncology Airway

Oncology Airway • Airway is stabilized

more definitive treatment options can be considered

• Detailed and careful Bronchoscopy and imaging studies to plan additional measures.

Definitive Therapy


Central airway obstruction 1.Laser resection

2.Endoscopic resection

• Mechanical debridement

• Electrocautery • Argon plasma

coagulation • Stenting

Palliative setting

Definitive therapy

Immediate relief


• Cryotherapy,• Brachytherapy • Photodynamic therapy

Palliative setting

Definitive therapy

Delayed effects


Central Airway Obstruction

Definitive therapy • Radiation to be

delivered endobronchially thus minimizing exposure to normal tissue.

• Iridium-192 (192Ir)• Catheters can be

placed in upper lobe & segmental bronchi [Inaccessible to laser therapy]

External beam radiation

BrachytherapyEMCON 2011 at Kolkatha, India 16 to 20 November 2011

Caution

“Radiotherapy may precipitate /exacerbate the obstruction by increasing peritumor edema or inducing intratumor hemorrhage”

Radiotherapy


Airway stents

• Airway stenting is the only endoluminal therapy available • Useful adjunct to

providing coverage of endoluminal tumor

Malignant obstruction from extrinsic disease


Airway Stents

• Silicone stents• Expandable metal

stents • Pneumatic dilators

• Malignant airway obstruction-

“Choice is covered models of metal stents, which prevent tumor ingrowth”

Covered &

Uncovered


Definitive therapy

• Radical resection with systemic nodal dissection • Benign and

relatively short tracheal lesions• Lung or thyroid

malignancies that invade the airway

Resectable cancers


Definitive Therapy

• Primary airway reconstruction.

• Primary end-to-end anastomosis & tracheal sleeve resection

Resection & reconstruction


CONCLUSIONOncology Airway

Conclusion

In hypoxic patients establishment of airway and restoration of oxygenation and ventilation is most important.

Airway emergencies in cancer can be extrinsic, intrinsic or mixed & Fixed or dyanamic


Conclusion

• Emergency Physician• Anaesthetists• Intensivist• Surgeons• Medical oncologists • Radiation oncologists “Essential in delivering

most appropriate intervention and minimize morbidity and hospital stay”

The team approach


Thank you

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www.angelsindia.org

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Airway emergencies in oncology

Healthcare

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