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yet despite the use of very low oxygen volumes&#44; prolonged expiratory times&#44; and vasopressor therapy with very high doses of noradrenaline&#46; The auscultation confirmed the presence of a very acute inspiratory wheezing at the sternal region&#46; In this context&#44; the patient suffered from two consecutive episodes of cardiac arrest of 10 and 5<span class="elsevierStyleHsp" style=""></span>min duration&#44; respectively with electromechanical dissociation from which she recovered precariously through cardiac massage and adrenaline&#44; followed by very severe hypoxemia&#44; hypercapnia and acidosis &#40;SatO<span class="elsevierStyleInf">2</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>50&#37;&#44; PaCO<span class="elsevierStyleInf">2</span> above the upper range of the gasometer and pH 6&#46;7&#41;&#44; and extreme hemodynamic instability that required vasopressor support at fairly high doses&#46; On suspicion of central airway obstruction &#40;CAO&#41;&#44; the medical team decided to conduct one fibrobronchoscopy under circulatory and respiratory assistance using extracorporeal membrane oxygenation &#40;ECMO&#41;&#46; This procedure was conducted in the operating room under general anesthesia through open femoro-femoral cannulation and veno-arterial assistance&#46; The fibrobronchoscopy conducted confirmed the almost complete obstruction of the tracheal lumen due to the presence of a white material of mamelonated appearance that was later biopsized obtaining a fibrin-leukocytarian material and mucoid without atypia &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#41;&#46; The argon-plasma coagulation electrocautery procedure allowed enough tracheal lumen to facilitate ventilation and improve gas exchange and hemodynamics&#44; leading the team to disconnect the ECMO at the very operating room&#46; On suspicion of an inflammatory process&#44; pulse methylprednisolone therapy &#40;0&#46;5<span class="elsevierStyleHsp" style=""></span>g IV&#41; was started followed by antibiotic therapy&#46; Some 12<span class="elsevierStyleHsp" style=""></span>h later&#44; while the patient was in a more stable hemodynamic and respiratory condition&#44; one thoracoabdominal CT scan was conducted that confirmed the presence of concentric thickening of the tracheal wall and main bronchi&#44; pneumomediastinum&#44; left hydropneumothorax&#44; thoracoabdominal subcutaneous emphysema&#44; and pneumoretroperitoneum &#40;<a class="elsevierStyleCrossRef" href="#fig0015">Fig&#46; 3</a>&#41;&#46; The left hydropneumothorax was drained and one rigid bronchoscopy was conducted that confirmed less inflammatory material and tracheobronchial occupation&#46; Even so&#44; contemplating the possibility of recurrence&#44; a Y-shaped tracheobronchial tube was implanted&#46; The patient&#39;s prognosis was favorable and she experienced a total neurological and cardiorespiratory recovery that allowed the early withdrawal &#40;&#8764;<span class="elsevierStyleHsp" style=""></span>24<span class="elsevierStyleHsp" style=""></span>h&#41; of mechanical ventilation and&#44; eventually&#44; hospital discharge without any sequelae&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0010" class="elsevierStylePara elsevierViewall">All the microbiological studies including bacteria&#44; mycobacteria&#44; fungi&#44; viruses and the biopsized material culture tested negative&#46; On suspicion of inflammatory bowel disease &#40;IBD&#41;&#44; the serological markers tested positive for ANCA-c and anti-<span class="elsevierStyleItalic">Saccharomyces cerevisiae</span> antibodies&#46; The endoscopic studies showed pancolitis and aphtous ileitis consistent with Crohn&#39;s disease&#44; and the biopsies confirmed the presence of &#8220;focal active ileitis and diffuse active colitis&#44; with architectural distortion&#44; surface irregularity&#44; and inflammatory infiltrate in the lamina propria of moderate intensity by lymphocytes&#44; plasma cells&#44; and neutrophils&#44; with neutrophil exocytosis&#44; cryptic abscesses and basal plasmacytosis without granulomas&#8221;&#8212;all of it consistent with IBD&#46; Today the patient is still on steroids and azathioprine with an acceptable control of the disease&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">The CAO is extremely rare&#44; and its diagnosis requires high clinical suspicion&#44; which is difficult in the absence of pathological history&#46;<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">1</span></a> It usually kicks in with cough&#44; respiratory failure&#44; and wheezing&#46; At times&#44; it can even simulate a process of asthmatic crisis or acute bronchitis&#46; A simple X-ray can show data of hyperinflation and&#44; in extreme cases&#44; signs of barotrauma due to entrapment&#46; Also&#44; the CT scan can show circumferential or nodular narrowing of the trachea and main bronchi&#46; For diagnostic purposes&#44; the morphology of the flow-volume loop that shows the intrathoracic obstruction in both phases of the respiratory cycle can be useful&#46;<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">2</span></a> Bronchoscopy is definitely the diagnostic and therapeutic procedure of choice&#46; In the most serious cases&#44; the use of ECMO can help with the therapeutic rescue and recent medical literature reports isolated cases with high survival rates&#46;<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">3</span></a> The type of cannulation and assistance that should be used&#44; whether veno-arterial or veno-venous&#44; depends on the clinical situation we are dealing with&#46; The veno-arterial option allows respiratory and hemodynamic support&#44; and it is the option of choice in patients in shock or who have suffered a cardiac arrest&#46; The veno-venous option should do in situations of hemodynamic stability when gas exchange is an issue&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">Extraintestinal manifestations of the IBD could involve almost every organ system&#44; being pulmonary damage the less common of all&#44; with a prevalence &#62;0&#46;5&#37;&#46;<a class="elsevierStyleCrossRefs" href="#bib0070"><span class="elsevierStyleSup">4&#44;5</span></a> The pathogenic mechanism is still unknown&#44; but it is common to the inflammatory process affecting the intestine&#46;<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">6</span></a> It usually occurs years after the diagnosis of IBD&#44; when the disease goes into remission or after one colectomy&#44; being pulmonary damage&#44; exceptional<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">7</span></a> and tracheobronchial damage&#44; incidental&#46; Thus&#44; until now only 11 cases of CAO<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">8</span></a> have been reported&#44; none of them serious&#46; The data available on these cases show how effective systemic or inhaled steroid treatment really is<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">8</span></a>&#59; occasionally it will be necessary to resort to bronchoscopic techniques to maintain airway patency&#46;<a class="elsevierStyleCrossRefs" href="#bib0095"><span class="elsevierStyleSup">9&#44;10</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">The case we presented here is unheard of due to its dramatic clinical presentation&#44; to its exceptionality given the CAO occurred at the beginning of the IBD&#59; and because it gave the medical team the opportunity to use ECMO allowing therapeutic rescue in a case whose outcome would have been dramatic in other circumstances&#46; It is the first case ever reported of rescue with ECMO&#44;<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">3</span></a> without a prior diagnosis&#44; with impossibility of ventilation&#44; and obstructive shock with cardiac arrest&#46;</p></span>"
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Scientific Letter
Central airway obstruction due to inflammatory bowel disease and rescue with extracorporeal membrane oxygenation
Obstrucción de la vía aérea central por enfermedad inflamatoria intestinal y rescate terapéutico con membrana de oxigenación extracorpórea
M. Ramírez-Romeroa,
Corresponding author
, B. Hernández-Alonsoa, C. García-Polob, A.J. Abraldes-Bechiarellic, A. Garrino-Fernándeza, A. Gordillo-Brenesa
a Servicio de Medicina Intensiva, Hospital Universitario Puerta del Mar, Cádiz, Spain
b Servicio de Neumología, Hospital Universitario Puerta del Mar, Cádiz, Spain
c Servicio de Aparato Digestivo, Hospital Universitario Puerta del Mar, Cádiz, Spain
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yet despite the use of very low oxygen volumes&#44; prolonged expiratory times&#44; and vasopressor therapy with very high doses of noradrenaline&#46; The auscultation confirmed the presence of a very acute inspiratory wheezing at the sternal region&#46; In this context&#44; the patient suffered from two consecutive episodes of cardiac arrest of 10 and 5<span class="elsevierStyleHsp" style=""></span>min duration&#44; respectively with electromechanical dissociation from which she recovered precariously through cardiac massage and adrenaline&#44; followed by very severe hypoxemia&#44; hypercapnia and acidosis &#40;SatO<span class="elsevierStyleInf">2</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>50&#37;&#44; PaCO<span class="elsevierStyleInf">2</span> above the upper range of the gasometer and pH 6&#46;7&#41;&#44; and extreme hemodynamic instability that required vasopressor support at fairly high doses&#46; On suspicion of central airway obstruction &#40;CAO&#41;&#44; the medical team decided to conduct one fibrobronchoscopy under circulatory and respiratory assistance using extracorporeal membrane oxygenation &#40;ECMO&#41;&#46; This procedure was conducted in the operating room under general anesthesia through open femoro-femoral cannulation and veno-arterial assistance&#46; The fibrobronchoscopy conducted confirmed the almost complete obstruction of the tracheal lumen due to the presence of a white material of mamelonated appearance that was later biopsized obtaining a fibrin-leukocytarian material and mucoid without atypia &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#41;&#46; The argon-plasma coagulation electrocautery procedure allowed enough tracheal lumen to facilitate ventilation and improve gas exchange and hemodynamics&#44; leading the team to disconnect the ECMO at the very operating room&#46; On suspicion of an inflammatory process&#44; pulse methylprednisolone therapy &#40;0&#46;5<span class="elsevierStyleHsp" style=""></span>g IV&#41; was started followed by antibiotic therapy&#46; Some 12<span class="elsevierStyleHsp" style=""></span>h later&#44; while the patient was in a more stable hemodynamic and respiratory condition&#44; one thoracoabdominal CT scan was conducted that confirmed the presence of concentric thickening of the tracheal wall and main bronchi&#44; pneumomediastinum&#44; left hydropneumothorax&#44; thoracoabdominal subcutaneous emphysema&#44; and pneumoretroperitoneum &#40;<a class="elsevierStyleCrossRef" href="#fig0015">Fig&#46; 3</a>&#41;&#46; The left hydropneumothorax was drained and one rigid bronchoscopy was conducted that confirmed less inflammatory material and tracheobronchial occupation&#46; Even so&#44; contemplating the possibility of recurrence&#44; a Y-shaped tracheobronchial tube was implanted&#46; The patient&#39;s prognosis was favorable and she experienced a total neurological and cardiorespiratory recovery that allowed the early withdrawal &#40;&#8764;<span class="elsevierStyleHsp" style=""></span>24<span class="elsevierStyleHsp" style=""></span>h&#41; of mechanical ventilation and&#44; eventually&#44; hospital discharge without any sequelae&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0010" class="elsevierStylePara elsevierViewall">All the microbiological studies including bacteria&#44; mycobacteria&#44; fungi&#44; viruses and the biopsized material culture tested negative&#46; On suspicion of inflammatory bowel disease &#40;IBD&#41;&#44; the serological markers tested positive for ANCA-c and anti-<span class="elsevierStyleItalic">Saccharomyces cerevisiae</span> antibodies&#46; The endoscopic studies showed pancolitis and aphtous ileitis consistent with Crohn&#39;s disease&#44; and the biopsies confirmed the presence of &#8220;focal active ileitis and diffuse active colitis&#44; with architectural distortion&#44; surface irregularity&#44; and inflammatory infiltrate in the lamina propria of moderate intensity by lymphocytes&#44; plasma cells&#44; and neutrophils&#44; with neutrophil exocytosis&#44; cryptic abscesses and basal plasmacytosis without granulomas&#8221;&#8212;all of it consistent with IBD&#46; Today the patient is still on steroids and azathioprine with an acceptable control of the disease&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">The CAO is extremely rare&#44; and its diagnosis requires high clinical suspicion&#44; which is difficult in the absence of pathological history&#46;<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">1</span></a> It usually kicks in with cough&#44; respiratory failure&#44; and wheezing&#46; At times&#44; it can even simulate a process of asthmatic crisis or acute bronchitis&#46; A simple X-ray can show data of hyperinflation and&#44; in extreme cases&#44; signs of barotrauma due to entrapment&#46; Also&#44; the CT scan can show circumferential or nodular narrowing of the trachea and main bronchi&#46; For diagnostic purposes&#44; the morphology of the flow-volume loop that shows the intrathoracic obstruction in both phases of the respiratory cycle can be useful&#46;<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">2</span></a> Bronchoscopy is definitely the diagnostic and therapeutic procedure of choice&#46; In the most serious cases&#44; the use of ECMO can help with the therapeutic rescue and recent medical literature reports isolated cases with high survival rates&#46;<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">3</span></a> The type of cannulation and assistance that should be used&#44; whether veno-arterial or veno-venous&#44; depends on the clinical situation we are dealing with&#46; The veno-arterial option allows respiratory and hemodynamic support&#44; and it is the option of choice in patients in shock or who have suffered a cardiac arrest&#46; The veno-venous option should do in situations of hemodynamic stability when gas exchange is an issue&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">Extraintestinal manifestations of the IBD could involve almost every organ system&#44; being pulmonary damage the less common of all&#44; with a prevalence &#62;0&#46;5&#37;&#46;<a class="elsevierStyleCrossRefs" href="#bib0070"><span class="elsevierStyleSup">4&#44;5</span></a> The pathogenic mechanism is still unknown&#44; but it is common to the inflammatory process affecting the intestine&#46;<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">6</span></a> It usually occurs years after the diagnosis of IBD&#44; when the disease goes into remission or after one colectomy&#44; being pulmonary damage&#44; exceptional<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">7</span></a> and tracheobronchial damage&#44; incidental&#46; Thus&#44; until now only 11 cases of CAO<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">8</span></a> have been reported&#44; none of them serious&#46; The data available on these cases show how effective systemic or inhaled steroid treatment really is<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">8</span></a>&#59; occasionally it will be necessary to resort to bronchoscopic techniques to maintain airway patency&#46;<a class="elsevierStyleCrossRefs" href="#bib0095"><span class="elsevierStyleSup">9&#44;10</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">The case we presented here is unheard of due to its dramatic clinical presentation&#44; to its exceptionality given the CAO occurred at the beginning of the IBD&#59; and because it gave the medical team the opportunity to use ECMO allowing therapeutic rescue in a case whose outcome would have been dramatic in other circumstances&#46; It is the first case ever reported of rescue with ECMO&#44;<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">3</span></a> without a prior diagnosis&#44; with impossibility of ventilation&#44; and obstructive shock with cardiac arrest&#46;</p></span>"
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Article information
ISSN: 21735727
Original language: English
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2019 October 41 16 57
2019 September 41 27 68
2019 August 31 22 53
2019 July 25 31 56
2019 June 20 20 40
2019 May 36 36 72
2019 April 13 42 55
2019 March 19 25 44
2019 February 18 35 53
2019 January 27 37 64
2018 December 22 31 53
2018 November 47 89 136
2018 October 13 13 26
2018 July 0 2 2
2018 June 0 1 1
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¿Es usted profesional sanitario apto para prescribir o dispensar medicamentos?

Are you a health professional able to prescribe or dispense drugs?