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Airway emergencies in oncology

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EMCON2011 ppt

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Airway emergencies in oncology

  1. 1. Airway Emergencies in Oncology Venugopalan P.P DA,DNB,MNAMS Chief ,Emergency Medicine ,MIMS,CLT,India Site Director ,Masters program in EM ,GWU ,USA Executive Director ,ANGELS EMCON 2011 at Kolkatha, India 16 to 20 November 2011
  2. 2. 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
  3. 3. Oncology Airway Proximal Distal EMCON 2011 at Kolkatha, India 16 to 20 November 2011
  4. 4. Proximal Airways • Hypopharynx • Larynx •Trachea up to the carina EMCON 2011 at Kolkatha, India 16 to 20 November 2011
  5. 5. Distal Airway •Mainstem •Lobar bronchi •Distal radicals. EMCON 2011 at Kolkatha, India 16 to 20 November 2011
  6. 6. Airway “Upper airway - part above the mid-trachea & Lower airway - distal to the mid trachea” EMCON 2011 at Kolkatha, India 16 to 20 November 2011
  7. 7. Oncology Head and neck cancer Larynx, pharynx and oral cavity dominant cancers in males and third in overall incidence in females Causes EMCON 2011 at Kolkatha, India 16 to 20 November 2011
  8. 8. Oncology • Primary or metastatic tumors • Head, neck, lung or mediastinum • Obstruction at larynx, trachea or bronchi Causes EMCON 2011 at Kolkatha, India 16 to 20 November 2011
  9. 9. Oncology Airway Standard airway management strategies may fail or become inappropriate Issues & challenges
  10. 10. Oncology Airway • Proximal upper airway obstruction can be bypassed by tracheostomy • Lower airway obstruction may not be bypassed Issues & challenges EMCON 2011 at Kolkatha, India 16 to 20 November 2011
  11. 11. Oncologic Airway Clinical differentiation between upper and lower airway obstructions may not be always possible EMCON 2011 at Kolkatha, India 16 to 20 November 2011
  12. 12. Oncologic Airway Cough Dyspnea Wheezing Infection Atelectasis Respiratory failure Death. Obstructive lesions EMCON 2011 at Kolkatha, India 16 to 20 November 2011
  13. 13. Oncologic Airway Level & Degree of obstruction Symptoms •Minimal stridor •Complete airway obstruction EMCON 2011 at Kolkatha, India 16 to 20 November 2011
  14. 14. Oncologic Airway • Primary pathology • Secondary causes  Inflammation Edema Bleeding EMCON 2011 at Kolkatha, India 16 to 20 November 2011
  15. 15. Oncologic Airway Airway obstruction • Impairs airflow • Increase the work of breathing • Alters cardiopulmonary interactions Signs & symptoms EMCON 2011 at Kolkatha, India 16 to 20 November 2011
  16. 16. Airway obstruction Intra luminal External compression EMCON 2011 at Kolkatha, India 16 to 20 November 2011
  17. 17. Oncology Airway • Superior vena cava syndrome • Recurrent laryngeal nerve palsy More issues & challenges EMCON 2011 at Kolkatha, India 16 to 20 November 2011
  18. 18. Oncology Airway • EPs to manage airway in uncontrolled environment • Manage airway crises at suboptimal conditions. Additional issues & challenges in E R EMCON 2011 at Kolkatha, India 16 to 20 November 2011
  19. 19. Oncology Airway • Poor general conditions • Suboptimal physiologic reserve • Cost factors • Ethical issues of aggressive resuscitation efforts Additional issues & challenges in E R EMCON 2011 at Kolkatha, India 16 to 20 November 2011
  20. 20. Oncology Airway WHAT SHOULD BE THE MANAGEMENT GOAL?
  21. 21. 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
  22. 22. Oncology Airway • It should not interfere with future definitive therapy. • Economical • Minimize hospitalization. What should be the management goal? EMCON 2011 at Kolkatha, India 16 to 20 November 2011
  23. 23. Rapid actions…. IDENTIFY THE LIFE THREATS!!
  24. 24. Emergent “Restless, diaphoretic, tachycardic, unable to lie down, using accessory muscles and cyanotic” Stridor Sign of severe laryngeal or tracheal obstruction Severe Obstruction EMCON 2011 at Kolkatha, India 16 to 20 November 2011
  25. 25. Emergent ... • Paradoxical breathing • Intercostal retractions. • Silent chest • Prolonged inspiratory and expiratory phase • Inspiratory and expiratory wheeze Total or Near total obstruction EMCON 2011 at Kolkatha, India 16 to 20 November 2011
  26. 26. Emergent ... “As the asphyxiation becomes worse , the patients appear cyanotic and obtunded and develop bradycardia” Every second …. Counts in terms of life EMCON 2011 at Kolkatha, India 16 to 20 November 2011
  27. 27. Caution Rapid evaluation to rule out foreign body or blood clot as a cause Acute life-threatening upper airway obstruction EMCON 2011 at Kolkatha, India 16 to 20 November 2011
  28. 28. Urgent Unable to tolerate supine position and more comfortable in sitting or leaning forward position. Mediastinal tumors & associated airway obstruction EMCON 2011 at Kolkatha, India 16 to 20 November 2011
  29. 29. Urgent • Unilateral wheezing • Persistent unilateral wheezing should always prompt the investigation of focal airway obstruction. Airway obstruction distal to the carina. EMCON 2011 at Kolkatha, India 16 to 20 November 2011
  30. 30. Urgent • Nonspecific symptoms like positional wheezing • Shortness of breath and wheezing are typically unresponsive to bronchodilators Anatomically fixed obstruction EMCON 2011 at Kolkatha, India 16 to 20 November 2011
  31. 31. Oncology Airway EVALUATION AND DIAGNOSIS
  32. 32. Oncology airway • ABG ,Spirometry & CXR – Not much value • CT Scan – Standard • Three dimensional reconstruction with internal (virtual bronchoscopy) and external images Support ABC EMCON 2011 at Kolkatha, India 16 to 20 November 2011
  33. 33. Oncology airway • Direct visualization • Level, Degree and Extend of obstruction • Diagnostic - Biopsy • Curative - Excision • Palliative – Stents/ Debulking Bronchoscopy •Rigid •Flexible EMCON 2011 at Kolkatha, India 16 to 20 November 2011
  34. 34. Caution • Can act as a double-edged sword. • May further precipitate the obstruction, making the patient hypoxic. Bronchoscopy Moderate to severe airway obstruction EMCON 2011 at Kolkatha, India 16 to 20 November 2011
  35. 35. Caution • Access to a team equipped for advanced airway management • Access to equipment for emergency airway control Bronchoscopy Moderate to severe airway obstruction EMCON 2011 at Kolkatha, India 16 to 20 November 2011
  36. 36. Oncology Airway TREATMENT STRATEGIES TO SECURE THE AIRWAY EMCON 2011 at Kolkatha, India 16 to 20 November 2011
  37. 37. Proximal airway obstruction • Emergency Physician • Chest radiologists • Anesthesiologists • Medical oncologists • Head and neck and Thoracic surgeons • Intensivist. Knowledge • Etiology • Physiology • Diagnostic • Treatment EMCON 2011 at Kolkatha, India 16 to 20 November 2011
  38. 38. Proximal airway obstruction • Establish airway most efficiently • Controlled environment like Operation Theatre • Position of comfort • Supplemental oxygen. Immediate goal Acute airway obstruction EMCON 2011 at Kolkatha, India 16 to 20 November 2011
  39. 39. Caution • Keep patient breathing spontaneously • Avoid any procedure that will precipitate total airway obstruction. EMCON 2011 at Kolkatha, India 16 to 20 November 2011
  40. 40. 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
  41. 41. Proximal airway obstruction • Avoid long acting sedatives, respiratory depressants and muscle relaxants . • Fibreoptic intubation-very limited role if tumor is bleeding. Caution EMCON 2011 at Kolkatha, India 16 to 20 November 2011
  42. 42. Proximal airway obstruction The patient is uncooperative or in severe respiratory distress - Surgical airway Caution
  43. 43. Proximal airway obstruction • Attempting intubation Can be disastrous • Competent surgeon to establish surgical airway. EMCON 2011 at Kolkatha, India 16 to 20 November 2011
  44. 44. Proximal airway obstruction • 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
  45. 45. Proximal airway obstruction • No role of emergency laryngectomy • No survival benefit. • Tracheostomy • Elective surgery at a later date Emergency laryngectomy? EMCON 2011 at Kolkatha, India 16 to 20 November 2011
  46. 46. Proximal airway obstruction • Life-saving Stab - cricothyrotomy • Tracheostomy later •Very combative patients in severe distress? •When patient can not even lie still for tracheostomy! EMCON 2011 at Kolkatha, India 16 to 20 November 2011
  47. 47. Proximal airway obstruction • Endotracheal intubation is preferred even in an emergency situation. • Tracheostomy should be avoided as far as possible as it can spread distally . EMCON 2011 at Kolkatha, India 16 to 20 November 2011
  48. 48. Distal airway obstruction • Rigid therapeutic bronchoscopy • Intubation & tracheotomy may not be of much use to alleviate the symptoms. Central airways obstruction EMCON 2011 at Kolkatha, India 16 to 20 November 2011
  49. 49. Distal airway obstruction • Critical airway obstruction • Helium-oxygen combination (80-20%) has been used effectively to tide over the crisis Heliox EMCON 2011 at Kolkatha, India 16 to 20 November 2011
  50. 50. Distal airway obstruction • 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
  51. 51. Distal airway obstruction • Prone position Ventilation • Radiation + corticosteroids • Empiric chemotherapy [Cyclophosphamide + Anthracycline or Vincristine] Anterior Mediastinal mass Acute emergencies EMCON 2011 at Kolkatha, India 16 to 20 November 2011
  52. 52. 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 EMCON 2011 at Kolkatha, India 16 to 20 November 2011
  53. 53. 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 EMCON 2011 at Kolkatha, India 16 to 20 November 2011
  54. 54. 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 EMCON 2011 at Kolkatha, India 16 to 20 November 2011
  55. 55. Oncology Airway DEFINITIVE THERAPY
  56. 56. 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 EMCON 2011 at Kolkatha, India 16 to 20 November 2011
  57. 57. Central airway obstruction 1.Laser resection 2.Endoscopic resection • Mechanical debridement • Electrocautery • Argon plasma coagulation • Stenting Palliative setting Definitive therapy Immediate relief EMCON 2011 at Kolkatha, India 16 to 20 November 2011
  58. 58. • Cryotherapy, • Brachytherapy • Photodynamic therapy Central Airway Obstruction Palliative setting Definitive therapy Delayed effects EMCON 2011 at Kolkatha, India 16 to 20 November 2011
  59. 59. 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 Brachytherapy EMCON 2011 at Kolkatha, India 16 to 20 November 2011
  60. 60. Caution “Radiotherapy may precipitate /exacerbate the obstruction by increasing peritumor edema or inducing intratumor hemorrhage” Radiotherapy EMCON 2011 at Kolkatha, India 16 to 20 November 2011
  61. 61. Airway stents • Airway stenting is the only endoluminal therapy available • Useful adjunct to providing coverage of endoluminal tumor Malignant obstruction from extrinsic disease EMCON 2011 at Kolkatha, India 16 to 20 November 2011
  62. 62. Airway Stents • Silicone stents • Expandable metal stents • Pneumatic dilators • Malignant airway obstruction- “Choice is covered models of metal stents, which prevent tumor ingrowth” EMCON 2011 at Kolkatha, India 16 to 20 November 2011
  63. 63. Definitive therapy • Radical resection with systemic nodal dissection • Benign and relatively short tracheal lesions • Lung or thyroid malignancies that invade the airway Resectable cancers EMCON 2011 at Kolkatha, India 16 to 20 November 2011
  64. 64. Definitive Therapy • Primary airway reconstruction. • Primary end-to-end anastomosis & tracheal sleeve resection Resection & reconstruction EMCON 2011 at Kolkatha, India 16 to 20 November 2011
  65. 65. Oncology Airway CONCLUSION
  66. 66. 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 EMCON 2011 at Kolkatha, India 16 to 20 November 2011
  67. 67. Conclusion • Emergency Physician • Anaesthetists • Intensivist • Surgeons • Medical oncologists • Radiation oncologists “Essential in delivering most appropriate intervention and minimize morbidity and hospital stay” EMCON 2011 at Kolkatha, India 16 to 20 November 2011
  68. 68. www.drvenu.net www.emergencymedicinemims.com www.angelsindia.org

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