Management of life-threatening malignant central airway obstruction: A novel approach of using extracorporeal membrane oxygenation with tumor debulking and stenting

Abstract

Extracorporeal membrane oxygenation (ECMO) is an artificial lung or heart used to oxygenate and circulate blood. Veno-venous ECMO is most commonly used as an emergency therapy in patients with acute respiratory distress syndrome (ARDS), but it has the potential to be useful in other respiratory-related diseases. We report a case where ECMO successfully allowed for interventional pulmonary procedures in a patient with life-threatening tracheal obstruction secondary to lung cancer, requiring tumor debulking and silicone Y stent placement. The patient was a 44-year-old male who was admitted to the intensive care unit (ICU) for an advanced stage subcarinal tumor invading into the trachea and bilateral main stem bronchi. The tumor was unresectable, and the first attempt to debulk the tumor was terminated due to the risk of complete airway occlusion. With the help of ECMO, the second attempt at tumor debulking was successful, and a Y stent was placed. The patient regained ventilation in both lungs and was transferred out of the ICU on day 2 post-op. The pathology confirmed squamous cell carcinoma, programmed death-ligand 1 (PD-L1) 99%. The patient received immunotherapy after hospital discharge. ECMO has the potential to be useful for patients with severe tracheal obstructions and compromised respiratory systems. For patients with certain types of lung cancer, who are good candidates for novel immunotherapies and targeted therapies, it offers a potential bridging therapy for procedures that would otherwise be too dangerous and should be considered when traditional treatments for these patients fail.

Keywords: Extracorporeal membrane oxygenation (ECMO); Immunotherapy; Malignant central airway obstruction; Tracheobronchial stent.

Fig. 1

CT showed subcarinal tumor invading into the carina.

Fig. 2

PET showed hypermetabolic subcarinal mass.

Fig. 3

The flexible bronchoscopy showed the tumor right above the carina.

Fig. 4

Tumor debulking with ECMO support.

Fig. 5

Y stent was placed (trachea view).

Fig. 6

Y stent was placed (carina view).