Long-term Survival after Endobronchial Fire during Treatment of Severe Malignant Airway Obstruction: Case Report

Both arterial oxygen saturation (SaOg) (Biox II ear oximeter) and mixed venous oxygen saturation (SvOa) were monitored. Her hemodynamic status became unstable and she required Flog 0.5 to maintain Sa02 above 90 percent and Sv02 above 60 percent Table 1, item 2 gives the laser settings and bronchoscopic findings. During LPT directed to the left main bronchus, the Teflon-coated laser fiber (TCF) tip was maintained 1 cm distal to the bronchoscope and 1 cm from the treatment site. After 201 pulses, the TCF was damaged and failed to function properly. Another TCF was not available. Since insufficient improvement in left main bronchus patency had been achieved, LPT was continued using an 0.6 mm quartz monofilament fiber without Teflon sheath (NTCF) (designed for intravascular procedures and lacking an air-feeding jacket). After 38 pulses were delivered uneventfully over 5-10 minutes, she became hypotensive and the Sa02 dropped below 90 percent. She was stablized over 15 minutes. Administration of enflurane was stopped and the FIo2 increased to 1.0.

The laser operator, unaware of the FIo2 of 1.0, resumed LPT. After 27 pulses over 4-5 min, microincineration with flash fire and explosive sound occurred. The endobronchial portions of the FOB, NTCF, ETT, and anesthesia circuit caught fire immediately, and were withdrawn within seconds, disconnected from the anesthesia machine, and the gases were turned off. The vigorously burning ETT and anesthesia circuit were extinguished by stepping on them. The distal FOB insertion tube melted. The patient was initially mask ventilated, then reintubated. Her airways were inspected (Table 1, item 3). She was given methylprednisolone 40 mg IY racemic epinephrine 0.3 ml by aerosol, and continued on mechanical ventilator in the ICU. Arterial blood gas levels 45 min later were: pH, 7.41; Po2, 63; Pco2, 48 (FlOa 0.5). A chest film showed total opacification of the left hemithorax. Emergency radiation therapy was begun. Her Karnofsky score was 10 percent.
Her clinical status remained critical and required FIo2 0.4 to 0.8 to maintain her Po2 above 60 mm Hg. Significant worsening of the airway narrowing had occurred by 48 hours after the fire. She required several therapeutic bronchoscopic procedures for alleviation of mucous plugging and three additional LPT sessions (Table 1, items 4-7) to establish full patency of both main bronchi. The chest film slowly showed improvement as her condition stabilized. She was weaned from ventilatory support, extubated on the 19th hospital day and discharged home 23 days after admission. Room air arterial blood gas levels at discharge were: pH, 7.45; Po2, 72; Pco2, 37.
By six weeks after the fire, she has received 4,500 rads of radiation therapy, her chest film has returned to baseline, and her Karnofsky score improved to 90 percent The bronchoscopic appearance is summarized in Table 1, item 8 (Fig 1B). Pulmonary function testing ten months after the fire showed: FVC, 2.25; FEVU 1.50; Deo, 10.0; and KCO, 3.13 (respectively 79, 72, 47, and 67 percent of predicted). She had a recurrence of tumor in February, 1987 unamenable to LPT (Table 1, item 9), and received additional radiation therapy to the mediastinum. Transient improvement was seen. She lived at home with her family, maintaining a Karnofsky score of 50-60 percent until September, 1987. She died with respiratory failure nearly 23 months after the endobronchial fire.

Category: Airway Obstruction

Tags: airway, endobronchial fire, trachea