Laser phototherapy (LPT) utilizing the neodymium-yttrium-aluminum-garnet (Nd:YAG) laser has been shown to be an effective tool in the therapy of malignant endobronchial obstruction12 especially when combined with radiation therapy. While LPT is generally safe, there are potential complications which can increase morbidity and mortality. We present a case of endobronchial fire during LPT and report long-term follow-up after successful outcome with no residual damage resulting from the occurrence.
A 65-year-old woman with squamous cell carcinoma (left upper lobe resection in June, 1985) was admitted to another hospital in November, 1985 with dyspnea and chest pain. Physical examination revealed pulse rate of 88/min; respirations, 24/min; blood pressure, 164/94 mm Hg; inspiratory and expiratory rhonchi and diffuse wheezes. The chest x-ray film showed elevation of the left hemi-diaphragm with well expanded left lower lobe. Arterial blood gas determinations showed: pH, 7.37; Po2, 49; Pco2, 46 (room air). Over nine days of therapy with bronchodilators and antibiotics, she developed stridor with Pco2 increasing to 55. She was transferred to our hospital.
Examination upon arrival showed a normal upper airway, labored respirations at 30/min, pulse rate of 126/min, and blood pressure, 126/90 mm Hg without pulsus paradoxus; arterial blood gas levels: FIo2, 0.45; pH, 7.58; Po2, 56; Pco2, 47. Lung auscultation revealed coarse rhonchi and wheezes diffusely. Chest x-ray film findings were unchanged from above. She received intensive bronchodilator therapy; however, over seven hours her Pco2 increased and Po2 declined. She was intubated and mechanically ventilated.
Fiberoptic bronchoscopic examination was performed 20 hours after admission (findings are given in Table 1, item 1). Thirty-six hours after admission, bradycardia, hypotension, and cardiac dysrhythmia developed. A pulmonary artery oximetry catheter showed: CV£ 4.0; PAE 18/11; PCWI? 5.0; CO, 4.3; Sv02, 75 percent Her hemodynamic status remained unstable. Emergency LPT was done under general anesthesia using enflu-rane and Fentanyl 44 hours after admission (Fig 1A). The 9.0 mm endotracheal tube (ETT) cuff was distended with water. An Olympus BF 2TR flexible fiberoptic bronchoscope (FOB) and Nd:YAG laser system (Molectron 8000) were used.
Table 1—Nd:YAG Laser Treatment and Bronchoscopic Findings
|No.||Date||Pulses||Duration(s)||Energy(watts)||Power(joules)||FIo2||02 Sat (oximeter)||Bronchoscopic Findings*|
|1||12-4-85||0.5||2 cm mass at level of carina with distortion. (RMBt) 5 mm (opening diameter); (LMBt) less than 1 mm|
|2||12-5-85||201||0.7||30-52||4763||0.5||93-97||RMB 5 mm; LMB l-2mm|
|3||12-5-85||65||0.7||15-22||768||0.5-1.0||90-93||Widespread carbonization of distal trachea and carina from endobronchial fire; RMB 5 mm, LMB 2 mm|
|4||12-7-85||0.5||2 cm mass at carina with distortion. Diffuse inflammation of the distal trachea and carina. RMB 3mm, LMB 0mm|
|5||12-10-85||371||0.7||15-35||7757||0.4||88-95||RMB 6mm, LMB 0mm|
|6||12-11-85||676||0.7||25-54||20060||0.4-0.6||90-96||RMB 6mm, LMB 5mm|
|7||12-12-85||452||0.7||25-50||12920||0.4||93-99||RMB 8mm, LMB 6mm|
|8||1-15-86||0.35||93-99||Diffuse erythema of distal trachea and both mainstem bronchi. Slightly widened carina. RMB 8mm, LMB 6mm|
|9||2-6-87||Posterior tracheal mass located 2 cm proximal to carina with less than 10% obstruction of tracheal lumen. No evidence of tumor in either mainstem. Rounded mass in the left lower lobe bronchus just distal to superior segment take-off with 90 + % obstruction of the lumen. RMB 8mm, LMB 6mm|
Figure 1. Pre-treatment (A, upper), and post-treatment (B, lower) bronchoscopic findings. The left main bronchus lumen (less than 1 mm diameter) and right main bronchus lumen (5 mm diameter) were occluded by metastatic squamous cell carcinoma of the lung. Complete patency was restored as seen six weeks later.