The document discusses airway emergencies in patients with malignancies. It covers causes of airway obstruction including primary tumors or metastases in the head, neck, lungs or mediastinum. Evaluation involves CT scans and bronchoscopy while treatment depends on whether the obstruction is proximal or distal. For proximal obstruction, tracheostomy or endotracheal intubation may be used. Distal obstruction may be treated with bronchoscopy, stents or radiotherapy. Definitive therapies aim to relieve the airway obstruction through procedures like laser resection or brachytherapy to allow further oncologic treatment.
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. 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
4. Proximal
Airways
• Hypopharynx
• Larynx
•Trachea up to
the carina
EMCON 2011 at Kolkatha, India 16 to 20 November 2011
5. Distal
Airway •Mainstem
•Lobar
bronchi
•Distal
radicals.
EMCON 2011 at Kolkatha, India 16 to 20 November 2011
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. 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. 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. Oncology
Airway
Standard airway
management
strategies may fail
or become
inappropriate
Issues &
challenges
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. 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. Oncologic
Airway
Cough
Dyspnea
Wheezing
Infection
Atelectasis
Respiratory failure
Death.
Obstructive
lesions
EMCON 2011 at Kolkatha, India 16 to 20 November 2011
13. Oncologic
Airway
Level &
Degree of
obstruction
Symptoms
•Minimal stridor
•Complete airway
obstruction
EMCON 2011 at Kolkatha, India 16 to 20 November 2011
14. Oncologic
Airway • Primary
pathology
• Secondary causes
Inflammation
Edema
Bleeding
EMCON 2011 at Kolkatha, India 16 to 20 November 2011
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. Airway
obstruction
Intra luminal
External
compression
EMCON 2011 at Kolkatha, India 16 to 20 November 2011
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. 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. 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
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. 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
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. 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. 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. 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. 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. 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. 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
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. 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. 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. 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. Oncology Airway
TREATMENT STRATEGIES
TO SECURE THE AIRWAY
EMCON 2011 at Kolkatha, India 16 to 20 November 2011
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. 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. 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. 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. 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. Proximal airway
obstruction
The patient is
uncooperative or
in severe
respiratory
distress -
Surgical airway
Caution
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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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
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. 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. • Cryotherapy,
• Brachytherapy
• Photodynamic
therapy
Central Airway
Obstruction
Palliative setting
Definitive therapy
Delayed effects
EMCON 2011 at Kolkatha, India 16 to 20 November 2011
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. 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. 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. 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. 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. 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
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. 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