PREOPERATIVE DIAGNOSES:
1. Acute respiratory failure.
2. Obstructing tumor, distal left main stem bronchus.
3. Postobstructive pneumonia.
POSTOPERATIVE DIAGNOSES:
1. Acute respiratory failure.
2. Obstructing tumor, distal left main stem bronchus.
PROCEDURES PERFORMED:
1. Flexible bronchoscopy with debridement and ablation of distal left main bronchial tumor at the secondary carina.
2. Therapeutic aspiration of the airways.
SURGEON: John Doe, MD
DISPOSITION: The patient remains in the surgical intensive care unit in stable condition.
INDICATIONS FOR PROCEDURE: The patient is a (XX)-year-old man who was admitted to the hospital after he suffered an ascending colon perforation 2 days following polypectomy for a malignant colon polyp.
He underwent a right hemicolectomy. In the postoperative period, he developed respiratory failure. He had abnormal ventilator mechanics.
A bronchoscopy had been performed by the ICU service and this revealed an obstructing lesion in the distal left main stem bronchus. This lesion arose from the secondary carina and this mushroomed out and obstructed the lumen to both the left upper lobe and left lower lobe bronchi.
The patient’s wife was counseled on the risks, benefits, and alternatives to a flexible bronchoscopy with ablation of the tumor and therapeutic aspiration of the airways in order to improve airway patency, resolve pneumonia and with a goal of getting the patient off of mechanical ventilation.
DETAILS OF PROCEDURE: The flexible bronchoscopy was performed in the ICU at the bedside. The patient was given sedation with a total of 2 mg of Ativan IV and 200 mcg of fentanyl IV. This was given sequentially throughout the procedure to those total doses.
The airway was treated topically with 1% lidocaine. Flexible thoracoscopy was performed. The distal trachea, right main stem bronchus, right upper lobe, right middle lobe, and right lower lobe bronchi were all normal.
The proximal left main stem bronchus was normal. The distal left main bronchus was obstructed by a polypoid lesion projecting from the secondary carina. We could squeeze the bronchoscope past the lesions superiorly and inferiorly and then through this compressed area, opened up into the obstructed bronchi. The bronchoscope was pulled back.
Inspired oxygen was dropped to below 50% or less, and then, using a hot snare, the tumor was debrided and portions were sent for pathologic evaluation.
Once the tumor was debrided back to the base of the lesion in the thickened area of carina, the base of the lesion was coagulated with the Argon plasma coagulator cauterizing tissue back to allowing a fully patent proximal left upper lobe and left lower lobe bronchi.
As the purulent mucus was aspirated from the left upper lobe and left lower lobe bronchi, it was then irrigated and aspirated clear. There was good hemostasis.
A significant amount of mucus was aspirated from the upper lobe and lower lobe bronchi. The patient tolerated the procedure well without incident. The bronchoscope was removed, and the patient remained in the ICU in satisfactory condition.
We should note that a time-out was held prior to the procedure confirming the correct patient and the correct procedure.
