Respiratory failure with hilar mass: Role of endobronchial ultrasound-guided transbronchial needle aspiration in the medical intensive care unit

Abstract

We report the case of a 58-year-old man on chronic steroid therapy, who developed a rapidly progressive right upper lobe infiltrate/mass that extended into the right hilum. Respiratory failure necessitated endotracheal intubation. Broad spectrum antibiotics were initiated without clinical improvement and because of his immunosuppressive therapy opportunistic pathogens were considered. Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) was performed in the Medical Intensive Care Unit (MICU) with rapid onsite evaluation. Specimens obtained from the right hilar mass revealed organisms suspicious for cryptococcal infection, subsequently confirmed via a culture. No complications occurred during the EBUS procedure despite the patient requiring vasopressor support and 100% inspired oxygen. Little data exists regarding the use of EBUS in patients admitted to the MICU with respiratory failure of unknown etiology and mediastinal/hilar lymphadenopathy. This case illustrates the potential safe use of EBUS-TBNA in patients presenting with respiratory failure, with a mediastinal or hilar mass and suspected infectious etiology.

Endoscopic ultrasound (with an echobronchoscope)-guided fine-needle aspiration for diagnosis of a mediastinal lesion in a mechanically ventilated patient: A case report and systematic review of the literature

“…Mediastinal or hilar lesions in critically ill patients can be approached endoscopically by the pulmonologist through the airway using TBNA that can be performed with or without EBUS guidance. Both conventional and EBUS-guided TBNA have been described in patients with respiratory failure, who are mechanically ventilated through an endotracheal tube;[ 5 6 7 ] however, they are not performed frequently. This is because a small-sized endotracheal tube does not allow the entry of the echobronchoscope (insertion tube diameter, 6.9 mm).…”

“…A systematic review of the PubMed database using the search string: (EBUS OR “endobronchial ultrasound” OR “endoscopic ultrasound” OR echobronchoscope OR echoendoscope OR endosonography OR “transbronchial needle aspiration”) AND (ICU OR “intensive care unit” OR “critically ill” OR “mechanical ventilation*” OR “mechanically ventilated” OR intubated OR “endotracheal tube”) yielded 10 reports (62 patients) of endoscopic interventions (conventional TBNA, EBUS-TBNA, EUS-FNA, or EUS-B-FNA) for mediastinal/hilar lesions in critically ill patients [ Table 1 ]. [ 5 6 7 8 9 10 11 13 14 15 ] Forty-six patients could be diagnosed successfully resulting in an overall yield of 74.2%; there were no major complications. Moreover, the diagnostic information obtained from the procedure led to a change in the treatment decision in most of these patients (49/62; 79%).…”

An evolving role for endobronchial ultrasonography in the intensive care unit

“…A majority of diagnosed patients (4 out of 7) had malignant disease (48). In a separate case report, Chichra et al elaborated on a case of cryptococcal right hilar mass diagnosed with EBUS-TBNA (49).…”