VV-ECMO–Assisted High-Risk Endobronchial Stenting as Rescue for Asphyxiating Mediastinal Mass

Abstract

The use of venovenous extracorporeal membrane oxygenation (VV-ECMO) has traditionally been limited to a narrow set of clinical circumstances, such as acute hypoxic respiratory failure, submassive pulmonary embolism, and cardiopulmonary collapse. Within the pediatric population, there have been cases of VV-ECMO in the context of extrinsic airway compression by a mediastinal mass, typically in the setting of either a lymphoma or germ cell tumors. However, the use of VV-ECMO for adults with extrinsic airway compression is comparatively limited. More specifically, VV-ECMO has been used as a bridge for tracheal reconstruction in both children and adults. Although, it has not been used in adults in the context of palliative endobronchial stent placement. We present a case of a 49-year-old woman with refractory multiple myeloma and extramedullary plasmacytoma presenting with acute hypoxic respiratory failure from extrinsic airway compression by a mediastinal plasmacytoma. We were able to use VV-ECMO to assist with endobronchial stent placement, followed by radiation therapy, and ultimately hospital discharge. In this article, we also review the literature surrounding VV-ECMO for extrinsic airway compression.

Rescue extracorporeal membrane oxygenation for massive anterior mediastinal masses

“…The use of ECMO in a subtotal thyroidectomy with distorted airway as a means for oxygenation has been reported [ 8 ]. Others have also reported the use of ECMO for the duration of surgery when resecting mediastinal and bronchoscopic masses [ 9 – 11 ]. Placing the patient on ECMO eliminates the need for constant airway ventilation during surgery allowing for better oncological resection.…”

VV-ECMO for surgical cure of a critical central airway obstruction

“…A review of the literature regarding the use of ECMO in other patients used as a replacement for endotracheal intubation when there are concerns of significant extrinsic airway compression from mediastinal masses is warranted [[3], [4], [5], [6], [7], [8]]. The mediastinal masses in these cases were of varying etiologies, including: goiter, plasmacytoma, seminoma, lymphoma, and in our patient, follicular adenoma (Table 1) [[3], [4], [5], [6]]. Shao et al., described severe rheumatoid arthritis as a major influencing factor into their decision to pursue ECMO over endotracheal intubation [7].…”

“…This is in addition to the risk of airway compromise from airway compression that was already present from the patient's goiter. It is also interesting to note that Nokes et al., had used ECMO for bronchial stenting rather than for surgery [3]. This was a palliative intervention in a patient with metastatic multiple myeloma.…”

“…[7]Multinodular goiterVA-ECMOSubtotal thyroidectomySevere rheumatoid arthritisNone reportedNokes et al. [3]PlasmacytomaVV-ECMOEndobronchial stent placementMultiple myelomaNone reportedWorku et al. [5]Diffuse B-cell lymphomaVA-ECMOInduction chemotherapyCrohn's diseaseNone reportedLueck et al.…”

“…Its applications are diverse and largely for supportive measures only, typically in the context of severe acute respiratory distress syndrome (ARDS) [2]. However, ECMO by veno-venous route (VV-ECMO) and veno-arterial route (VA-ECMO) have also been extensively described as a perioperative rescue or replacement of endotracheal intubation in the setting of extrinsic airway compression due to a mediastinal mass [[3], [4], [5]]. In this paper, we will outline the utility of ECMO in the context of extrinsic airway compression.…”