Stem bronchus

DQ is a 57-year-old man who came to the emergency room because of shortness of breath. A radiographic examination demonstrates a large mass pressing on the bifurcation of the main stem bronchus. A biopsy demonstrates an aggressive lymphoma a five-drug chemotherapy regimen with both intravenous and intrathecal chemotherapy will start today. 

The right main stem bronchus is cross-clamped with a hemostat and the left lung is lavaged with 5 separate 15-mL aliquots of 0.9% NaCl containing 0.6 mM... 

EDTA at 37°C. The left main stem bronchus is then cross-clamped and the right lung is lavaged using the same protocol. 

B. Perform endotracheal intubation if personnel trained in the procedure are available. Intubation of the trachea provides the most reliable protection of the ainvay, preventing aspiration and obstmcfion and allowing for mechanically assisted ventilation. However, it is not a simple procedure and should be attempted only by those with training and experience. Complications include vomiting with pulmonary aspiration local trauma to the oropharynx, nasopharynx, and larynx inadvertent intubation of the esophagus or a main-stem bronchus and failure to intubate the patient after respiratory arrest has been... 

Check breathing sounds to rule out accidental esophageal intubation or intubation of the right main-stem bronchus. 

At fluoroscopy in the AP-projection, the vast majority of the bronchial arteries have their origin at the level where the left main stem bronchus over-lies the aorta, slightly below the level of the tracheal Carina (Fig. 16.3) [19,24). 

Fig. 16.3. a Fluoroscopic image demonstrating relationship of catheter tip with respect to left main stem bronchus (asterisk). b Selective angiography in same patient as (a) visualization of left bronchial artery... 

Ivanick MJ, Thorwarth W, Donohue J, Mandell V, Delany D, Jaques PF (1983) Infarction of the left main-stem bronchus a complication of bronchial artery embolization. AJR Am J Roentgenol 141 535-537... 

The series from Brescia, Italy reported by Cavaliere et al. comprises 306 patients and placement of 393 silicone stents (Cavaliere et al. 1996). The vast majority of patients were treated with 363 Dumon stents in 27 cases a Y-shaped Hood stent was placed, and in another four cases a Y-shaped Dynamic stent. Stents were inserted into the trachea in 38.7%, right main stem bronchus and bronchus intermedius in 19.8%, left main stem bronchus in 15.5%, trachea and right or left main stem bronchus in 13.5%, and in other positions in 12.5%. Stent insertion resulted in improvement in pulmonary function tests and quality of life in all but six patients (98% success rate). The median survival of patients was 108 days. All patients had malignant tracheobronchial tumors. 

A larger patient population was reported by Beer et al. (1999). A total of 27 Palmaz stents were placed in 21 patients with malignant obstructive tracheobronchial obstructions (trachea, n=2 left main stem bronchus, n=8 intermediate bronchus, n=7 right main stem bronchus, n=l lobar bronchi, n=4). Following stent insertion, six patients had no further respiratory distress, and the remaining 15 patients reported relief of dyspnea. In seven patients, postobstructive pneumonia was successfully treated by stent placement. Mean survival time was 12 months. Restenosis occurred in four patients and was treated with redilation in three, and laser ablation in one patient. 

Song et al. (1996) treated three patients with esophagorespiratory fistulas with their own covered (potentially retrievable) self-expanding nitinol stent. All three fistulas were successfully sealed off by stent insertion. In one patient the stent was initially malpositioned with coverage of the right main stem bronchus, but this problem was successfully solved with repositioning. Two patients died after 2 and 3 weeks one patient was alive at 24 weeks with good respiratory status. 

H. Osada, K. Kojima, Experimental tracheal reconstruction with a rotated right stem bronchus, Ann. Thorac. Surg. 70 (6) (December 2000) 1886—1890. 

Whether via the upper airway or via indwelling airway tubes, routine airway suctioning misses the left main stem bronchus about 90% of the time. MI-E, on the other hand, provides the same exsufflation flows in both left and right airways without the discomfort or airway trauma of tracheal suctioning and it can be effective when suctioning is not. Patients almost invariably prefer MI-E to suctioning for comfort and effectiveness and they also find it to be less tiring (77,78). 

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