Endobronchial Embolization of Metastatic Endobronchial Sarcoma

-L:Iil communicationsto

the editor

Communications priorities permit.

length, printed.

with

for

may or they

Specific

will

be

published

should

offive

not

references;

as

space

and

350 words

exceed

onefigure

or table

in

can be

may occur under particular circumstance& include comments on articles published in this may be reports ofunique educational character to publish should be cited in a covering letter or

Exceptions

periodical,

section

comments

a maximum

Contributions

pennission

appended

this

The

as a postscript.

REFERENCES

1 Campbell

JC.

Colorado, Sivak

2

ED,

Neurol

1980; ED,

authors’

Resp

Care

1983;

ED,

Gipson

in the

literature

disclosed

reports

but,

care

as our

addressing

nevertheless,

Of further

care.

for home

is a bit ill-founded,

ten

anecdotal

possibilities

that

review

very

is that

been

ofthe

subject.

all expound

importance

have

neglected

literature

Some

on the “feasibility”

there

may

has

reports

be other

are

of home

reasons

why

the literature is replete with further emphasis on home care. This is borne out by the fact that conservative estimate there are in excess of 3,000 individuals in this country who receive some type of mechanical ventilation

continuously

Fischer

and

which

preference

grown

29

to

patients

“feasibility”

of

literature

but

rather

over

the

may

the

obvious

not

the

ventilation)

or intermittently

be due

fear

five

is that

the

to the

that

has become

last

what

may

a necessity

necessity

for the support

save health term.

care

Finally,

recognition care,

is the

third-party

for

home moneys

and and

ability

payers care

in the

far beyond

ofclinicians

the

colleagues,

unorthodox

(home

vital

to home

home

care

truly

which

the

authors

care

hinges mention

term,

the

importance

but

which will

to

the technical the

not

the

long

of home

oflife

of those

a footnote.45

Sivak,

Medical

w

Department Kay

Department Clinic

M.D.,

intensive Terry

F.C.C.P; Care

Gipson,

Unit; M.D., and

ofPsychiatry; Stelmak,

ofRespiratory Foundation,

in motor

insufficiency.

Ann

Pulmonary less

mechanical

expensive

alternative.

WF,

Hanson

MR.

in amyotrophic

Long-term lateral

management

sclerosis.

of

Ann

Neurol

1982

ED,

Cordasco

EM,

in the

Gipson

W1

implementation

in 24 patients.

Cleve

Stelmak

K.

of home

care

Quart

(in press)

Clin

Clinical

ventilation:

To the Editor:

We recognize form

that

of respiratory

people,

most

there

are many

assistance.

suffering

individuals

In our

area,

defects

restrictive

at home

we

have

following ofthe

clearly

care

restrictive that

the

problem.

the

I think

initiation

report

is

the

feasibility

ofthis

it is important

option

is still

introduction

respirator-dependent

of home

of

chronic

form

The of

obstructive

such

for

1940s and 1950s for

this

to remind valid.

this

100

poliomyelitis,

whom we offer medical care. The experience during the polio epidemics established

on some

over

the

type

of

profession

unique

part

of our

management

to

pulmonary

the

disease

pa-

tient.

I

that

agree

the

home

environment

and

the

home are essential to the success ofthe Indeed, these criteria are inevitably a necessary

return

to send

such

a patient

patient’s

desire

to

home

care

part

ofthe

decision

M.D.,

F.C.C.P

program.

home. D. A. Fischer,

Chief Chest Medicine Service, Rancho Los Amigos Hospital, Downey, California

Endobronchial Embolization of Metastatic Endobronchial Sarcoma

third-party

aspects

quality

of

may

over

importance

EdwardD.

Cleveland

WT and

support.

by home-care ventilation. Spouses, of the ventilator-dependent patient management. Our own experience is that on a suitable domestic environment, a fact

Director,

Gipson

becomes obvious, then the technical aspects of home report. It will become the

to preserve

as only

EM,

and

who assist the patient supported children, relatives, and friends

are

respiratory

care

technology

a concept

equal

in

of our

to recognize

short

of

beyond

of emphasis

to advanced

ventilation,

perhaps

perhaps

lack

seem due

Perhaps

L3

inarticulateness

the ability to prolong life by mechanical If, indeed, the necessity for home care true issues of home care will not be the care outlined in Fischer and Prentice’s their

at home.’

report the obvious cost reduction and patient is similar to our own experience which now has

Prentice

of hypoventilation

with

A reasonable

failure

Observations

that

, Boulder,

Inc.

1983

28:42-9

considerations

concern

Management

Cordasco

4 Sivak

Editor:

Services

March

7:191-93

at home:

12:18-23,

The experience ofFischer and Prentice with home care ventilation is a welcome addition to the literature (Chest 1982; 82:739-43). Their data support the assumption that intermittent full respiratory support can improve quality oflife and reduce morbidity in patients with certain restrictive and obstructive pulmonary disease. The

EW.

presenting

ventilation

respiratory

Lifecare

communication,

Streib

disease

5 Sivak

manager,

personal

neuron

3 Sivak

Home Care Ventilation To the

General

RN.

, ARRT, Therapy, Cleveland

To the

A oped

Editor:

22-year-old fever

white

eight

genograms

woman

weeks

with

after

demonstrated

right

right

pelvic

chondrosarcoma

hemipelvectomy.

lung

collapse

develChest

and

roent-

multiple

pulmo-

nary nodules. The patient underwent fiberoptic bronchoscopy (Olympus BF-B4) through an 8 mm endotracheal tube with supplemental oxygen. The right main stem bronchus was completely occluded by tumorat thelevelofthe right upperlohe orifice. The left endobronchial tree was normal. Multiple pieces of necrotic tissue were

withdrawn

through

It was not possible scope Within tions

and

endotracheal

minutes, and

the

to relieve

decreased

the

bronchoscope

tube patient breath

utilizing

the obstruction were

became sounds

CHEST

removed cyanotic over

I 84

biopsy

entirely. without with the

I 2 I

left

forceps.

The bronchodifficulty.

labored

respira-

chest.

Marked

AUGUST,

1983

239

1. Tumor

FIGURE

hypoxemia

embolus

developed

tracheal

intubation

tensive

and

was

required

impression chest

ofleft

stem

lobe orifice obstructed.

scope

were

disease,

patient

The

to confirm case,

tion

during

is often

two

months

indicated

Major,

Dr

stem

TX

endotracheal

from

USAF,

to relieve

the

oflarge

tumor

been

MC;

Terry

Hall

obstruction. emboliza-

lesion

becomes

resulting

from

L. Kilgore,

an

Major,

Captain,

USAF,

MC,

Lackland

AFB,

Texas

authors

USAF

and

Medical

do

not

Center,

78236

Intern

2 King

Whitcomb ME. Endobronchial Med 1975; 135:543-47 DS, Castleman B. Bronchial involvement

pulmonary

3 Fitzgerald 70:440-41

4 Baumgartner

55,

J

malignancy.

RH.

Thorac

Endobronchial

WA,

Mark

Surg

1943;

metastases.

JBD.

Metastatic

distant sites to the tracheobronchial Surg 1980, 79:499-503 5 Trinidad 5, Lisa JR. Rosenblatt simulated by metastatic tumors.

tree.

metastases. in

Arch metastatic

12:305-15

South

Med

J

1977;

malignancies from J Thorac Cardiovasc

MB. Bronchogenic carcinoma Cancer 1963; 16:1521-29

Knotting of a Swan-Ganz

catheter The catheter

did

Catheter

Editor:

We read with interest the letter by Drs. Iberti and Jayogopal (Chest 1983; 83:711). We recently had a similar knotting of a Swan-

240

show

a good

pulmonary

artery

or wedge

and each time

tracing

untilafter

60

cm. The patient was septic with a temperature of4l#{176}C,pulse rate of 150 per minute, and blood pressure ofl3O/50 mm Hg. The surgeon believed the patient was about to suffer a perforated gall bladder. As there was a good pulmonary artery and wedge tracing, surgery was the procedure, the balloon ofthe Swan-Ganz catheter was The tracingbelieved to be the CVP flattened. A check of the revealed the pulmonary artery and CVP transducers

had been reversed. During insertion, what was believed to be the CVP transducer, but was actually the PA tracing, was turned off and the proximal port was transduced. Postoperative x-ray film revealed a knot in the Swan-Ganz catheter. The cardiac output determinations were also inconsistent and unbelievably high for an 81-year-old woman, despite her severe sepsis. Attempts

the catheter

to remove

to withdrawal. catheterization

Therefore, laboratory.

ters

in a similar

manner

in the SICU

the patient The catheter

the use ofguide wires without previously untied intracardiac,

was

met with resistance taken

to

the

cardiac

was gradually unknotted by complication. Our cardiologists have loosely knotted, Swan-Ganz cathe-

as described

by Mond

et

In two patients with tightly knotted Swan-Ganz catheters one of us ( FAP) cut down over the femoral vein and used a basket to retrieve the knotted catheter from the superior vena cava. The knotted catheter was removed from the femoral vein, easily controlling the blood loss. This technique avoided uncontrollable hemorrhage from laceration of the subclavian vein as the knotted catheter was withdrawn, as reported by Sabel and Bramwit.2 We believe the moral herein is: attention to details can make the difference

between

Gwendolyn

William

Reprint

70112 1

To the

not

1

in the pulmonary artery (Fig 1). was inserted and withdrawn six times

Ganz

During inflated. transducers

obstruc-

REFERENCES

1 Braman

FIGURE

begun.

metastatic

described.

R. Cavett,

Wilford

to the

airway

complication not

success-

identical

endobronchial

has

andJames

Shenk,

the

to assess risk

a similar lesion

FCCP;

requests:

LacklandAFB,

main

earlier.

The opinions expressed are those of the necessarily represent official USAF policy.

Reprint

left

obstruction

the

knowledge

A.. Schenk, MC,

histologically

if the

metastatic

David

the

stem cardio-

left lung and improvement

or to attempt

bronchoscopy

USAF,

main

during

clear

was

demonstrates

To our

a portable

left

and was subsequently

plug

malignancy,

endobronchial

ofthe

of endobronchial

however,

dislodged.

when

through

stabilized

resected

bronchoscopy

tion,

to

together

tumor

evaluation

This

attempt

re-expansion

The

chondrosarcoma

In the

clinical

was noted just proximal to the left (Fig 1). The right main stem bronchus was no Utilizing biopsy forceps, the tumor and broncho-

tube with subsequent

pelvic

hypo-

The

ofthe

was performed

endo-

became

plug

withdrawn

extubated.

and

was verified obstruction

in an

bronchus.

subsequently

occlusion

white

slowly

in oxygenation.

mainstem

resuscitation.

bronchoscopy

A smooth

upper longer

left

supplementation

She

demonstrated

resuscitation

bronchus.

fully

required.

main

Fiberoptic

pulmonary

from

oxygen

cardiopulmonary

roentgenogram

bronchus.

removed

despite

Mond

Smith,

a sophisticated

monitor

Dr

HG,

Clark

Graybar,

disaster.

FC.C.P; Elena Adler, M.D.; Puyau, Tulane Medical Center,

B. Graybar, M.D., M.D.; and FrancisA.

requests:

and

Tulane

1430

Avenue,

New

Orleans

New

Orleans

REFERENCES

DW,

unknotting an intracardiac 1975; 67:731-33 2 Sabel GN, Bramwit DN.

semi-floating

pacing

Nesbitt

wire.

flow

SJ, Schlant directed

Removal

Chest

RC. A technique balloon

catheter.

of a knotted

1972; 62:654

Communications

subclavian

for Chest and

to the EdItor