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Gas Embolism Following Bronchoscopic Argon Plasma Coagulation
.. . . CHEST CHEST
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Gas Embolism Gas Embolism Following Following Bronchoscopic Bronchoscopic Argon Argon Plasma Plasma Coagulation* Coagulation* A Case A Case Series Series Chakravarthy Reddy, MD; Adnan Majid, MD; Gaetane Michaud, MD, FCCP; FCCP; David Feller-Kopman, MD, FCCP; FCCP; Ralph Eberhardt, MD; Felix Herth, Herth, MD, MD, FCCP; FCCP; and Amlin Ernst, MD, FCCP Felix
Thennal Thermal ablation ablation using using argon argon plasma plasma coagulation coagulation (APC) is (APC) is aa commonly commonly used used modality modality in in the the bronchobronchoscopic management scopic management of of central central airway airway obstruction obstnlCtion and hemoptysis. and hemoptysis. In In experienced experienced hands, hands, APC APC is is conconsidered to sidered to be be aa relatively relatively safe safe tool. tool. Reported Reported complicomplications associated cations associated with with APC APC use use are are rare rare and and include include hemorrhage, hemorrhage, airway airway perforation, perforation, or or airway airway fires. fires. Systemic gas Systemic gas embolism embolism has has been been reported reported with with APC APC during laparoscopic during laparoscopic hepatic hepatic surgeries, surgeries, and and we we have have reported one reported one case case of of systemic systemic gas gas embolism embolism with with cardiovascular collapse cardiovascular collapse in in the the past. past. We We now now report report the first the first case case series series of of systemic, systemic, life-threatening life-threatening gas gas embolism occurring embolism occurring as as aa complication complication of of bronchobronchoscopic application scopic application of of APC. APC. (CHEST 2008; (CHEST 2008; 134:1066-1069) 134:1066-1069) Key words: Key words: argon argon plasma plasma coagulation; coagulation; bronchoscopy; bronchoscopy; complicacomplication; gas tion; gas embolism embolism Abbreviations: ACLS Abbreviations: ACLS == advanced advanced cardiac cardiac life life support; support; = argon argon plasma plasma coagulation; coagulation; CPR CPR = = cardiopulmonary cardiopulmonary APC = APC resuscitation; LV resuscitation; LV = = left left ventricIeiventricular; ventricle/ventricular; TEE TEE = = transesophageal transesophageal echocardiography echocardiography
A rgon A rgon plasma plasma coagulation coagulation
(APC) is (APC) is aa tool tool for for the the bronchoscopic bronchoscopic management management of of central central ailWay airway obstrucobstruction or hemoptysis tion hemoptysis caused caused by by benign benign or or malignant malignant ailWay airway 'From Interventional 'From Interventional Pulmonology Pulmonology (Drs. (Drs. Reddy, Reddy, Majid, Majid, Michaud, Michaud, and and Ernst), Ernst), Beth Beth Israel Israel Deaconess Deaconess Medical Medical Center, Center, Harvard Harvard Medical Medical School, School, Boston, Boston, MA; MA; Interventional Interventional Pulmonology Pulmonology (Dr. (Dr. Feller-Kopman), Feller-Kopman), Johns Johns Hopkins Hopkins Hospital, Hospital, Baltimore, Baltimore, MD; MD; and and Department Department of of Pulmonary Pulmonary Medicine Medicine (Drs. (Drs. Eberhardt Eberhardt and and Herth), Thoraxklinik, Thoraxklinik, Heidelberg, Heidelberg, Germany. Germany. Herth), The authors authors have have no no conflicts conflicts of of interest interest to to disclose. disclose. The Manuscript received received February February 20,2008; 20,2008; revision revision accepted accepted May May 9, 9, Manuscript 2008. 2008. I,teproductionof permission I,teproduction of this tillS article article is is prohibited prohibited without without written written pennission from the Physicians (www.chestjournal. (www.chestjournal. from the American American College College of of Chest Chest Physicians orglmisclreprints.shtml). orglmisclreprints.shtml). Correspondence to: Armin Emst, Ernst, MD, MD, FCCP, FCCP, Chief, Chief, IntervenIntervenCorrespondence to: Armin tional Pulnwnology, Pulnwnology, Beth Beth Israel Israel Deaconess Deaconess Medical Medical Center, Center, HarHartional vard Medical Medical School, School, One One Deaconess Deaconess Rd, Rd, Boston, Boston, MA MA 02115; 02115; vard e-mail: [email protected] [email protected] e-mail: DOl: IO.1378/chest.08-0474 IO.1378/chest.08-0474 DOl: 1066 1066
lesions. 11 APC lesions. APC is is aa noncontact noncontact form form of of electrocoagulation electrocoagulation and has and has been been used used extenSively extensively in in the the fields fields of of interveninterventional tional pulmonology pulmonology and and gastroenterology.21t gastroenterology.21t is is considered considered to to be be safe safe in in the the hands hands of of experienced experienced bronchoscopists, bronchoscopists, and and the the reported reported frequency frequency of of adverse adverse events events is is < < 1%.3 1%.3 The reported The reported complications complications from from APC APC in in the the ailWays airways include hemorrhage, include hemorrhage, perforation, perforation, stenosis, stenosis, and and ailWay airway fires. l fires.' APC utilizes APC utilizes argon argon flow flow through through an an endoscopic endoscopic probe probe to to deliver an deliver an electric electric current current to to the the target target tissue. tissue. Prior Prior to to exiting the exiting the tip tip of of the the probe, probe, argon argon comes comes in in contact contact with with an an electrode gas and and creates creates aa plasma plasma jet electrode that that ionizes ionizes the the gas jet that that conducts aa high-voltage conducts high-voltage electric electric current current to to the the target target tissue. tissue. Gas Gas flowing flowing out out of of aa probe probe under under pressure pressure into into the the ailWay airway can can cross cross aa disrupted disrupted mucosal mucosal membrane membrane into into the the microvasculature microvasculature and and pose pose aa theoretical theoretical risk risk of of systemic systemic gas embolism. embolism. This This has has been been known known to to occur occur with with the the gas bronchoscopic of Nd-YAG Nd-YAG laser, laser, in in which which the the laser laser bronchoscopic use use of 4 .5 fiber tip tip is is cooled cooled with with gas gas flowing flowing across across the the probe. fiber probe.w Systemic gas gas embolism embolism from from APC APC has has been been reported reported with with Systemic hepatic surgeries,6-10 hepatic surgeries,6-10 and and we we have have reported reported aa single single such such case case associated associated with with the the use use of of APC APC in in the the central central airways.'! of systemic systemic ailWays.ll We We now now present present the the first first case case series series of gas embolism gas embolism occurring occurring dUring during bronchoscopic bronchoscopic use use of of APC. APC. CASE REPORTS REPORTS
In this In this single-center single-center experience, experience, all all patients patients underwent underwent rigid rigid bronchoscopy bronchoscopy with with high-frequency high-frequency jet jet ventilation ventilation in in tile tile operating operating room, room, under under general general anesthesia. anesthesia. The The working working channel channel of of aa flexible bronchoscope bronchoscope was was used used to to guide guide the the APC APC probe probe to to the the flexible desired location location (Fig (Fig 1). desired 1). Apnea Apnea was was maintained maintained during during the the application of APC application of APC (ERBOTOM (ERBOTOM ICC ICC 200 200 with with APC APC 300; 300; ERBE ERBE USA; USA; Atlanta, Atlanta, GA) GA) during during all all procedures procedures to to avoid avoid ignition ignition and and airway fires. applied at at 1noncontact airway fires. APC APC was was applied 1- to to 3-s 3-s bursts bursts in in aa noncontact mode to to ablate ablate lesions. lesions. Patient The mode Patient 11 has has been been reported reported prior.!' prior. ll The data data review review was was approved approved by by the the Institutional Institutional Review Review Board Board at at Beth Center, and and informed consent Beth Israel Israel Deaconess Deaconess Medical Medical Center, informed consent was waived. waived. was Patient 1
A 75-year-old A 75-year-old woman woman with with an an endobronchial endobronchial carcinoid carcinoid tumor tumor presented presented with with hemoptysis. hemoptysis. Underlying Underlying coronary coronary artery artery disease disease rendered rendered her her aa poor poor candidate candidate for for resection. resection. DUring DUring bronchosbronchoscopy, an an endobronchial endobronchial lesion lesion seen seen in in the the right right middle middle lobe lobe was was copy, confirmed as confirmed as the the source source for for the the hemoptysis. hemoptysis. APC APC was was performed performed with Umin and and power power of of 40 with argon argon flow flow rate rate of of 22 Umin 40 W, W, and and hemostasis was was achieved. achieved. Moments Moments following following termination hemostasis termination of of APC, patient became became bradycardic bradycardic and and hypotensive, hypotensive, progressprogressAPC, the the patient ing into into ventricular ventricular fibrillation fibrillation and and arrest. arrest. Cardiopulmonary Cardiopulmonary ing resuscitation (CPR) (CPR) was per advanced advanced cardiac cardiac life life resuscitation was initiated initiated per support support (ACLS) (ACLS) protocol. protocol. When When 20 20 min min of of CPR CPR did did not not convert convert the the rhythm, rhythm, emergent emergent transesophageal transesophageal echocardiography echocardiography (TEE) (TEE) was was performed, performed, which which revealed revealed fibrillating fibrillating ventricles ventricles with with aa large large gas (LV). No No septal septal defects defects were were gas bubble bubble in in the the left left ventricle ventricle (LV). Selected Reports Selected Reports
Patient Patient 33
FIGURE 1. Endobronchial use use of of APC APC for for tumor tumor ablation. ablation. FIGURE 1. Endobronchial
present to to explain explain an an intracardiac intracardiac right-to-left right-to-left shunt; shunt; however, however, aa present bubble study study was was not not performed performed due due to to the the emergent emergent nature nature of of bubble the diagnostic diagnostic procedure. procedure. The The patient patient was was placed placed on on extracorpoextracorpothe real membrane membrane oxygenation oxygenation and and transferred transferred to to the the cardiac cardiac cathcathreal eterization laboratory laboratory for for angiography. angiography. Coronary Coronary arteries arteries were were eterization unremarkable, and and aa large large gas gas bubble bubble in in the the LV LV was was again again noted. noted. unremarkable, The gas gas bubble bubble was was aspirated aspirated with catheter The \'lith an an 6F 6F angled angled pigtail pigtail catheter advanced through through the the angiocatheter. angiocatheter. Defibrillation Defibrillation restored restored nornoradvanced mal sinus sinus rhythm. rhythm. The The patient patient stabilized stabilized hemodynamically hemodynamically over over mal next few few hours, hours, and and was was weaned weaned from from extracorporeal extracorporeal membrane membrane next oxygenation. She She recovered recovered to to her her baseline baseline mental oxygenation. mental status status over over the the next few few days; days; however, however, she she refused refused any next any further further interventions interventions and and died died aa week week later later from from cardiac cardiac complications. complications. Patient 22 Patient
A 61-year-old 61-year-old woman woman was was transferred A transferred from from an an outside outside hospital hospital for for evaluation evaluation and and management management of of acute acute hemoptysis hemoptysis with with radioradiologic of aa right logic evidence evidence of right middle middle lobe lobe mass. mass. Airway Airway evaluation evaluation revealed aa right right middle middle lobe lobe endobronchial endobronchial mass mass with with active active revealed bleeding in in addition bleeding addition to to old old blood blood clots. clots. APC APC was was employed employed at at aa flow of 1.5 Umin and and power power of flow of 1.5 Umin of 40 40 W W in in the the right right middle middle lobe lobe to to ablate ablate the the tumor, tumor, and and the the bleeding bleeding was was controlled. controlled. Shortly Shortly after, after, acute acute T-wave T-wave inversions inversions developed developed on on telemetry, telemetry, followed followed by by bradycardia, bradycardia, hypotension, hypotension, and and loss loss of of peripheral peripheral pulses. pulses. CPR CPR was was initiated initiated per per ACLS ACLS protocol. protocol. Within Within aa few few minutes, minutes, the the patient patient was was hemodynamically hemodynamically stable stable with with recovery recovery of of peripheral peripheral pulses. pulses. ECG ECG revealed revealed changes changes consistent consistent with with acute acute inferior inferior wall wall myomyocardial TEE was was performed, performed, which which cardial infarction. infarction. An An emergent emergent TEE revealed gas gas bubbles revealed bubbles in in the the LV LV without without any any evidence evidence of of intracarintracardiac bubble study study was performed. She She diac septal septal defects. defects. A A bubble was not not performed. was transferred transferred to to the the cardiac cardiac catheterization catheterization laboratory laboratory and and was underwent angiography. angiography. Results Results were were unremarkable, unremarkable, with with nornorunderwent mal coronary coronary arteries, arteries, normal normal LV mal LV ejection ejection fraction, fraction, and and no no evidence The patient patient recovered recovered in in the the evidence of of intracardiac intracardiac shunts. shunts. The ICU in in 1 1 day, day, was was transferred transferred to to the floor, and discharged ICU the floor, and was was discharged days later. later. She She subsequently subsequently underwent underwent right right middle middle lobeclobec33 days tumor and and remains remains tomy for for aa localized, atypical carcinoid carcinoid tumor tomy localized, atypical asymptomatic at at this this time. asymptomatic time. www.chestjournal.org www.chestjournal.org
A 72-year-old transferred from from an A 72-year-old woman woman was was transferred an outside outside hospital hospital for management of acute for management of acute hemoptysis. hemoptysis. Non-small Non-small cell cell lung lung carcicarcinoma upper lobe lobe was diagnosed 44 weeks noma involving involving the the left left upper was diagnosed weeks prior prior to to presentation, presentation, and and she she received received external external beam beam radiation radiation thertherapy. apy. Cough Cough with with hemoptysis hemoptysis developed developed the the day day before, before, with with rapid rapid deterioration deterioration in in clinical clinical status. status. An An urgent urgent rigid rigid bronchoscopy bronchoscopy revealed revealed fresh fresh blood blood in in the the trachea, trachea, left left mainstem mainstem bronchus, bronchus, and and left left upperupper- and and left left lower-lobe lower-lobe segmental segmental bronchi. bronchi. Airwayswere AiIways were suctioned suctioned clean, clean, and and aa thorough thorough evaluation evaluation revealed revealed an an endoendobronchial bronchial lesion lesion in in the the left left upper upper lobe lobe with with active active bleeding. bleeding. The The rigid rigid bronchoscope bronchoscope was was advanced advanced into into the the left left mainstem mainstem bronbronchus chus to to isolate isolate the the lung lung and and maintain maintain adequate adequate ventilation ventilation in in the the normal normal right right lung. lung. APC APC was was utilized utilized in in the the left left upper upper lobe lobe at at aa flow Umin flow of 40 flow of of 11 Umin flow and and power power of 40 W W to to ablate ablate the the lesion lesion and and control the the bleeding. bleeding. While While APC APC was control was being being administered, administered, acute acute ST-segment ECG leads, leads, and and ST-segment elevations elevations developed developed on on the the inferior inferior ECG progressed progressed to to pulseless pulseless electrical electrical activity activity and and cardiac cardiac arrest. arrest. CPR CPR was initiated per ACLS ACLS protocol. urgent TEE TEE was was initiated per protocol. An An urgent was performed performed that that revealed revealed gas gas in in the the LV LV apex apex and and in in ascending ascending aorta, aorta, at at the the right right coronary coronary ostia. ostia. Severe Severe LV LV global global hypokinesis hypokinesis (LV (LV ejection ejection fraction of 10 to to 20%) ventricular fraction of 20%) and and severe severe global global right right ventricular free-wall hypokinesis hypokinesis with with apical apical sparing sparing (Fig (Fig 2) 2) were were also also noted. noted. free-wall No No intracardiac intracardiac septal septal defects defects were were noted, noted, and and aa bubble bubble study study was was not not performed. performed. CPR CPR was was continued continued for for aa few few minutes, minutes, and and with IV vasopressors vasopressors cardiac cardiac status status improved improved with with recovery recovery of of aa with IV palpable peripheral peripheral pulse. pulse. TEE TEE monitoring monitoring showed showed resolution resolution of of palpable the gas emboli the intracardiac intracardiac gas emboli during during the the course course of of the the CPR. CPR. She She was transferred transferred to to the the ICU ICU for for further further care. care. The The next next day, day, the the was neurologic evaluation evaluation and and the the severe severe cerebral neurologic cerebral edema edema on on CT CT scan scan were were consistent consistent with with anoxic anoxic brain brain injury. injury. After After discussion discussion with with family family members, members, life life support support was was withdrawn withdrawn the the following following day day and and the the patient patient died died shortly shortly thereafter. thereafter. DISCUSSION DISCUSSION
APC with with aa flexible flexible probe probe has has been been available APC available for for use use with endoscopic endoscopic procedures since the the early early 1990s. 1990s. Used Used with procedures since initially for for hemostasis GI polypectoinitially hemostasis during during endoscopic endoscopic GI polypectomies.v application of of APC expanded into into the mies,12 application APC has has expanded the fields fields of of otolaryngology, and urologic urologic surgersurgerotolaryngology, laparoscopic laparoscopic hepatic, hepatic, and ies.'·13-15 In interventional pulmonology, pulmonology, APC APC is widely ies.'·13-15 In interventional is aa widely used tool tool to to debulk debulk malignant malignant or or benign benign airway airway tumors, tumors, used manage hemoptysis, hemoptysis, and and remove granulation tissue tissue from from manage remove granulation 6 - IS stents or or anastamosis.1 anastamosis.Iv-" stents
FIGURE 2. TEE showing showing air FIGURE 2. TEE air embolism embolism at at the the LV LV apex. apex. CHEST /134/5/ NOVEMBER, NOVEMBER, 2008 2008 CHEST /134/5/
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APC APC is is aa noncontact noncontact mode mode of of tissue tissue coagulation. coagulation. Argon Argon flows from the the tip of the flows from tip of the probe probe at at 0.3 0.3 to to 2 2 L'min Umin and and conducts the conducts an an electrical electrical charge charge from from an an electrode electrode in in the probe probe to to the the target target tissue. tissue. It It is is applied applied in in bursts bursts of of 11 to to 3 3 ss of 80 W W of of power. power. At At these these settings, settings, the the depth depth of of of 20 20 to to 80 penetration is penetration is < < 55 mm, mm, which which is is designed designed to to reduce reduce the the risk of of damage damage to to underlying underlying structures structures and and supposedly supposedly risk makes it it aa safe safe modality modality for for use use in in the the airways. airways. makes Systemic gas gas embolism embolism may may be be aa potentially potentially fatal fatal comcomSystemic plication from from APC APC use use in in the the airways. airways. It plication It has has been been reported in hepatiC surgeries,9.10 surgeries,9.10 and and we we present present the the first first reported in hepatic case of this case series series of this complication complication from from endobronchial endobronchial use. use. Endobronchial Endobronchial systemic systemic gas gas embolism embolism is is not not new new and and has has been laser in in the the been reported reported with with the the use use of of Nd-YAG Nd-YAG laser airways. laser uses uses gas gas flow flow to to cool the tip tip of of the the airways. Nd-YAG Nd-YAG laser cool the probe, probe, and and flow flow rates rates as as low low as as 0.4 0.4 Umin have have been been shown shown pressures> 500 500 mm mm Hg.19 Hg.19 Gas Gas exihng exihng the the tip tip to to generate generate pressures> of of the the probe probe under under pressure pressure is is thought thought to to be be able able to to cross cross the mucosal mucosal membranes membranes into into blood blood vessels vessels through through bronbronthe chovascular fistulae fistulae created created by by coagulation coagulation of of tissue. tissue. The The chovascular precise etiology etiology of of gas gas embolism embolism with with APC APC is is unclear. unclear. precise Based on Based on animal animal experiments,"? experiments,20 APC APC application application in in the the trachea is is associated associated more more commonly commonly with with gas gas embolizaembolizatrachea tion to the tion to the right right atrium, atrium, presumably presumably via via systemic systemic veins, veins, whereas ablation ablation in bronchi is is associated associated more more commonly commonly whereas in bronchi with gas gas embolization embolization to to the the left atrium through through the the left atrium with pulmonary venous venous system. system. Mortality Mortality associated associated with with intraintrapulmonary operative systemic systemic gas embolism from operative gas embolism from Nd-YAG Nd-YAG laser laser use use in the the airways airways is is high, fatalities reported reported from from 21 21 high, with with nine nine fatalities in cases in in literature. literature."s Hanowell Hanowell et et al al21 reported cases reported aa procedural procedural incidence of incidence of cardiovascular cardiovascular complication complication with with Nd-YAG Nd-YAG laser use use at We speculate that the 27.6% from from 87 87 cases. cases. We speculate that the laser at 27.6% pathogenesis involved involved in in systemic gas embolism embolism from from APC pathogenesis systemic gas APC may be be similar to that of Nd-YAG similar to that of Nd-YAG laser, laser, but but that that argon argon is is may crossing crossing over over instead instead of of the the cooling cooling gas. gas. It It is is unlikely unlikely for for the visualized the visualized gas gas to to be be derived derived from from jet jet ventilation ventilation because apnea apnea was was maintained maintained during during all all procedures. procedures. because Diagnosis of of gas gas embolism embolism intraoperatively intraoperatively requires requires aa Diagnosis high level level of of suspicion suspicion and and can can be be confirmed confirmed with with TEE.s TEE.s high Intraoperative changes changes in in the the inferior inferior ECG Intraoperative ECG leads leads should should arouse the the suspicion of systemic systemic gas gas embolism. embolism. In In the the arouse suspicion of supine supine position, position, right right coronary coronary artery artery ostium ostium is is anterior, anterior, in in the dependant position position and the least least dependant and may may be be the the most most vulnervulnerable to air able to air embolism. embolism. In In two two of of our our patients, patients, acute acute changes changes the cardiac arrest. in inferior leads leads preceded preceded the in inferior cardiac arrest. Cardiovascular or changes changes are are not not ununCardiovascular complications complications or common common during dUring therapeutic therapeutic bronchoscopy bronchoscopy and and are are often often attributed the high-risk high-risk patient attributed to to the patient population population who who may may have just tobacco-induced tobacco-induced lung lung disease disease but have not not just but also also corocoronary artery disease with increased increased operative operative risk. risk. It nary artery disease with It is is also also reasonable undetected systemic reasonable to to postulate postulate that that undetected systemic air air ememboli may have been boli been contributory contributory in in many many of of these these cases. cases. may have The by The risk risk of of systemic systemic gas gas embolism embolism may may be be influenced influenced by the exiting the the rate rate of of gas gas flow flow exiting the tip tip of of the the probe. probe. With With Nd-YAG, Tellides Tellides et visualized air air bubbles Nd-YAG, et al alss visualized bubbles on on TEE TEE with rate set Umin, and the bubbles with coolant coolant gas gas flow flow rate set at at 1.5 1.5 Umin, and the bubbles resolved Umin. In In resolved when when the the flow flow rate rate was was decreased decreased to to 0.8 0.8 Umin. our patients, systemic our patients, systemic air air embolism embolism occurred occurred with with gas gas flow flow 2, 1.5, gas flow flow rate rate for rates rates of of 2, 1.5, and and 1 1 Umin. Umin. The The ideal ideal gas for Nd-YAG or or APC APC use use in in airways airways is is unknown, unknown, and and the the Nd-YAG current recommendations recommendations are are to to set flow to to lowest lowest current set the the flow 1068 1068
pOSSible possible rate rate to to prevent prevent gas gas embolism. embolism. However, However, animal animal experiments 20 have have suggested suggested that that there there may may be be no no safe safe experiments-" level for for gas gas flow flow rates, rates, as as APC APC use use at at any any flow flow lead lead to to level vascular gas gas bubbles bubbles in in healthy healthy sheep. sheep. vascular The incidence incidence of of gas gas embolism embolism with with APC APC application application is is The unknown. The The three three reported reported cases cases occurred occurred at at aa single single unknown. referral center center over over aa period period of of 3 3 years, years, and and endobronchial endobronchial referral APC application application is is performed performed approximately approximately 50 50 to to 75 75 APC times aa year. year. We We suggest suggest that that APC APC use use within within the the airways airways times should be be studied studied in in aa prospective prospective fashion fashion to to ensure ensure that that is is should truly safe safe modality, modality, or or at at least least establish establish the the true true risk risk aa truly associated with with its its use. use. associated CONCLUSION CONCLUSION
Systemic Systemic gas gas embolism embolism is is aa potentially potentially fatal fatal complicacomplication of of APC APC use use in in the the airways. airways. It It should should be be suspected suspected in in tion cases when when intraoperative intraoperative ECG ECG changes changes are are noted, noted, espeespecases cially in in the the inferior inferior leads. leads. Care Care should should be to cially be taken taken to maintain gas gas flow flow at at the maintain the lowest lowest possible possible rate, rate, although although there may there may be be no no safe safe level level that that may may prevent prevent this this complication. It It may may be be indicated indicated at at this this time time to to complication. formally evaluate evaluate the the true true incidence incidence of of gas gas embolism embolism formally with with the the use use of of APe. APe. REFERENCES REFERENCES 11 Ernst Ernst A, A, Feller-Kopman Feller-Kopman D, D, Becker Becker HD, HD, et et al. al. Central Central airway airway Am JJ Respir Respir Crit Crit Care Care Med Med 2004; 2004; 169:1278obstruction. obstruction. Am 169:12781297 1297 22 Conio Conio M, M, Gostout Gostout CJ. CJ. Argon Argon plasma plasma coagulation coagulation (APC) (APC) in in gastroenterology: gastroenterology: experimental experimental and and clinical clinical experiences. experiences. GasGastrointest Endosc trointest Endosc 1998; 1998; 48:109-110 48:109-110 33 Reichle Reichle G, Freitag L, L, Kullmann Kullmann HJ, HJ, et et al. al. Argon Argon plasma G, Freitag plasma coagulation in in bronchology: bronchology: aa new new method; method; alternative alternative or or coagulation complimentary? complimentary? JJ Bronchol Bronchol 2000; 2000; 7:109-117 7:109-117 44 Peachey air embolism embolism Peachey T, T, Eason Eason J, J, Moxham Moxham J, J, et et al. al. Systemic SystemiC air during laser laser bronchoscopy. during bronchoscopy. Anaesthesia Anaesthesia 1988; 1988; 43:872--875 43:872--875 55 Tellides Tellides G, G, Uguriu Uguriu BS, BS, Kim Kim RW, RW, et et al. al. Pathogenesis Pathogenesis of of systemic systemic air air embolism embolism during dUring bronchoscopic bronchoscopic Nd. Nd: YAG YAG laser laser operations. Ann operations. Ann Thorac Thorac Surg Surg 1998; 1998; 65:930-934 65:930-934 66 Emergency Emergency Care Care Research Research Institute. Institute. Fatal Fatal gas gas embolism embolism caused caused by by overpressurization overpressurization during during laparoscopic laparoscopic use use of of argon argon enhanced enhanced coagulation. coagulation. Health Health Devices Devices 1994; 1994; 23:257-259 23:257-259 77 Croce M, Russo Russo R, R, et et al. al. Laparoscopic Laparoscopic liver liver tumor tumor Croce E, E, Azzola Azzola M, resection resection with with the the argon argon beam. beam. Endosc Endosc Surg Surg Allied Allied Technol Technol 1994; 1994; 2:186-188 2:186-188 M, Vallet Vallet B. B. Venous Venous gas gas embolism embolism 88 Ousmane Ousmane ML, ML, Fleyfel Fleyfel M, during liver liver surgery surgery with with argon-enhanced argon-enhanced coagulation coagulation [letter]. [letter]. during Eur JJ Anaesthesiol Eur Anaesthesiol 2002; 2002; 19:225 19:225 M, Miller gas 99 Palmer Palmer M, Miller CW, CW, Van Van Way Way CW CW III, III, et et al. al. Venous Venous gas embolism embolism associated associated with with argon-enhanced argon-enhanced coagulation coagulation of of liver. liver. JJ Invest Invest Surg Surg 1993; 1993; 6:391-399 6:391-399 I. Venous Venous gas gas embolism embolism from from an an argon argon 10 10 Veyckemans Veyckemans F, F, Michel Michel I. coagulator. coagulator. Anesthesiology Anesthesiology 1996; 1996; 85:443-444 85:443-444 11 11 Yaron Yaron G, G, Panzica Panzica PJ, PJ, Pinto Pinto DS, DS, et et al. al. Cardiac Cardiac arrest arrest due due to to left left ventricular gas embolism embolism after after bronchoscopic bronchoscopic argon argon plasma plasma ventricular gas coagulation: coagulation: aa case case report. report. JJ Bronchol Bronchol 2007; 2007; 14:33-35 14:33-35 12 Grund KE, KE, Storek Storek D, D, Farin Farin G. 12 Grund G. Endoscopic Endoscopic argon argon plasma plasma coagulation coagulation (APC) (APC) first first clinical clinical experiences experiences in in flexible flexible endosendoscopy. copy. Endosc Endosc Surg Surg Allied Allied Technol1994; Technol1994; 2:42-46 2:42-46 13 Bergler W, W, Riedel Riedel F, F, Baker-Schreyer Baker-Schreyer A, A, et et al. al. Argon Argon plasma plasma 13 Bergler coagulation for for the the treatment treatment of of hereditary hereditary hemorrhagic hemorrhagic coagulation telangiectasia. Laryngoscope Laryngoscope 1999; 1999; 109:15-20 telangiectasia. 109:15-20 Selected Reports Selected Reports
14 Quinlan Quinlan DM, DM, Naslund Naslund MJ, MJ, Brendler Brendler CB. CB. Application Application of of argon 14 argon beam coagulation coagulation in in urological urological surgery. surgery. JJ Uro11992; Uro11992; 147:410beam 147:410412 412 15 of ovarian 15 Brand Brand E, E, Pearlman Pearlman N. N. Electrosurgical Electrosurgical debulking debulking of ovarian cancer: aa new new technique technique using using argon argon plasma plasma beam beam coagulator. coagulator. cancer: Gynecol Onco11990; Onco11990; 39:115-118 39:115-118 Gynecol 16 Crosta Crosta C, C, Spaggiari Spaggiari L, L, De De Stefano Stefano A, A, et et al. al. Endoscopic Endoscopic argon argon 16 plasma coagulation coagulation for for palliative palliative treatment treatment of of malignant malignant plasma airway obstructions: obstructions: early early results results in in 47 47 cases. cases. Lung Lung Cancer Cancer airway 2001; 33:75--80 33:75--80 2001; 17 Keller Keller CA, CA, Hinerman Hinerman R, R, Singh Singh R, R, et et al. al. The The use use of of endoscopic endoscopic 17 argon plasma argon plasma coagulation coagulation in in airway airway complications complications after after solid solid organ organ transplantation. transplantation. Chest Chest 2001; 2001; 119:1968-1975 119:1968-1975 18 18 Morice Morice RC, RC, Ece Ece T, T, Ece Ece G, G, et et al. al. Endobronchial Endobronchial argon argon plasma plasma coagulation for for treatment treatment of coagulation of hemoptysis hemoptysis and and neoplastic neoplastic airway airway obstruction. obstruction. Chest Chest 2001; 2001; 119:781-787 119:781-787 19 19 Lang Lang NP, NP, Wait Wait GM, GM, Read Read RR. RR. Cardio-cerebrovascular Cardio-cerebrovascular comcomplications t;'ethnent of of lung lung cancer. cancer. Am plications from from Nd: Nd: YAG YAG laser laser t;'ethnent Am Surg 1991; 1991; 162:629-632 162:629-632 JJ Surg 20 Feller-Kopman Feller-Kopman D, D, Lukanich Lukanich JM, JM, Shapira Shapira G, G, et et al. al. Gas Gas flow flow 20 during bronchoscopic bronchoscopic ablation ablation therapy therapy causes causes gas gas emboli emboli to to during the heart: heart: aa comparative comparative animal animal study. study. Chest Chest 2008; 2008; 133: 133: the 892-896 892-896 21 Hanowell Complications of of 21 Hanowell LH, LH, Martin Martin WR, WR, Savelle Savelle JE, JE, et et al. al. Complications general anesthesia anesthesia for for Nd:YAG Nd:YAG laser laser resection resection of of endobrongeneral endobronchial chial tumors. tumors. Chest Chest 1991; 1991; 99:72-76 99:72-76
Anthracofibrosis, Bronchial Bronchial Anthracofibrosis, Stenosis With Stenosis With Overlying Overlying Anthracotic Mucosa: Possibly Possibly Anthracotic Mucosa: a New New Occupational Occupational Lung Lung a Disorder* Disorder* A Series Series of of Seven Seven Cases A Cases From From One One UK Hospital Hospital UK Gareth j. j. Wynn, Wynn, MBChB; MBChB; Peter Peter M. Turkington, MD; Gareth M. Turkington, MD; and and B. O'Driscoll, MD MD B. Ronan Ronan O'Driscoll,
Anthracofibrosis, which which was was recently recently defined defined as as bronbronAnthracofibrosis, chial stenosis stenosis with with overlying overlying anthracotic anthracotic mucosa, mucosa, has has chial 'From the the Department Department of of Respiratory Respiratory Medicine, 'From Medicine, Salford Salford Royal Royal University University Hospital, Hospital, Salford, Salford, UK. UK. Dr. is the the Chief Chief Investigator Investigator for for aa research research project, project, with with Dr. Turkington Turkington is £50,000 grant grant from from the the Pfizer Pfizer Foundation, Foundation, on on the the early early diagnosis aa £50,000 diagnosis of COPD COPD and and targeted targeted smoking smoking cessation. cessation. He He has has given given six six lectures lectures of per year year to to primary per primary care care staff staff with with honoraria honoraria from from various various pharmapharmaceutical ceutical companies companies (AstraZeneca, (AstraZeneca, GlaxoSmithKline,and GlaxoSmithKline, and Pfizer). Pfizer). Dr. Dr. signifiWynn have reported reported to to the the ACCP ACCP that that no no signifiWynn and and Dr. Dr. O'Driscoll O'Driscoll have cant conflicts interest exist exist with with any any companies/organizations companies/organizations of interest cant conflicts of whose products products or or services services may may be be discussed discussed in in this this article. article. whose Manuscript received received March March 24, 24, 2008; 2008; revision revision accepted accepted May May 22, 22, Manuscript 2008. 2008. Reproduction of of this this article article is is prohibited prohibited without without written written permission permission Reproduction from of Chest Chest Physicians Physicians (www.chestjoumal. (www.chestjoumal. from the the American American College College of orglmisc/reprints.shtml). orgimiscireprints.shtml). Correspondence to: Ronan O'Driscoll, O'Driscoll, MD, MD, Hope Hope Hospital, Hospital, Correspondence to: B. B. Ronan Respiratory Medicine, Medicine, Stott Stott Ln, Ln, Salford Salford M6 M6 8HD, 8HD, UK; Respiratory UK; e-mail: e-mail: ronan.o'dnscoliesrft.nhs.uk ronan.o'driscoll@srft·nhs.uk DOl: lO.1378/chest.08-0814 lO.1378/chest.08-0814 DOl: www.chestjournal.org www.chestjournal.org
been infrequently infrequently reported reported in in Asia complication of of been Asia as as aa complication tuberculosis tuberculosis (TB). (TB). It It has has not not been been reported reported in in the the United Kingdom Kingdom or or the the United United States, States, or, or, to to our our knowlknowlUnited edge, in in non-Asian have identified identified seven seven edge, non-Asian patients. patients. We We have cases of of patients patients presenting presenting to to aa single single teaching teaching hospihospicases tal in in the the northwest northwest of of England England over over aa 13-year 13-year period. period. tal Only one one patient patient had had aa history history of of TB, TB, but but six six of of the the Only seven patients patients had had aa history history of of occupational occupational dust dust expoexposeven sure, including including one one patient patient with with pneumoconiosis. pneumoconiosis. It It is is sure, possible that anthracofibrosis anthracofibrosis is is an an exaggerated exaggerated endoendopossible that bronchial form form of of the the much much more more common common condition condition of of bronchial anthracosis in in coal coal miners miners and and other other workers workers who have anthracosis who have been exposed exposed to mineral dusts. dusts. Our Our study study suggests suggests that that been to mineral this is essentially essentially aa benign benign condition, condition, although although it it may this is may progress very very slowly, slowly, leading leading to to gradually gradually progressive progressive progress bronchial stenosis. stenosis. The The diagnosis diagnosis is is important important bebebronchial cause most most patients patients have have clinical, clinical, radiologic, radiologic, and and cause bronchoscopic changes changes that that are are highly highly suspicious suspicious of of bronchoscopic malignancy. (CHEST 2008; 2008; 134:1069-1073) 134:1069-1073) malignancy. (CHEST Key words: words: anthracofibrosis; anthracofibrosis; anthracosis; Key anthracosis; bronchoscopy; bronchoscopy; pigment pigment left lower left Abbreviations: LLL LLL == left lower lobeJlobar lobeJlobar bronchus; bronchus; LUL LUL == left Abbreviations: upper lobellobar massive fibrosis; fibrosis; upper lobellobar bronchus; bronchus; PMF PMF == progressive massive = right right lower = right right middle RLL lower lobellobar lobellobar bronchus; bronchus; RML RML = middle lobel lobel RLL = = right right upper upper lobe; lobe; TB = Mycobacterium Mycobacterium lobar bronchus; TB = lobar bronchus; RUL RUL = tuberculosis tuberculosis
A nthracosis nthracosis is term that that is A is aa term is used used when when descnbing describing the the effects of soot soot inhalation, inhalation, which which can can cause cause black black effects of pigmentation of of bronchial bronchial mucosa mucosa or or lung lung parenchyma, parenchyma, or or pigmentation the histologic histologic finding finding of of anthracotic anthracotic pigment pigment in in macromacrothe phages. It It is not usually usually associated associated with with structural structural abnorabnorphages. is not malities of of the the tissue. tissue. In In the the context context used malities used here, here, the the defining feature feature is of an an otherwise otherwise normal normal mucosa mucosa with with defining is of deep blue blue pigmentation pigmentation akin akin to to the the appearance appearance of of aa tattoo. tattoo. deep Histology classically classically reveals reveals soot-laden soot-laden macrophages. macrophages. It It is Histology is most commonly commonly found found in most in those those persons persons who who have have worked worked as coal miners, miners, sometimes sometimes described described deSCriptively descriptively as as aa as coal "coal tattoo," tattoo," and and is is rarely rarely seen seen in in persons persons without without heavy heavy "coal exposure to to inhaled inhaled soot soot or or smoke. smoke. Anthracosis Anthracosis has has been been exposure previously described described as being associated associated with with underlying underlying previously as being pneumoconiosis.' Endobronchial Endobronchial pigmentation pigmentation with with airairpneumoconiosis.I way narrowing narrowing was was first first described in way described in in 1951 1951 by by AbrahamAbraham 2 in patients patients with with perforated perforated tuberculous tuberculous lymph lymph nodes. nodes. HowHowever, anthracofibrosis has has more more recently recently been been ever, the the term term anthracofibrosis coined3--S to to describe describe aa distinct distinct entity entity of coined3--S of inflammatory inflammatory bronbronchial chial stenosis stenosis with with overlyinganthracotic overlying anthracotic mucosa. mucosa. AnthracofiAnthracofibrosis brosis has has not, not, to to our our knowledge, knowledge, been been previouslyreported previously reported in in Europe in patients patients of of non-Asian non-Asian Europe or or the the United United States, States, or or in origin. origin.
MATERIALS AND AND METHODS METHODS MATERIALS We report We report on on aa series series of of seven seven patients patients who who presented presented to to aa Single of England, England, single teaching teaching hospital hospital in in Salford, Salford, in in the the northwest northwest of between 1993 1993 and and 2007 2007 (see (see Table Table 11 for for summary). between summary). These These patients patients were were identified identified from from among among approximately approximately 7,000 7,000 records records in the Department Department of of Respiratory in the the bronchoscopy bronchoscopy database database of of the Respiratory Medicine The medical medical records Medicine at at Salford Salford Royal Royal Hospital. Hospital. The records were were then reviewed reviewed to then to look look for for key key clinical clinical features, features, risk risk factors, factors, and and record of progress. progress. All All patients patients presented presented in in aa manner manner that that raised record of raised CHEST/134/5/ NOVEMBER, 2008 2008 CHEST /134/5/ NOVEMBER,
1069 1069
Selected Reports Selected Reports
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Gas Embolism Gas Embolism Following Following Bronchoscopic Bronchoscopic Argon Argon Plasma Plasma Coagulation* Coagulation* A Case A Case Series Series Chakravarthy Reddy, MD; Adnan Majid, MD; Gaetane Michaud, MD, FCCP; FCCP; David Feller-Kopman, MD, FCCP; FCCP; Ralph Eberhardt, MD; Felix Herth, Herth, MD, MD, FCCP; FCCP; and Amlin Ernst, MD, FCCP Felix
Thennal Thermal ablation ablation using using argon argon plasma plasma coagulation coagulation (APC) is (APC) is aa commonly commonly used used modality modality in in the the bronchobronchoscopic management scopic management of of central central airway airway obstruction obstnlCtion and hemoptysis. and hemoptysis. In In experienced experienced hands, hands, APC APC is is conconsidered to sidered to be be aa relatively relatively safe safe tool. tool. Reported Reported complicomplications associated cations associated with with APC APC use use are are rare rare and and include include hemorrhage, hemorrhage, airway airway perforation, perforation, or or airway airway fires. fires. Systemic gas Systemic gas embolism embolism has has been been reported reported with with APC APC during laparoscopic during laparoscopic hepatic hepatic surgeries, surgeries, and and we we have have reported one reported one case case of of systemic systemic gas gas embolism embolism with with cardiovascular collapse cardiovascular collapse in in the the past. past. We We now now report report the first the first case case series series of of systemic, systemic, life-threatening life-threatening gas gas embolism occurring embolism occurring as as aa complication complication of of bronchobronchoscopic application scopic application of of APC. APC. (CHEST 2008; (CHEST 2008; 134:1066-1069) 134:1066-1069) Key words: Key words: argon argon plasma plasma coagulation; coagulation; bronchoscopy; bronchoscopy; complicacomplication; gas tion; gas embolism embolism Abbreviations: ACLS Abbreviations: ACLS == advanced advanced cardiac cardiac life life support; support; = argon argon plasma plasma coagulation; coagulation; CPR CPR = = cardiopulmonary cardiopulmonary APC = APC resuscitation; LV resuscitation; LV = = left left ventricIeiventricular; ventricle/ventricular; TEE TEE = = transesophageal transesophageal echocardiography echocardiography
A rgon A rgon plasma plasma coagulation coagulation
(APC) is (APC) is aa tool tool for for the the bronchoscopic bronchoscopic management management of of central central ailWay airway obstrucobstruction or hemoptysis tion hemoptysis caused caused by by benign benign or or malignant malignant ailWay airway 'From Interventional 'From Interventional Pulmonology Pulmonology (Drs. (Drs. Reddy, Reddy, Majid, Majid, Michaud, Michaud, and and Ernst), Ernst), Beth Beth Israel Israel Deaconess Deaconess Medical Medical Center, Center, Harvard Harvard Medical Medical School, School, Boston, Boston, MA; MA; Interventional Interventional Pulmonology Pulmonology (Dr. (Dr. Feller-Kopman), Feller-Kopman), Johns Johns Hopkins Hopkins Hospital, Hospital, Baltimore, Baltimore, MD; MD; and and Department Department of of Pulmonary Pulmonary Medicine Medicine (Drs. (Drs. Eberhardt Eberhardt and and Herth), Thoraxklinik, Thoraxklinik, Heidelberg, Heidelberg, Germany. Germany. Herth), The authors authors have have no no conflicts conflicts of of interest interest to to disclose. disclose. The Manuscript received received February February 20,2008; 20,2008; revision revision accepted accepted May May 9, 9, Manuscript 2008. 2008. I,teproductionof permission I,teproduction of this tillS article article is is prohibited prohibited without without written written pennission from the Physicians (www.chestjournal. (www.chestjournal. from the American American College College of of Chest Chest Physicians orglmisclreprints.shtml). orglmisclreprints.shtml). Correspondence to: Armin Emst, Ernst, MD, MD, FCCP, FCCP, Chief, Chief, IntervenIntervenCorrespondence to: Armin tional Pulnwnology, Pulnwnology, Beth Beth Israel Israel Deaconess Deaconess Medical Medical Center, Center, HarHartional vard Medical Medical School, School, One One Deaconess Deaconess Rd, Rd, Boston, Boston, MA MA 02115; 02115; vard e-mail: [email protected] [email protected] e-mail: DOl: IO.1378/chest.08-0474 IO.1378/chest.08-0474 DOl: 1066 1066
lesions. 11 APC lesions. APC is is aa noncontact noncontact form form of of electrocoagulation electrocoagulation and has and has been been used used extenSively extensively in in the the fields fields of of interveninterventional tional pulmonology pulmonology and and gastroenterology.21t gastroenterology.21t is is considered considered to to be be safe safe in in the the hands hands of of experienced experienced bronchoscopists, bronchoscopists, and and the the reported reported frequency frequency of of adverse adverse events events is is < < 1%.3 1%.3 The reported The reported complications complications from from APC APC in in the the ailWays airways include hemorrhage, include hemorrhage, perforation, perforation, stenosis, stenosis, and and ailWay airway fires. l fires.' APC utilizes APC utilizes argon argon flow flow through through an an endoscopic endoscopic probe probe to to deliver an deliver an electric electric current current to to the the target target tissue. tissue. Prior Prior to to exiting the exiting the tip tip of of the the probe, probe, argon argon comes comes in in contact contact with with an an electrode gas and and creates creates aa plasma plasma jet electrode that that ionizes ionizes the the gas jet that that conducts aa high-voltage conducts high-voltage electric electric current current to to the the target target tissue. tissue. Gas Gas flowing flowing out out of of aa probe probe under under pressure pressure into into the the ailWay airway can can cross cross aa disrupted disrupted mucosal mucosal membrane membrane into into the the microvasculature microvasculature and and pose pose aa theoretical theoretical risk risk of of systemic systemic gas embolism. embolism. This This has has been been known known to to occur occur with with the the gas bronchoscopic of Nd-YAG Nd-YAG laser, laser, in in which which the the laser laser bronchoscopic use use of 4 .5 fiber tip tip is is cooled cooled with with gas gas flowing flowing across across the the probe. fiber probe.w Systemic gas gas embolism embolism from from APC APC has has been been reported reported with with Systemic hepatic surgeries,6-10 hepatic surgeries,6-10 and and we we have have reported reported aa single single such such case case associated associated with with the the use use of of APC APC in in the the central central airways.'! of systemic systemic ailWays.ll We We now now present present the the first first case case series series of gas embolism gas embolism occurring occurring dUring during bronchoscopic bronchoscopic use use of of APC. APC. CASE REPORTS REPORTS
In this In this single-center single-center experience, experience, all all patients patients underwent underwent rigid rigid bronchoscopy bronchoscopy with with high-frequency high-frequency jet jet ventilation ventilation in in tile tile operating operating room, room, under under general general anesthesia. anesthesia. The The working working channel channel of of aa flexible bronchoscope bronchoscope was was used used to to guide guide the the APC APC probe probe to to the the flexible desired location location (Fig (Fig 1). desired 1). Apnea Apnea was was maintained maintained during during the the application of APC application of APC (ERBOTOM (ERBOTOM ICC ICC 200 200 with with APC APC 300; 300; ERBE ERBE USA; USA; Atlanta, Atlanta, GA) GA) during during all all procedures procedures to to avoid avoid ignition ignition and and airway fires. applied at at 1noncontact airway fires. APC APC was was applied 1- to to 3-s 3-s bursts bursts in in aa noncontact mode to to ablate ablate lesions. lesions. Patient The mode Patient 11 has has been been reported reported prior.!' prior. ll The data data review review was was approved approved by by the the Institutional Institutional Review Review Board Board at at Beth Center, and and informed consent Beth Israel Israel Deaconess Deaconess Medical Medical Center, informed consent was waived. waived. was Patient 1
A 75-year-old A 75-year-old woman woman with with an an endobronchial endobronchial carcinoid carcinoid tumor tumor presented presented with with hemoptysis. hemoptysis. Underlying Underlying coronary coronary artery artery disease disease rendered rendered her her aa poor poor candidate candidate for for resection. resection. DUring DUring bronchosbronchoscopy, an an endobronchial endobronchial lesion lesion seen seen in in the the right right middle middle lobe lobe was was copy, confirmed as confirmed as the the source source for for the the hemoptysis. hemoptysis. APC APC was was performed performed with Umin and and power power of of 40 with argon argon flow flow rate rate of of 22 Umin 40 W, W, and and hemostasis was was achieved. achieved. Moments Moments following following termination hemostasis termination of of APC, patient became became bradycardic bradycardic and and hypotensive, hypotensive, progressprogressAPC, the the patient ing into into ventricular ventricular fibrillation fibrillation and and arrest. arrest. Cardiopulmonary Cardiopulmonary ing resuscitation (CPR) (CPR) was per advanced advanced cardiac cardiac life life resuscitation was initiated initiated per support support (ACLS) (ACLS) protocol. protocol. When When 20 20 min min of of CPR CPR did did not not convert convert the the rhythm, rhythm, emergent emergent transesophageal transesophageal echocardiography echocardiography (TEE) (TEE) was was performed, performed, which which revealed revealed fibrillating fibrillating ventricles ventricles with with aa large large gas (LV). No No septal septal defects defects were were gas bubble bubble in in the the left left ventricle ventricle (LV). Selected Reports Selected Reports
Patient Patient 33
FIGURE 1. Endobronchial use use of of APC APC for for tumor tumor ablation. ablation. FIGURE 1. Endobronchial
present to to explain explain an an intracardiac intracardiac right-to-left right-to-left shunt; shunt; however, however, aa present bubble study study was was not not performed performed due due to to the the emergent emergent nature nature of of bubble the diagnostic diagnostic procedure. procedure. The The patient patient was was placed placed on on extracorpoextracorpothe real membrane membrane oxygenation oxygenation and and transferred transferred to to the the cardiac cardiac cathcathreal eterization laboratory laboratory for for angiography. angiography. Coronary Coronary arteries arteries were were eterization unremarkable, and and aa large large gas gas bubble bubble in in the the LV LV was was again again noted. noted. unremarkable, The gas gas bubble bubble was was aspirated aspirated with catheter The \'lith an an 6F 6F angled angled pigtail pigtail catheter advanced through through the the angiocatheter. angiocatheter. Defibrillation Defibrillation restored restored nornoradvanced mal sinus sinus rhythm. rhythm. The The patient patient stabilized stabilized hemodynamically hemodynamically over over mal next few few hours, hours, and and was was weaned weaned from from extracorporeal extracorporeal membrane membrane next oxygenation. She She recovered recovered to to her her baseline baseline mental oxygenation. mental status status over over the the next few few days; days; however, however, she she refused refused any next any further further interventions interventions and and died died aa week week later later from from cardiac cardiac complications. complications. Patient 22 Patient
A 61-year-old 61-year-old woman woman was was transferred A transferred from from an an outside outside hospital hospital for for evaluation evaluation and and management management of of acute acute hemoptysis hemoptysis with with radioradiologic of aa right logic evidence evidence of right middle middle lobe lobe mass. mass. Airway Airway evaluation evaluation revealed aa right right middle middle lobe lobe endobronchial endobronchial mass mass with with active active revealed bleeding in in addition bleeding addition to to old old blood blood clots. clots. APC APC was was employed employed at at aa flow of 1.5 Umin and and power power of flow of 1.5 Umin of 40 40 W W in in the the right right middle middle lobe lobe to to ablate ablate the the tumor, tumor, and and the the bleeding bleeding was was controlled. controlled. Shortly Shortly after, after, acute acute T-wave T-wave inversions inversions developed developed on on telemetry, telemetry, followed followed by by bradycardia, bradycardia, hypotension, hypotension, and and loss loss of of peripheral peripheral pulses. pulses. CPR CPR was was initiated initiated per per ACLS ACLS protocol. protocol. Within Within aa few few minutes, minutes, the the patient patient was was hemodynamically hemodynamically stable stable with with recovery recovery of of peripheral peripheral pulses. pulses. ECG ECG revealed revealed changes changes consistent consistent with with acute acute inferior inferior wall wall myomyocardial TEE was was performed, performed, which which cardial infarction. infarction. An An emergent emergent TEE revealed gas gas bubbles revealed bubbles in in the the LV LV without without any any evidence evidence of of intracarintracardiac bubble study study was performed. She She diac septal septal defects. defects. A A bubble was not not performed. was transferred transferred to to the the cardiac cardiac catheterization catheterization laboratory laboratory and and was underwent angiography. angiography. Results Results were were unremarkable, unremarkable, with with nornorunderwent mal coronary coronary arteries, arteries, normal normal LV mal LV ejection ejection fraction, fraction, and and no no evidence The patient patient recovered recovered in in the the evidence of of intracardiac intracardiac shunts. shunts. The ICU in in 1 1 day, day, was was transferred transferred to to the floor, and discharged ICU the floor, and was was discharged days later. later. She She subsequently subsequently underwent underwent right right middle middle lobeclobec33 days tumor and and remains remains tomy for for aa localized, atypical carcinoid carcinoid tumor tomy localized, atypical asymptomatic at at this this time. asymptomatic time. www.chestjournal.org www.chestjournal.org
A 72-year-old transferred from from an A 72-year-old woman woman was was transferred an outside outside hospital hospital for management of acute for management of acute hemoptysis. hemoptysis. Non-small Non-small cell cell lung lung carcicarcinoma upper lobe lobe was diagnosed 44 weeks noma involving involving the the left left upper was diagnosed weeks prior prior to to presentation, presentation, and and she she received received external external beam beam radiation radiation thertherapy. apy. Cough Cough with with hemoptysis hemoptysis developed developed the the day day before, before, with with rapid rapid deterioration deterioration in in clinical clinical status. status. An An urgent urgent rigid rigid bronchoscopy bronchoscopy revealed revealed fresh fresh blood blood in in the the trachea, trachea, left left mainstem mainstem bronchus, bronchus, and and left left upperupper- and and left left lower-lobe lower-lobe segmental segmental bronchi. bronchi. Airwayswere AiIways were suctioned suctioned clean, clean, and and aa thorough thorough evaluation evaluation revealed revealed an an endoendobronchial bronchial lesion lesion in in the the left left upper upper lobe lobe with with active active bleeding. bleeding. The The rigid rigid bronchoscope bronchoscope was was advanced advanced into into the the left left mainstem mainstem bronbronchus chus to to isolate isolate the the lung lung and and maintain maintain adequate adequate ventilation ventilation in in the the normal normal right right lung. lung. APC APC was was utilized utilized in in the the left left upper upper lobe lobe at at aa flow Umin flow of 40 flow of of 11 Umin flow and and power power of 40 W W to to ablate ablate the the lesion lesion and and control the the bleeding. bleeding. While While APC APC was control was being being administered, administered, acute acute ST-segment ECG leads, leads, and and ST-segment elevations elevations developed developed on on the the inferior inferior ECG progressed progressed to to pulseless pulseless electrical electrical activity activity and and cardiac cardiac arrest. arrest. CPR CPR was initiated per ACLS ACLS protocol. urgent TEE TEE was was initiated per protocol. An An urgent was performed performed that that revealed revealed gas gas in in the the LV LV apex apex and and in in ascending ascending aorta, aorta, at at the the right right coronary coronary ostia. ostia. Severe Severe LV LV global global hypokinesis hypokinesis (LV (LV ejection ejection fraction of 10 to to 20%) ventricular fraction of 20%) and and severe severe global global right right ventricular free-wall hypokinesis hypokinesis with with apical apical sparing sparing (Fig (Fig 2) 2) were were also also noted. noted. free-wall No No intracardiac intracardiac septal septal defects defects were were noted, noted, and and aa bubble bubble study study was was not not performed. performed. CPR CPR was was continued continued for for aa few few minutes, minutes, and and with IV vasopressors vasopressors cardiac cardiac status status improved improved with with recovery recovery of of aa with IV palpable peripheral peripheral pulse. pulse. TEE TEE monitoring monitoring showed showed resolution resolution of of palpable the gas emboli the intracardiac intracardiac gas emboli during during the the course course of of the the CPR. CPR. She She was transferred transferred to to the the ICU ICU for for further further care. care. The The next next day, day, the the was neurologic evaluation evaluation and and the the severe severe cerebral neurologic cerebral edema edema on on CT CT scan scan were were consistent consistent with with anoxic anoxic brain brain injury. injury. After After discussion discussion with with family family members, members, life life support support was was withdrawn withdrawn the the following following day day and and the the patient patient died died shortly shortly thereafter. thereafter. DISCUSSION DISCUSSION
APC with with aa flexible flexible probe probe has has been been available APC available for for use use with endoscopic endoscopic procedures since the the early early 1990s. 1990s. Used Used with procedures since initially for for hemostasis GI polypectoinitially hemostasis during during endoscopic endoscopic GI polypectomies.v application of of APC expanded into into the mies,12 application APC has has expanded the fields fields of of otolaryngology, and urologic urologic surgersurgerotolaryngology, laparoscopic laparoscopic hepatic, hepatic, and ies.'·13-15 In interventional pulmonology, pulmonology, APC APC is widely ies.'·13-15 In interventional is aa widely used tool tool to to debulk debulk malignant malignant or or benign benign airway airway tumors, tumors, used manage hemoptysis, hemoptysis, and and remove granulation tissue tissue from from manage remove granulation 6 - IS stents or or anastamosis.1 anastamosis.Iv-" stents
FIGURE 2. TEE showing showing air FIGURE 2. TEE air embolism embolism at at the the LV LV apex. apex. CHEST /134/5/ NOVEMBER, NOVEMBER, 2008 2008 CHEST /134/5/
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APC APC is is aa noncontact noncontact mode mode of of tissue tissue coagulation. coagulation. Argon Argon flows from the the tip of the flows from tip of the probe probe at at 0.3 0.3 to to 2 2 L'min Umin and and conducts the conducts an an electrical electrical charge charge from from an an electrode electrode in in the probe probe to to the the target target tissue. tissue. It It is is applied applied in in bursts bursts of of 11 to to 3 3 ss of 80 W W of of power. power. At At these these settings, settings, the the depth depth of of of 20 20 to to 80 penetration is penetration is < < 55 mm, mm, which which is is designed designed to to reduce reduce the the risk of of damage damage to to underlying underlying structures structures and and supposedly supposedly risk makes it it aa safe safe modality modality for for use use in in the the airways. airways. makes Systemic gas gas embolism embolism may may be be aa potentially potentially fatal fatal comcomSystemic plication from from APC APC use use in in the the airways. airways. It plication It has has been been reported in hepatiC surgeries,9.10 surgeries,9.10 and and we we present present the the first first reported in hepatic case of this case series series of this complication complication from from endobronchial endobronchial use. use. Endobronchial Endobronchial systemic systemic gas gas embolism embolism is is not not new new and and has has been laser in in the the been reported reported with with the the use use of of Nd-YAG Nd-YAG laser airways. laser uses uses gas gas flow flow to to cool the tip tip of of the the airways. Nd-YAG Nd-YAG laser cool the probe, probe, and and flow flow rates rates as as low low as as 0.4 0.4 Umin have have been been shown shown pressures> 500 500 mm mm Hg.19 Hg.19 Gas Gas exihng exihng the the tip tip to to generate generate pressures> of of the the probe probe under under pressure pressure is is thought thought to to be be able able to to cross cross the mucosal mucosal membranes membranes into into blood blood vessels vessels through through bronbronthe chovascular fistulae fistulae created created by by coagulation coagulation of of tissue. tissue. The The chovascular precise etiology etiology of of gas gas embolism embolism with with APC APC is is unclear. unclear. precise Based on Based on animal animal experiments,"? experiments,20 APC APC application application in in the the trachea is is associated associated more more commonly commonly with with gas gas embolizaembolizatrachea tion to the tion to the right right atrium, atrium, presumably presumably via via systemic systemic veins, veins, whereas ablation ablation in bronchi is is associated associated more more commonly commonly whereas in bronchi with gas gas embolization embolization to to the the left atrium through through the the left atrium with pulmonary venous venous system. system. Mortality Mortality associated associated with with intraintrapulmonary operative systemic systemic gas embolism from operative gas embolism from Nd-YAG Nd-YAG laser laser use use in the the airways airways is is high, fatalities reported reported from from 21 21 high, with with nine nine fatalities in cases in in literature. literature."s Hanowell Hanowell et et al al21 reported cases reported aa procedural procedural incidence of incidence of cardiovascular cardiovascular complication complication with with Nd-YAG Nd-YAG laser use use at We speculate that the 27.6% from from 87 87 cases. cases. We speculate that the laser at 27.6% pathogenesis involved involved in in systemic gas embolism embolism from from APC pathogenesis systemic gas APC may be be similar to that of Nd-YAG similar to that of Nd-YAG laser, laser, but but that that argon argon is is may crossing crossing over over instead instead of of the the cooling cooling gas. gas. It It is is unlikely unlikely for for the visualized the visualized gas gas to to be be derived derived from from jet jet ventilation ventilation because apnea apnea was was maintained maintained during during all all procedures. procedures. because Diagnosis of of gas gas embolism embolism intraoperatively intraoperatively requires requires aa Diagnosis high level level of of suspicion suspicion and and can can be be confirmed confirmed with with TEE.s TEE.s high Intraoperative changes changes in in the the inferior inferior ECG Intraoperative ECG leads leads should should arouse the the suspicion of systemic systemic gas gas embolism. embolism. In In the the arouse suspicion of supine supine position, position, right right coronary coronary artery artery ostium ostium is is anterior, anterior, in in the dependant position position and the least least dependant and may may be be the the most most vulnervulnerable to air able to air embolism. embolism. In In two two of of our our patients, patients, acute acute changes changes the cardiac arrest. in inferior leads leads preceded preceded the in inferior cardiac arrest. Cardiovascular or changes changes are are not not ununCardiovascular complications complications or common common during dUring therapeutic therapeutic bronchoscopy bronchoscopy and and are are often often attributed the high-risk high-risk patient attributed to to the patient population population who who may may have just tobacco-induced tobacco-induced lung lung disease disease but have not not just but also also corocoronary artery disease with increased increased operative operative risk. risk. It nary artery disease with It is is also also reasonable undetected systemic reasonable to to postulate postulate that that undetected systemic air air ememboli may have been boli been contributory contributory in in many many of of these these cases. cases. may have The by The risk risk of of systemic systemic gas gas embolism embolism may may be be influenced influenced by the exiting the the rate rate of of gas gas flow flow exiting the tip tip of of the the probe. probe. With With Nd-YAG, Tellides Tellides et visualized air air bubbles Nd-YAG, et al alss visualized bubbles on on TEE TEE with rate set Umin, and the bubbles with coolant coolant gas gas flow flow rate set at at 1.5 1.5 Umin, and the bubbles resolved Umin. In In resolved when when the the flow flow rate rate was was decreased decreased to to 0.8 0.8 Umin. our patients, systemic our patients, systemic air air embolism embolism occurred occurred with with gas gas flow flow 2, 1.5, gas flow flow rate rate for rates rates of of 2, 1.5, and and 1 1 Umin. Umin. The The ideal ideal gas for Nd-YAG or or APC APC use use in in airways airways is is unknown, unknown, and and the the Nd-YAG current recommendations recommendations are are to to set flow to to lowest lowest current set the the flow 1068 1068
pOSSible possible rate rate to to prevent prevent gas gas embolism. embolism. However, However, animal animal experiments 20 have have suggested suggested that that there there may may be be no no safe safe experiments-" level for for gas gas flow flow rates, rates, as as APC APC use use at at any any flow flow lead lead to to level vascular gas gas bubbles bubbles in in healthy healthy sheep. sheep. vascular The incidence incidence of of gas gas embolism embolism with with APC APC application application is is The unknown. The The three three reported reported cases cases occurred occurred at at aa single single unknown. referral center center over over aa period period of of 3 3 years, years, and and endobronchial endobronchial referral APC application application is is performed performed approximately approximately 50 50 to to 75 75 APC times aa year. year. We We suggest suggest that that APC APC use use within within the the airways airways times should be be studied studied in in aa prospective prospective fashion fashion to to ensure ensure that that is is should truly safe safe modality, modality, or or at at least least establish establish the the true true risk risk aa truly associated with with its its use. use. associated CONCLUSION CONCLUSION
Systemic Systemic gas gas embolism embolism is is aa potentially potentially fatal fatal complicacomplication of of APC APC use use in in the the airways. airways. It It should should be be suspected suspected in in tion cases when when intraoperative intraoperative ECG ECG changes changes are are noted, noted, espeespecases cially in in the the inferior inferior leads. leads. Care Care should should be to cially be taken taken to maintain gas gas flow flow at at the maintain the lowest lowest possible possible rate, rate, although although there may there may be be no no safe safe level level that that may may prevent prevent this this complication. It It may may be be indicated indicated at at this this time time to to complication. formally evaluate evaluate the the true true incidence incidence of of gas gas embolism embolism formally with with the the use use of of APe. APe. REFERENCES REFERENCES 11 Ernst Ernst A, A, Feller-Kopman Feller-Kopman D, D, Becker Becker HD, HD, et et al. al. Central Central airway airway Am JJ Respir Respir Crit Crit Care Care Med Med 2004; 2004; 169:1278obstruction. obstruction. Am 169:12781297 1297 22 Conio Conio M, M, Gostout Gostout CJ. CJ. Argon Argon plasma plasma coagulation coagulation (APC) (APC) in in gastroenterology: gastroenterology: experimental experimental and and clinical clinical experiences. experiences. GasGastrointest Endosc trointest Endosc 1998; 1998; 48:109-110 48:109-110 33 Reichle Reichle G, Freitag L, L, Kullmann Kullmann HJ, HJ, et et al. al. Argon Argon plasma G, Freitag plasma coagulation in in bronchology: bronchology: aa new new method; method; alternative alternative or or coagulation complimentary? complimentary? JJ Bronchol Bronchol 2000; 2000; 7:109-117 7:109-117 44 Peachey air embolism embolism Peachey T, T, Eason Eason J, J, Moxham Moxham J, J, et et al. al. Systemic SystemiC air during laser laser bronchoscopy. during bronchoscopy. Anaesthesia Anaesthesia 1988; 1988; 43:872--875 43:872--875 55 Tellides Tellides G, G, Uguriu Uguriu BS, BS, Kim Kim RW, RW, et et al. al. Pathogenesis Pathogenesis of of systemic systemic air air embolism embolism during dUring bronchoscopic bronchoscopic Nd. Nd: YAG YAG laser laser operations. Ann operations. Ann Thorac Thorac Surg Surg 1998; 1998; 65:930-934 65:930-934 66 Emergency Emergency Care Care Research Research Institute. Institute. Fatal Fatal gas gas embolism embolism caused caused by by overpressurization overpressurization during during laparoscopic laparoscopic use use of of argon argon enhanced enhanced coagulation. coagulation. Health Health Devices Devices 1994; 1994; 23:257-259 23:257-259 77 Croce M, Russo Russo R, R, et et al. al. Laparoscopic Laparoscopic liver liver tumor tumor Croce E, E, Azzola Azzola M, resection resection with with the the argon argon beam. beam. Endosc Endosc Surg Surg Allied Allied Technol Technol 1994; 1994; 2:186-188 2:186-188 M, Vallet Vallet B. B. Venous Venous gas gas embolism embolism 88 Ousmane Ousmane ML, ML, Fleyfel Fleyfel M, during liver liver surgery surgery with with argon-enhanced argon-enhanced coagulation coagulation [letter]. [letter]. during Eur JJ Anaesthesiol Eur Anaesthesiol 2002; 2002; 19:225 19:225 M, Miller gas 99 Palmer Palmer M, Miller CW, CW, Van Van Way Way CW CW III, III, et et al. al. Venous Venous gas embolism embolism associated associated with with argon-enhanced argon-enhanced coagulation coagulation of of liver. liver. JJ Invest Invest Surg Surg 1993; 1993; 6:391-399 6:391-399 I. Venous Venous gas gas embolism embolism from from an an argon argon 10 10 Veyckemans Veyckemans F, F, Michel Michel I. coagulator. coagulator. Anesthesiology Anesthesiology 1996; 1996; 85:443-444 85:443-444 11 11 Yaron Yaron G, G, Panzica Panzica PJ, PJ, Pinto Pinto DS, DS, et et al. al. Cardiac Cardiac arrest arrest due due to to left left ventricular gas embolism embolism after after bronchoscopic bronchoscopic argon argon plasma plasma ventricular gas coagulation: coagulation: aa case case report. report. JJ Bronchol Bronchol 2007; 2007; 14:33-35 14:33-35 12 Grund KE, KE, Storek Storek D, D, Farin Farin G. 12 Grund G. Endoscopic Endoscopic argon argon plasma plasma coagulation coagulation (APC) (APC) first first clinical clinical experiences experiences in in flexible flexible endosendoscopy. copy. Endosc Endosc Surg Surg Allied Allied Technol1994; Technol1994; 2:42-46 2:42-46 13 Bergler W, W, Riedel Riedel F, F, Baker-Schreyer Baker-Schreyer A, A, et et al. al. Argon Argon plasma plasma 13 Bergler coagulation for for the the treatment treatment of of hereditary hereditary hemorrhagic hemorrhagic coagulation telangiectasia. Laryngoscope Laryngoscope 1999; 1999; 109:15-20 telangiectasia. 109:15-20 Selected Reports Selected Reports
14 Quinlan Quinlan DM, DM, Naslund Naslund MJ, MJ, Brendler Brendler CB. CB. Application Application of of argon 14 argon beam coagulation coagulation in in urological urological surgery. surgery. JJ Uro11992; Uro11992; 147:410beam 147:410412 412 15 of ovarian 15 Brand Brand E, E, Pearlman Pearlman N. N. Electrosurgical Electrosurgical debulking debulking of ovarian cancer: aa new new technique technique using using argon argon plasma plasma beam beam coagulator. coagulator. cancer: Gynecol Onco11990; Onco11990; 39:115-118 39:115-118 Gynecol 16 Crosta Crosta C, C, Spaggiari Spaggiari L, L, De De Stefano Stefano A, A, et et al. al. Endoscopic Endoscopic argon argon 16 plasma coagulation coagulation for for palliative palliative treatment treatment of of malignant malignant plasma airway obstructions: obstructions: early early results results in in 47 47 cases. cases. Lung Lung Cancer Cancer airway 2001; 33:75--80 33:75--80 2001; 17 Keller Keller CA, CA, Hinerman Hinerman R, R, Singh Singh R, R, et et al. al. The The use use of of endoscopic endoscopic 17 argon plasma argon plasma coagulation coagulation in in airway airway complications complications after after solid solid organ organ transplantation. transplantation. Chest Chest 2001; 2001; 119:1968-1975 119:1968-1975 18 18 Morice Morice RC, RC, Ece Ece T, T, Ece Ece G, G, et et al. al. Endobronchial Endobronchial argon argon plasma plasma coagulation for for treatment treatment of coagulation of hemoptysis hemoptysis and and neoplastic neoplastic airway airway obstruction. obstruction. Chest Chest 2001; 2001; 119:781-787 119:781-787 19 19 Lang Lang NP, NP, Wait Wait GM, GM, Read Read RR. RR. Cardio-cerebrovascular Cardio-cerebrovascular comcomplications t;'ethnent of of lung lung cancer. cancer. Am plications from from Nd: Nd: YAG YAG laser laser t;'ethnent Am Surg 1991; 1991; 162:629-632 162:629-632 JJ Surg 20 Feller-Kopman Feller-Kopman D, D, Lukanich Lukanich JM, JM, Shapira Shapira G, G, et et al. al. Gas Gas flow flow 20 during bronchoscopic bronchoscopic ablation ablation therapy therapy causes causes gas gas emboli emboli to to during the heart: heart: aa comparative comparative animal animal study. study. Chest Chest 2008; 2008; 133: 133: the 892-896 892-896 21 Hanowell Complications of of 21 Hanowell LH, LH, Martin Martin WR, WR, Savelle Savelle JE, JE, et et al. al. Complications general anesthesia anesthesia for for Nd:YAG Nd:YAG laser laser resection resection of of endobrongeneral endobronchial chial tumors. tumors. Chest Chest 1991; 1991; 99:72-76 99:72-76
Anthracofibrosis, Bronchial Bronchial Anthracofibrosis, Stenosis With Stenosis With Overlying Overlying Anthracotic Mucosa: Possibly Possibly Anthracotic Mucosa: a New New Occupational Occupational Lung Lung a Disorder* Disorder* A Series Series of of Seven Seven Cases A Cases From From One One UK Hospital Hospital UK Gareth j. j. Wynn, Wynn, MBChB; MBChB; Peter Peter M. Turkington, MD; Gareth M. Turkington, MD; and and B. O'Driscoll, MD MD B. Ronan Ronan O'Driscoll,
Anthracofibrosis, which which was was recently recently defined defined as as bronbronAnthracofibrosis, chial stenosis stenosis with with overlying overlying anthracotic anthracotic mucosa, mucosa, has has chial 'From the the Department Department of of Respiratory Respiratory Medicine, 'From Medicine, Salford Salford Royal Royal University University Hospital, Hospital, Salford, Salford, UK. UK. Dr. is the the Chief Chief Investigator Investigator for for aa research research project, project, with with Dr. Turkington Turkington is £50,000 grant grant from from the the Pfizer Pfizer Foundation, Foundation, on on the the early early diagnosis aa £50,000 diagnosis of COPD COPD and and targeted targeted smoking smoking cessation. cessation. He He has has given given six six lectures lectures of per year year to to primary per primary care care staff staff with with honoraria honoraria from from various various pharmapharmaceutical ceutical companies companies (AstraZeneca, (AstraZeneca, GlaxoSmithKline,and GlaxoSmithKline, and Pfizer). Pfizer). Dr. Dr. signifiWynn have reported reported to to the the ACCP ACCP that that no no signifiWynn and and Dr. Dr. O'Driscoll O'Driscoll have cant conflicts interest exist exist with with any any companies/organizations companies/organizations of interest cant conflicts of whose products products or or services services may may be be discussed discussed in in this this article. article. whose Manuscript received received March March 24, 24, 2008; 2008; revision revision accepted accepted May May 22, 22, Manuscript 2008. 2008. Reproduction of of this this article article is is prohibited prohibited without without written written permission permission Reproduction from of Chest Chest Physicians Physicians (www.chestjoumal. (www.chestjoumal. from the the American American College College of orglmisc/reprints.shtml). orgimiscireprints.shtml). Correspondence to: Ronan O'Driscoll, O'Driscoll, MD, MD, Hope Hope Hospital, Hospital, Correspondence to: B. B. Ronan Respiratory Medicine, Medicine, Stott Stott Ln, Ln, Salford Salford M6 M6 8HD, 8HD, UK; Respiratory UK; e-mail: e-mail: ronan.o'dnscoliesrft.nhs.uk ronan.o'driscoll@srft·nhs.uk DOl: lO.1378/chest.08-0814 lO.1378/chest.08-0814 DOl: www.chestjournal.org www.chestjournal.org
been infrequently infrequently reported reported in in Asia complication of of been Asia as as aa complication tuberculosis tuberculosis (TB). (TB). It It has has not not been been reported reported in in the the United Kingdom Kingdom or or the the United United States, States, or, or, to to our our knowlknowlUnited edge, in in non-Asian have identified identified seven seven edge, non-Asian patients. patients. We We have cases of of patients patients presenting presenting to to aa single single teaching teaching hospihospicases tal in in the the northwest northwest of of England England over over aa 13-year 13-year period. period. tal Only one one patient patient had had aa history history of of TB, TB, but but six six of of the the Only seven patients patients had had aa history history of of occupational occupational dust dust expoexposeven sure, including including one one patient patient with with pneumoconiosis. pneumoconiosis. It It is is sure, possible that anthracofibrosis anthracofibrosis is is an an exaggerated exaggerated endoendopossible that bronchial form form of of the the much much more more common common condition condition of of bronchial anthracosis in in coal coal miners miners and and other other workers workers who have anthracosis who have been exposed exposed to mineral dusts. dusts. Our Our study study suggests suggests that that been to mineral this is essentially essentially aa benign benign condition, condition, although although it it may this is may progress very very slowly, slowly, leading leading to to gradually gradually progressive progressive progress bronchial stenosis. stenosis. The The diagnosis diagnosis is is important important bebebronchial cause most most patients patients have have clinical, clinical, radiologic, radiologic, and and cause bronchoscopic changes changes that that are are highly highly suspicious suspicious of of bronchoscopic malignancy. (CHEST 2008; 2008; 134:1069-1073) 134:1069-1073) malignancy. (CHEST Key words: words: anthracofibrosis; anthracofibrosis; anthracosis; Key anthracosis; bronchoscopy; bronchoscopy; pigment pigment left lower left Abbreviations: LLL LLL == left lower lobeJlobar lobeJlobar bronchus; bronchus; LUL LUL == left Abbreviations: upper lobellobar massive fibrosis; fibrosis; upper lobellobar bronchus; bronchus; PMF PMF == progressive massive = right right lower = right right middle RLL lower lobellobar lobellobar bronchus; bronchus; RML RML = middle lobel lobel RLL = = right right upper upper lobe; lobe; TB = Mycobacterium Mycobacterium lobar bronchus; TB = lobar bronchus; RUL RUL = tuberculosis tuberculosis
A nthracosis nthracosis is term that that is A is aa term is used used when when descnbing describing the the effects of soot soot inhalation, inhalation, which which can can cause cause black black effects of pigmentation of of bronchial bronchial mucosa mucosa or or lung lung parenchyma, parenchyma, or or pigmentation the histologic histologic finding finding of of anthracotic anthracotic pigment pigment in in macromacrothe phages. It It is not usually usually associated associated with with structural structural abnorabnorphages. is not malities of of the the tissue. tissue. In In the the context context used malities used here, here, the the defining feature feature is of an an otherwise otherwise normal normal mucosa mucosa with with defining is of deep blue blue pigmentation pigmentation akin akin to to the the appearance appearance of of aa tattoo. tattoo. deep Histology classically classically reveals reveals soot-laden soot-laden macrophages. macrophages. It It is Histology is most commonly commonly found found in most in those those persons persons who who have have worked worked as coal miners, miners, sometimes sometimes described described deSCriptively descriptively as as aa as coal "coal tattoo," tattoo," and and is is rarely rarely seen seen in in persons persons without without heavy heavy "coal exposure to to inhaled inhaled soot soot or or smoke. smoke. Anthracosis Anthracosis has has been been exposure previously described described as being associated associated with with underlying underlying previously as being pneumoconiosis.' Endobronchial Endobronchial pigmentation pigmentation with with airairpneumoconiosis.I way narrowing narrowing was was first first described in way described in in 1951 1951 by by AbrahamAbraham 2 in patients patients with with perforated perforated tuberculous tuberculous lymph lymph nodes. nodes. HowHowever, anthracofibrosis has has more more recently recently been been ever, the the term term anthracofibrosis coined3--S to to describe describe aa distinct distinct entity entity of coined3--S of inflammatory inflammatory bronbronchial chial stenosis stenosis with with overlyinganthracotic overlying anthracotic mucosa. mucosa. AnthracofiAnthracofibrosis brosis has has not, not, to to our our knowledge, knowledge, been been previouslyreported previously reported in in Europe in patients patients of of non-Asian non-Asian Europe or or the the United United States, States, or or in origin. origin.
MATERIALS AND AND METHODS METHODS MATERIALS We report We report on on aa series series of of seven seven patients patients who who presented presented to to aa Single of England, England, single teaching teaching hospital hospital in in Salford, Salford, in in the the northwest northwest of between 1993 1993 and and 2007 2007 (see (see Table Table 11 for for summary). between summary). These These patients patients were were identified identified from from among among approximately approximately 7,000 7,000 records records in the Department Department of of Respiratory in the the bronchoscopy bronchoscopy database database of of the Respiratory Medicine The medical medical records Medicine at at Salford Salford Royal Royal Hospital. Hospital. The records were were then reviewed reviewed to then to look look for for key key clinical clinical features, features, risk risk factors, factors, and and record of progress. progress. All All patients patients presented presented in in aa manner manner that that raised record of raised CHEST/134/5/ NOVEMBER, 2008 2008 CHEST /134/5/ NOVEMBER,
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