Laser Resection of Granulation Tissue Secondary to Transtracheal Oxygen Catheter

studies and improvement without antibiotic therapy or pleural drainage. With pleural space infections and other inflammatory pleural processes, pleural fluid acidosis, reduced glucose concentration, and elevation of LD H often ~cur together. 1 In the 14 patients with LE pleurisy whose cases were reported by Good et al,• all three with pleural fluid acidosis showed reduction of glucose levels as well. In some situations, however, this may not be true. Some parapneumonic effusions, for example, may demonstrate a decline in pH before a fall in glucose concentration. 1 In our patient, pleural fluid acidosis was found with a normal glucose concentration and a marked elevation ofLDH. In contrast to LE pleurisy, pleural effusions in rheumatoid arthritis usually have low pH and low glucose levels (85 percent of cases), and they often show a high LDH in excess of 1,000 IU/L as well. 5 These features have been proposed as a means to differentiate rheumatoid and LE pleurisy. 6 In some cases, these findings in rheumatoid effusions are due to concomitant empyema resulting from the breakdown of necrobiotic nodules in the visceral pleura and formation of bronchopleural fistulas. 1 Our patient demonstrates that a markedly high LDH concentration may not discriminate between LE and rheumatoid effusions. Based on our experience, LE pleuritis may be considered in the differential diagnosis of pleural effusions with marked elevations ofWBC and LDH and reduction of pleural fluid pH, features that usually suggest pleural space infection. The patient's persistent dyspnea, abnormal chest roentgenogram, restrictive ventilatory pattern, and positive serum ANA nine months after d.iscontination of procainamide therapy is consistent with residual disease due to druginduced LE. Although rapid improvement usually occurs when the offending agent is withdrawn, in some cases abnormalities persist for months or even years. 7·8 REFERENCES 1 Light Rw. Pleural diseases. Philadelphia: Lea & Febiger; 1983: 163-75 2 Good JT, King TE, Antony VB, Sahn SA. Lupus pleuritis: clinical

Laser Resection of Granulation Tissue Secondary to Ti'anstracheal Oxygen Catheter* Hlrcival A. l\mzal, M.D.; Roseann Myers, R.N.; Andmw L. Ries, M.D., F.C.C.P.; and James H. Ham1U II, M.D., F.C.C.P.

Oxygen therapy through a transtracheal catheter has been used increasingly fur the long-term delivery of continuous oxygen. Compared to nasal cannula it results in significant reduction in oxygen flow requirements. This form of therapy has gained patient acceptance because of several advantages including improved convenience, aesthetics, compliance, and mobility. Reported complications generally have been minor, including subcutaneous emphysema, cough, "mucous ball" furmation and mild hemoptysis. In this report, we describe a case of granulation tissue furmation at the transtracheal catheter puncture site which was treated with Nd:YAG laser bronchoscopy to reestablish patency of the upper airway. No recurrence was noted after two years of fullow-up. (Cheat 1992; 101:269-71) COPD =chronic obstructive pulmonary disease; Dsb =single breath diffusing capacity for carbon monoxide; FEV, =forced expiratory volume in ls; FVC =forced vital capacity; PaC01 = arterial carbon dioxide pressure; Pa01 =arterial oxygen pressure; RV= residual volume; TLC= total lung capacity

Tong-term transtracheal oxygen therapy has been used increasingly in hypoxemic patients with chronic lung disease.'.., Previous reports have demonstrated significant reduction in oxygen fl.ow compared with nasal cannula to achieve equivalent arterial oxygenation (50 percent at rest, less with exercise). 2.•.7 This technique is highly acceptable to many patients and is associated with minor problems. In this report, we describe a case of tracheal obstruction secondary to granulation tissue at the transtracheal puncture site which responded readily to treatment with Nd:YAG laser bronchoscopy.

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features and pleural fluid characteristics with special reference to pleural fluid antinuclear antibody titers. Chest 1983; 84:714-

18 3 Hunder GG, McDuffie FC, Hepper NGG. Pleural fluid complement in systemic lupus erytbematosus and rheumatoid arthritis. Ann Intern Med 1972; 76:357-62 4 Cush

JJ,

Goldings EA. Drug-induced lupus: clinical spectrum

and pathogenesis (review). Am J Med Sci 1985; 290:36-45 5 Sahn SA. The pleura: state of the art. Am Rev Respir Dis 1988; 138:184-234 6 Halla JT, Schronhenloher RE, \blanakis JE. Immune complexes and other laboratory features of pleural effusions. Ann Intern Med 1980; 92:748-52 7 Goldberg SK, Lipshutz JB, Ricketts RM, Fein AM. Procainamide-induced lupus lung disease characterized by neutrophil alveolitis. Am J Med 1984; 76:146-49 8 Donato AS. Drug-induced lupus syndromes. Mayo Clin Proc 1969; 44:664-81

CASE REPORT A 59-yeaN>ld black woman with a 40 pack-year smoking history was hospitalized for the 6rst time in 1986 for progressive dyspnea and cough. Evaluation revealed advanced chronic obstructive pulmonary disease with an FEV, of0.80 L, an FEV,IFVC ratio of 0.46, an RV/fLC ratio of 0.62 and a Dsb value of 3.8 mVmin/mm Hg. A chest radiograph showed evidence of hyperinflated lung 6elds. She had severe resting arterial hypoxemia with a Pa02 level of 54 mm Hg and a PaC02 of 36 mm Hg while breathing room air. Pulmonary hypertension was evidenced by right atrial and right ventricular enlargement as well as increased pulmonary artery size by two-dimensional echocardiography. Evaluation for possible pulmonary thromboembolism with a ventilation-perfusion lung scan and impedance plethysmography disclosed no abnormalities. Subsequently, room air arterial blood gas analysis demonstrated progressive hypoxemia (resting PaO, down to 45 mm Hg) necessitating continuous oxygen at rest (2 Umin) and with exercise (4 U min) by nasal cannula. She was maintained on inhaled bronchodi*From the Department of Medicine, Division of Pulmonary and Critical Care, University of California, San Diego. Reprint tl!quests: Dr. Ries, UCSD Medical Center, 225 Dickinson

Street, San Diego 92103

CHEST I 101 I 1 I JANUARY, 1992

269

F1cuRE I. View through rigid bronchoscope showing a 3 X 4-mm mass of granulation tissue on the anterior tracheal wall along the superior horder of the catheter insertion site marked by a guide "~re. Laser tip is visihle on the left. lators, orally administered theophylline, furosemide, nifedipine and intermittently administered prednisone. In 1987, she completed a comprehensive, multidisciplinary pulmonary rehabilitation program. Two years after beginning t'lntinuous oxygen therapy, transtracheal therapy (SCOOP. Transtracheal Systems, Denver, CO) was initiated to treat severe hypoxemia, to reduce the high oxygen How requirement and to improve t'lmpliance. 2 A transtracheal stent was placed without complications. One week later, this was replaced by a SCOOP l catheter and oxygen therapy was begun at l.5 Umin at rest and 4 Umin with exercise to maintain adequate arterial oxygen saturation. After eight weeks, the tract was mature and a SCOOP 2 catheter was inserted. The patient was instructed in catheter care and cleaning and advised to change the catheter at least ™ce daily. After four months of transtracheal therapy, fiheroptic bronchost~>py was performed hecause of problems in removing and inserting the catheter and persistent "tracheal discomfort." This demon-

F1cuRE 2. View through fiberoptic bronchoscope two years after laser treatment showing no evidence of granulation tissue around the transtracheal catheter.

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strated a 3 x 4-mm mass of granulation tissue on the anterior tracheal wall along the superior border of the catheter insertion site (Fig l). A large amount of thick mucous also was noted around the catheter. The granulation tissue subsequently was removed using a Nd:YAG laser through a 10.4-mm Dumon-Harrell rigid bronchoscope with the patient under general anesthesia. During the procedure, the a wire guide inserted tract was maintained and visualized ~th through the catheter which was removed . The lesion was treated ~th 13 pulses at 45 W for 0.5 s. Removal was completed ~th rigid forceps reestablishing a normally patent airway. There was very minimal bleeding after laser control and the catheter was reinserted over the guide ~re. The patient tolerated the procedure well. No additional therapy was given after laser treatment. Pathologic examination of the resected material revealed only granulation tissue. Subsequently, the patient was noted to be symptomatically periodic exacerbations of her underlying hmg improved ~th disease . Follow-up fiberoptic bronchoscopy performed two years later because of recurrent "tracheal discomfort" showed no evidence of any granulation tissue (Fig 2). DISCUSSION

Two major studies have demonstrated that long-term continuous oxygen therapy in hypoxemic patients with COPD improves survival and reduces morbidity."·" Oxygen conservation devices have been developed to improve the efficiency of oxygen therapy and reduce oxygen flow requirements,'" but have not yet gained widespread acceptance." Transtracheal therapy has been shown to reduce oxygen flow rates with a high degree of acceptance and compliance for many patients. Lower flow rates increase the duration of portable oxygen units and allow patients greater mobility and freedom from the stationary gas source. Complications oflong-term nasal cannula use are avoided . Also, unlike the nasal cannula, the transtracheal catheter can be hidden from view, making patients less self-conscious about their appearance . All of these factors add up to improved patient compliance. Complications reported from transtracheal catheters have generally been minor and amenable to conservative management. In 100 patients on transtracheal oxygen delivery followed up for more than two years, Christopher and coworkers• reported complications of hoarseness (3), cephalad catheter displacement (3), subcutaneous emphysema (3) and bronchospasm (2). Long-term sequelae included "mucous ball" formation (10), bacterial cellulitis (1), keloid (4) and hemoptysis (2) among others. In seven years of experience with transtracheal oxygen therapy, Heimlich and Carr reported no life-threatening complications related to catheter insertion. There were two cases of minor bleeding and two instances of pneumothorax from extratracheal catheter placement treated by thoracostomy tube . There also were three late complications related to portions of catheters breaking off. Fletcher and colleagues•• reported one case of tracheal obstruction developing over four days from a mucousinflammatory mass at the tip of a transtracheal catheter. The mass was dislodged by removing the catheter and was subsequently coughed up by the patient. Granulation tissue formation in the airway associated with a transtracheal catheter has not been reported previously. It is recognized as a consequence of standard tracheostomy Laser Resection of Granulation TJSSUe (Punzal et al)

and has been attributed to chronic infection in a moist wound as well as to mechanical irritation from tube motion. 13 Initially, granulation tissue is soft and vascular but as it matures it becomes fibrous and covered with epithelium. Laser bronchoscopy has been used to treat obstructing lesions in the central tracheobronchial tree. 14·ia It is particularly suitable for obstructing tumors which may be lifethreatening. In experienced hands, laser treatment using a rigid bronchoscope under general anesthesia has the advantages of being safe and effective immediately. Cavaliere and colleagues1• utilized it in 37 cases of tracheal granulation tissue resulting from metallic tracheostomy tubes and suture threads after sleeve resection. Their results were almost always curative. Similarly, our patient demonstrated no recurrence of the lesion two years after Nd:Yag laser treatment, suggesting that the procedure was curative. An obstructing central airway lesion may be associated with few symptoms, as in our patient who noted only minor "tracheal discomfort." This may be particularly difficult to detect in a patient with underlying lung disease which produces similar signs and symptoms. Clues may include findings atypical for the patient's disease (eg, positional dyspnea, localized wheezing) or unusual difficulty in removing or inserting the catheter. The true incidence of granulation tissue in the airway from a transtracheal catheter is unknown. However, it is important to consider this possibility since it is potentially life-threatening and amenable to treatment.

13 Myers EN, Stool SE. Complications of tracheotomy. In: Myers EN, Stool SE, Johnson JT. Tracheotomy. New York:Churchill Livingstone, 1985:147-69 14 Emslander HP, Munteanu J, Prauer HJ, Heinl K, Hinke K, Sebening H, et al. Palliative tumor reduction by laser therapy. Respiration 1987; 51:73-79 15 Kvale PA, Eichenhorn MS, Radke JR, Miks V. YAG laser photoresection of lesions obstructing the central airways. Chest 1985; 87:283-88 16 Cavaliere S, Focooli P, Farina PL. Nd:YAG laser bronchoscopy: a five year experience with 1,396 applications in 1,000 patients. Chest 1988; 94:15-21

Acute Myocardial Infarction Compllcatlng the Cllnlcal Course of Diiated C&rdlomyopathy in Childhood* Marcus Viniciua SinWes, M.D.; lbulo Roberto FelU:, M.D.; and }o8I Antonio Marin-Neto, M.D., Sc.D., F.C.C.P.

An acute myocardial infarction occurred in a 6-year-old

child with dilated cardiomyopathy. This caused severe hemodynamic deterioration that led to a fatal outcome. Autopsy revealed diffuse myocardial atrophy without cell infiltrate, normal epicardial coronary arteries, and a mas-

sive healed anteroapical infarction. Coronary embolism or spasm could not be ruled out as the cause of the infarction. (Chat 1992; 101:271-72)

REFERENCES

1 Christopher KL, Spofford BT, Brannin PK, Petty TL. Transtracheal oxygen therapy for refractory hypoxemia. JAMA 1986;

256:494-97 2 Christopher KL, SpofJord BT, Petron MD, McCarty DC, Goodman JR, Petty TL. A program for transtracheal oxygen delivery: assessment of safety and efficacy. Ann Intern Med 1987; 107:802-08 3 Heimlich HJ, Carr GC. Transtracheal catheter technique for pulmonary rehabilitation. Ann Oto) Rhinol Laryngol 1985; 94:502--04 4 Heimlich HJ, Carr GC. The Micro-Trach: a seven year experience with transtracheal oxygen therapy. Chest 1989; 95:1008-12 5 Hoffinan LA, Dauber JH, Ferson PF, Openbrier DR, Zullo TG. Patient response to transtracheal oxygen delivery. Am Rev Respir Dis 1987; 135:153-56 6 Banner NR, Govan JR. Long term transtracheal oxygen delivery through microcatheter in patients with hypoxaemia due to chronic obstructive airways disease. Br Med J 1986; 293:111-14 7 Myers R, Ries AL. Transtracheal catheter versus nasal cannula in the prescription of oxygen using arterial blood gases or cutaneous oximetry. J Cardiopulmonary Rehabil 1989; 9:392 8 Nocturnal Oxygen Therapy Trial Group. Continuous or nocturnal oxygen therapy in hypoxemic obstructive lung disease: a clinical trial. Ann Intern Med 1980; 93:391-98 9 Medical Research Council Working Party. Long term domiciliary oxygen therapy in chronic hypoxic cor pulmonale complicating chronic bronchitis and emphysema. Lancet 1981; 1:681-86 10 Tiep BL, Lewis MI. Oxygen conservation and oxygen conserving-devices in chronic lung disease. Chest 1987; 92:263-72 11 Block AJ. Intermittent flow oxygen devices: technically feasible, but rarely used. Chest 1984; 86:657-58 12 Fletcher EC, Nickeson D, Costarangos-Ga1arza C. Endotracheal mass resulting &om a transtracheal oxygen catheter. Chest 1988; 93:438-39

,l cute myocardial infarction is extremely rare in children. 1•1 Even though acute myocardial infarction may be detected in association with dilated cardiomyopathy in adults, this association has never been previously proved in

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childhood. CASE REPORT

A 6-yeaN>ld white boy was referred because of progressive congestive heart failure lasting for 10 months. There was neither previously detected fever nor evidence of infectious disease. No clinical problems during pregnancy and delivery and no relatives with cardiac disease were reported. The physical examination revealed a dyspneic child with blood pressure of 90/60 mm Hg and a regular pulse rate of 120 beats per minute. Edema of the lower limbs and face ( + V + 4) and a third heart sound were noted. The liver was palpable 5 cm under the costal margin. The chest x-ray film showed moderate cardiac silhouette enlargement and pulmonary vascular congestion. The electrocardiogram (ECG) showed right and left atrial and left ventricular overload (Fig 1). Blood biochemical studies disclosed the following values: creatinine, 0.5 mg/ml; urea, 12 mg/ml; phosphorus, 4.5 mg/ml; and calcium, 9. 7 mg/ml. On the basis of these findings, a diagnosis of idiopathic dilated cardiomyopathy was made. The patient was put on a regimen of digitalis and diuretics, with little improvement, and outpatient follow-up was recommended for further diagnostic evaluation. One month later, the patient was admitted with severe substernal burning pain of recent onset accompanied by pallor, diaphoresis, vomiting, and intense dyspnea. The ECG (Fig 1) was compatible *From the Department of Internal Medicine, Division of Cardiology (Drs. Sim
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