Publisher: American College of Chest Physicians. Published by Elsevier Inc.
TOPIC: Critical Care TYPE: Fellow Case Reports INTRODUCTION: Endobronchial obstruction can be a potentially life-threatening condition leading to respiratory failure. A significant cause includes endobronchial blood clots. The presence of blood clots in a patient with SARS COV 2 pneumonia and ARDS is even more detrimental. If the clot burden is obstructing central airways, it may result in fatal respiratory failure. This report will describe a case where removing endobronchial clots was unsuccessful by suctioning during bronchoscopy;therefore, endobronchial tPA was administered to reduce the clot burden successfully. CASE PRESENTATION: Fifty-six-year-old African American male with a past medical history of multiple myeloma;on chemotherapy, was positive for SARS COV 2 by rapid PCR. He presented with severe respiratory failure. He was intubated, and due to the severity of ARDS not responding to salvage techniques, he was started on ECMO via Avalon catheter.Thirty days into ECMO treatment, patients' tidal volumes suddenly dropped to 40mL/breath. Bronchoscopy revealed extensive clot burden extending from the endotracheal tube distally. After two unsuccessful attempts at clot extraction, endobronchial tPA for thrombolysis was administered. The patient received three such treatments. There was no evidence of acute pulmonary hemorrhage or other adverse effects throughout and between each procedure due to tPA administration. The patient showed significant improvement in tidal volumes. DISCUSSION: The presence of large clots in the bronchial tree can lead to compromised oxygenation. The presence of ARDS requiring ECMO highlights the severity of illness in a patient. Conservative management is reasonable in a patient without instability. Otherwise, more aggressive management will be needed. The gold standard therapy includes bronchoscopy with suction, forceps, and basket extraction. When these strategies do not give desired results, administering tPA is another option.Other invasive methods to dissolve the bronchial blood clots have been described in literature including cryo-adhesion and topical thrombolysis with streptokinase or urokinase. CONCLUSIONS: Management of endobronchial blood clots using tPA appears to be safe and effective, clearing the blot burden from the larger airways without resulting in any acute or worsening pulmonary hemorrhage. REFERENCE #1: Anderson, D., De la Cruz, P., Dellavolpe, J., & Walter, R. (2016). Endobronchial blood Clot extraction with Tissue plasminogen activator. Chest, 150(4). doi:10.1016/j.chest.2016.08.1102 REFERENCE #2: Veress, L. A., Anderson, D. R., Hendry-Hofer, T. B., Houin, P. R., Rioux, J. S., Garlick, R. B.,… White, C. W. (2014). Airway tissue plasminogen activator prevents acute mortality due to lethal sulfur mustard inhalation. Toxicological Sciences, 143(1), 178-184. doi:10.1093/toxsci/kfu225 DISCLOSURES: No relevant relationships by Muhammad Ehtesham, source=Web Response No relevant relationships by Waseem Farra, source=Web Response No relevant relationships by Elise Landa, source=Web Response