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
Background Despite numerous advances in the understanding of the pathophysiology, progression, and management of acute respiratory failure (ARF) and ARDS, limited contemporary data are available on the mortality burden of ARF and ARDS in the United States. Research Question What are the contemporary trends and geographic variation in ARF and ARDS-related mortality in the United States? Study Design and Methods A retrospective analysis of the National Center for Health Statistics’ nationwide mortality data was conducted to assess the ARF and ARDS-related mortality trends from 2014 through 2018 and the geographic distribution of ARF and ARDS-related deaths in 2018 for all American residents. Piecewise linear regression was used to evaluate the trends in age-adjusted mortality rates (AAMRs) in the overall population and various demographic subgroups of age, sex, race, urbanization, and region. Results Among 1,434,349 ARF-related deaths and 52,958 ARDS-related deaths during the study period, the AAMR was highest in older individuals (≥ 65 years), non-Hispanic Black people, and those living in the nonmetropolitan region. The AAMR for ARF-related deaths (per 100,000 people) increased from 74.9 (95% CI, 74.6-75.2) in 2014 to 85.6 (95% CI, 85.3-85.9) in 2018 (annual percentage change [APC], 3.4 [95% CI, 2.2-4.6]; Ptrend = .003). The AAMR (per 100,000 people) for ARDS-related deaths was 3.2 (95% CI, 3.2-3.3) in 2014 and 3.0 (95% CI, 3.0-3.1 in 2018; APC, −0.9 [95% CI, −5.4 to 3.8]; Ptrend = .56). The observed increase in rates for ARF mortality was consistent across the subgroups of age, sex, race or ethnicity, urbanization status, and geographical region (Ptrend Interpretation The ARF-related mortality increased at approximately 3.4% annually, and ARDS-related mortality showed a lack of decline in the last 5 years. These data contextualize important health information to guide priorities for research, clinical care, and policy, especially during the coronavirus disease 2019 pandemic in the United States.