Medical Image of the Week: Bronchial Clot Removal via Cryotherapy

Figure 1. Chest x-ray showing complete opacification of the left hemithorax.

Figure 2. Flexible bronchoscopy with cryotherapy was used to remove clot that formed casts of the bronchial tree. Black arrow: depicts segmental branch of the left upper lobe.

A 38-year-old man with a history of non-ischemic dilated cardiomyopathy presented with decompensated heart failure, acute renal failure, and possible sepsis. He underwent right cardiac catheterization but developed hemoptysis with concern for pulmonary artery rupture. Subsequently, the patient suffered a cardiac arrest but was resuscitated. Emergent bronchoscopy revealed copious amounts of blood and clot that could not be cleared at the time. The patient was then taken to the operating room and placed on A-A ECMO (left ventricle to aorta). The following morning chest x-ray (Figure 1) revealed a completely opacified left lung. Flexible bronchoscopy showed blood clot along the entire left bronchial tree. Initial attempts to remove the clot with suction and endobronchial graspers was unsuccessful. Ultimately, cryotherapy was used to remove the majority of the clot in fragments (Figure 2).

The use of cryotherapies and specifically, in this case, a cryoprobe, has been shown to safely and effectively remove thrombus from the bronchial tree. The basis behind this technique is the use of pressurized nitrous oxide or carbon dioxide to cool a metal probe tip. The probe then freezes any substance it comes in direct contact with, such as a blood clot. Thus, cryoadherence of the probe to the clot allows for effective removal via flexible endoscopy.  Sriratanaviriyakul et al. (1) reported success rates for cryoextraction of blood clots to be >90%.

Cathy V. Ho MD, Ryan Matika MD, and Mimi Amberger MD

¹Division of Trauma, Critical Care, Burn and Emergency Surgery. Department of Surgery

²The Department of Anesthesia

University of Arizona

Tucson, AZ USA

Reference

1. Sriratanaviriyakul N, Lam F, Morrissey BM, Stollenwerk N, Schivo M, Yoneda KY.Safety and clinical utility of flexible bronchoscopic cryoextraction in patients with non-neoplasm tracheobronchial obstruction: a retrospective chart review. J Bronchology Interv Pulmonol. 2015 Oct;22(4):288-93. [CrossRef] [PubMed] 

Cite as: Ho CV, Matika R, Amberger M. Medical image of the week: bronchial clot removal via cryotherapy. Southwest J Pulm Crit Care. 2016;13(5):253-4. doi: https://doi.org/10.13175/swjpcc109-16 PDF 

Medical Image of the Week: Extrapleural Pneumolysis for Tuberculosis

Figure 1. PA (A)/Lateral (B) chest films showing a mass like opacity of the left upper lung field.

Figure 2. Representative image from the thoracic CT in soft tissue windows showing a well-circumscribed, oval-shaped, heterogeneous density within the left upper and mid anterior chest with some expansion and destruction of overlying ribs.

The advent of antibiotics revolutionized the management of tuberculosis, a disease that even in the 1950s was a top 10 cause of death in the United States. The first drug to be developed was streptomycin, approved after a clinical trial in 1946. The following decade saw the addition of ethambutol, rifampin, and isoniazid (1). Though we take for granted the use our multidrug regimens nowadays, physicians once had limited interventions for this frequent and devastating infection. Such interventions included surgical techniques to collapse the affected lobes, starving the mycobacterium of their preferred oxygen rich environment. One such technique was known as plombage, or extrapleural pneumolysis. Plombage is a term derived from the Latin for lead or plumbum and entails the insertion of a space occupying material into the pleural space with subsequent compression of the affected lung portion. This was seen as an alternative to the use of thoracoplasty, which required removal of multiple ribs allowing the chest wall to collapse, leading to deformity and a loss of lung function (2). Though rarely seen now, we present the imaging of an elderly female with endometrial cancer with lung metastasis who interestingly had undergone such a procedure when she developed cavitary tuberculosis as a teenager in 1952.

Tuffler first developed extrapleural pneumolysis in 1891; he placed fat into the pleural cavity reporting successful control of tuberculosis infection. The technique over the subsequent decades became popular especially as a response to the endemic tuberculosis seen post- the Second World War. Many attempts were made to designate an ideal inert material for use. Though unclear in our patient given the remote history of the procedure, published reports include placement of muscle, fat, air, mineral oil, gauze, paraffin, rubber sheeting, and even inflated Lucite balls. Fortunately, complications of the procedure, even decades later, are rarely seen now. Complications listed in the literature, however, do include infection, hemorrhage, fistula formation, migration of material, and even malignancy. Despite its popularity, there were mixed results in effectiveness and variable complication rates, in one series nearly 50% of patients developed an infection (3). In our patient, it was successful, with no history of recurrence with negative sputum and serologic testing. She did notably report having been treated with a long course of antibiotics as well.

Kareem Ahmad, MD

Department of Internal Medicine

Division of Pulmonary, Critical Care, Sleep, and Allergy Medicine

University of Arizona

Tucson, AZ, USA

References

1. Zumla A, Nahid P, Cole ST. Advances in the development of new tuberculosis drugs and treatment regimens. Nat Rev Drug Discov. 2013 May;12(5):388-404. [CrossRef] [PubMed]
2. Young FH. Extraperiosteal plombage in the treatment of pulmonary tuberculosis. Thorax. 1958; 13(2):130-5. [CrossRef] [PubMed]
3. Murphy JD, Elrod PD, et al. Surgical treatment of residual cavities following thoracoplasties for tuberculosis. Dis Chest. 1948 Sep-Oct;14(5):694-706. [CrossRef] [PubMed]

Cite as: Ahmad K. Medical image of the week: extraplerural pneumolysis for tuberculosis. Southwest J Pulm Crit Care. 2016;13(5):244-5. doi: https://doi.org/10.13175/swjpcc106-16 PDF