title: Therapeutic rigid bronchoscopy allows level of care changes in patients with acute respiratory failure from central airways obstruction.
abstract: OBJECTIVE
  To determine whether emergency rigid bronchoscopic intervention, including Nd-YAG laser resection or stenting, immediately affected the need for continued mechanical ventilation or intensive care level of support in critically ill patients with acute respiratory failure from malignant or benign central airways obstruction.
  
  
  METHODS
  Retrospective review of medical records of all patients with acute respiratory failure and malignant or benign tracheobronchial obstruction necessitating intubation, mechanical ventilation, or hospitalization in the ICU prior to referral for therapeutic bronchoscopy.
  
  
  METHODS
  University of California San Diego, a tertiary care institution specialized in airway management.
  
  
  METHODS
  Medical records of 32 patients with malignant or benign central airways obstruction requiring admission to the ICU prior to rigid bronchoscopic intervention between January 1994 and April 1996.
  
  
  METHODS
  Emergent rigid bronchoscopy with dilatation, Nd-YAG laser resection, or silicone stent insertion performed in the operating room under general anesthesia.
  
  
  RESULTS
  Thirty-two patients with central airways obstruction requiring emergent hospitalization in the ICU were referred for therapeutic rigid bronchoscopy. Airway strictures were caused by benign disease in 18 patients, and by primary bronchogenic lung cancer in 14. Of the 19 patients who were mechanically ventilated, bronchoscopic intervention allowed immediate discontinuation of mechanical ventilation in 10 (52.6%). Twenty-five patients had indwelling artificial airways (12 endotracheal tubes, 13 tracheotomy tubes). Two, however, were considered tracheotomy-dependent because of neuromuscular disease. Of the remaining 23 patients, immediate extubation or decannulation was possible in seven (30.4%). Of seven patients with no indwelling airway, five (71.4%) were immediately transferred to a lower level of care after intervention. Of the 32 total patients, 20 (62.5%) were immediately transferred to a lower level of care immediately after intervention.
  
  
  CONCLUSIONS
  Emergency laser resection or stent insertion can favorably affect health-care utilization in patients with acute respiratory distress from central airways obstruction. Treatment may be lifesaving and allows successful withdrawal from mechanical ventilation, hospitalization in a lower level of care environment, relief of symptoms, and extended survival in critically ill patients. In patients with regionally advanced cancer, the palliative nature of this procedure postpones death by respiratory distress and may prompt consideration for institution of conservative comfort measures to reduce patient suffering.
authors.affiliation: Pulmonary Special Procedures and Nd-YAG Laser Unit, University of California San Diego Medical Center, 92103-8330, USA.
authors.forename: H G
authors.initials: HG
authors.lastname: Colt
authors.forename: J H
authors.initials: JH
authors.lastname: Harrell
mesh_terms: D001982:Bronchial Diseases / Q000150:complications / Q000209:etiology; D001999:Bronchoscopy / Q000379:methods; D003251:Constriction, Pathologic / Q000150:complications / Q000209:etiology; D003422:Critical Care / Q000379:methods; D004630:Emergencies; D005260:Female; D006801:Humans; D007362:Intensive Care Units / Q000706:statistics & numerical data; D007442:Intubation, Intratracheal; D053685:Laser Therapy; D008171:Lung Diseases / Q000150:complications; D008175:Lung Neoplasms / Q000150:complications; D008297:Male; D008875:Middle Aged; D012121:Respiration, Artificial; D012131:Respiratory Insufficiency / Q000209:etiology / Q000628:therapy*; D012189:Retrospective Studies; D015607:Stents; D014135:Tracheal Stenosis / Q000150:complications / Q000209:etiology; D014140:Tracheotomy; D015300:Ventilator Weaning