Teodoro-Teoxon Laiza P, Manderico Rommel Vincent D, Esguerra Vidal A, Pardo Jacqueline D
Department of Anesthesiology, Philippine General Hospital, University of the Philippines Manila, Manila, Philippines.
Department of Anesthesiology, ManilaMed Medical Center Manila, Manila, Philippines.
Acta Med Philipp. 2024 May 23;58(9):76-83. doi: 10.47895/amp.v58i9.8839. eCollection 2024.
Lung cancer is the leading cause of cancer death worldwide. It may present as airway obstruction in a patient with endobronchial masses. Endobronchial brachytherapy (EBBT) has been shown to provide palliative therapy. It is the insertion of a radioactive material near the mass to reduce tumor size, thereby improving airway obstruction. This is the first case of EBBT done in our institution during the COVID-19 pandemic. A 53-year-old male, 60 kg, ASA Physical Status 2 for hypertension, smoker, malignancy, and previous pulmonary tuberculosis patient, presented with a cough and dyspnea. An endobronchial mass almost obstructing the right mainstem bronchus was seen on a computed tomography (CT) scan. He was diagnosed with squamous cell carcinoma of the lung and underwent radiotherapy and erlotinib chemotherapy. On repeat CT scan, there was no noted decrease in the size of the mass. EBBT was suggested, and a multi-disciplinary team was formed for the planned procedure. Pulmonology, radiation oncology, and anesthesiology teams were identified, and thorough planning was done prior to the actual procedure. Three fractions of EBBT were done under sedation using midazolam, fentanyl, and dexmedetomidine infusion. Lidocaine spray and transtracheal block were also performed as adjuncts prior to sedation. The procedure went as planned, and points for improvement were discussed for subsequent fractions. Due to persistent cough and discomfort from the catheter, additional ipratropium nebulization for minimization of secretions, and oral dextromethorphan for cough suppression were incorporated. After each fraction, the patient was monitored post-procedure for any side effects both from the radiotherapy and anesthetic technique. Qualitative reduction in mass size was noted in subsequent fractions. The patient was able to complete 3 fractions and was advised to follow-up after a month. EBBT is an emerging palliative and treatment modality for lung cancer, especially for intraluminal masses. Anesthetic considerations will depend on each case's characteristics such as airway anatomy, patient comfort and capacity, and procedural requirements. Conscious sedation with topical anesthesia is an adequate and appropriate anesthetic option, especially in cases where severe airway obstruction may compromise ventilation if airway reflexes are blunted. A multidisciplinary approach with different services and stakeholders is important for the proper planning, execution, and management of such patients.
肺癌是全球癌症死亡的主要原因。它可能表现为支气管内肿块患者的气道阻塞。支气管内近距离放射疗法（EBBT）已被证明可提供姑息治疗。它是在肿块附近插入放射性物质以缩小肿瘤大小，从而改善气道阻塞。这是我们机构在新冠疫情期间进行的首例EBBT病例。一名53岁男性，体重60公斤，美国麻醉医师协会（ASA）身体状况评分为2级，患有高血压、吸烟、恶性肿瘤，既往有肺结核病史，出现咳嗽和呼吸困难。计算机断层扫描（CT）显示一个几乎阻塞右主支气管的支气管内肿块。他被诊断为肺鳞状细胞癌，并接受了放疗和厄洛替尼化疗。复查CT扫描时，肿块大小未见缩小。建议进行EBBT，并组建了一个多学科团队来规划该手术。确定了肺病学、放射肿瘤学和麻醉学团队，并在实际手术前进行了全面规划。在使用咪达唑仑、芬太尼和右美托咪定输注镇静的情况下进行了三次EBBT治疗。在镇静前还使用利多卡因喷雾和经气管阻滞作为辅助手段。手术按计划进行，并讨论了后续治疗的改进要点。由于导管导致持续咳嗽和不适，增加了异丙托溴铵雾化以尽量减少分泌物，并使用口服右美沙芬抑制咳嗽。每次治疗后，对患者进行术后监测，观察放疗和麻醉技术产生的任何副作用。在后续治疗中发现肿块大小有定性减小。患者能够完成3次治疗，并被建议在一个月后进行随访。EBBT是一种新兴的肺癌姑息和治疗方式，特别是对于腔内肿块。麻醉考虑将取决于每个病例的特点，如气道解剖结构、患者舒适度和耐受性以及手术要求。局部麻醉下的清醒镇静是一种充分且合适的麻醉选择，特别是在严重气道阻塞可能因气道反射减弱而影响通气的情况下。多学科方法，包括不同的科室和相关人员，对于此类患者的正确规划、实施和管理非常重要。
