(1253) Dynamic Airway Obstruction

Introduction: This case presents a case study focusing on an incidental finding of airway obstruction caused by dynamic intrathoracic obstruction. We aim to provide insights into the challenges, diagnostic process, and management strategies associated with this critical condition, highlighting the importance of prompt recognition and appropriate intervention in similar scenarios.

Description: A 37-year-old male patient presented to the Emergency Department for evaluation of a “mass in his chest.” Further imaging workup upon admission confirmed a large 10.5 cm confluent anterior mediastinal mass with an isolated 3.5 cm lymph node in the deep soft tissue of the left supraclavicular region. The patient underwent an eventful excision biopsy of the mass under general anesthesia. After the procedure, the patient developed pulmonary edema and respiratory obstruction despite an in situ endotracheal tube. ETT was advanced to the carina, and the patient was admitted to the ICU. Over the following few days, the patient remained intubated and sedated on high PEEP settings and no muscle paralysis. CT chest imaging confirmed supracarinal tracheal compression from the anterior mediastinal mass. He received systemic Dexamethasone therapy. Pathology results confirmed a diagnosis of diffuse large B-cell lymphoma favorable to adjuvant chemotherapy for tumor burden reduction.    Interventional Pulmonology placed a tracheal stent under bronchoscopic guidance, allowing for extubation.  After roughly one
week of continued chemotherapy and systemic Dexamethasone, the patient’s stent was removed with
maintenance of airway patency.   He was later discharged from the hospital with plans for continued
outpatient chemotherapy with Hematology/Oncology.

Discussion: Intrathoracic obstruction caused by tracheal lumen lymphoma is a serious life-threatening condition . The resulting acute respiratory obstruction presents significant challenges in management. To address this complex issue effectively, a comprehensive approach is recommended with multidisciplinary team involvement, regular assessment of airway and ventilation, simultaneous management of the tumor, plan a safe extubation environment, with preparation of alternative oxygenation methods, such as cardiopulmonary bypass.