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Cerebral Arterial Air Embolism After Endobronchial Electrocautery

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Cerebral Arterial Air Embolism After Endobronchial Electrocautery He et al. BMC Pulm Med (2021) 21:222 https://doi.org/10.1186/s12890-021-01580-w CASE REPORT Open Access Cerebral arterial air embolism after endobronchial electrocautery: a case report and review of the literature Yu‑Ping He1†, Yuan‑Ling Liu2,3†, Xing‑Lin Gao2,3 and Li‑Hua Wang1* Abstract Background: Endobronchial electrocautery is a common and safe therapeutic endoscopic treatment for malignant airway obstruction. Cerebral arterial air embolism (CAAE) is a rare but potentially fatal complication of endobronchial electrocautery. Case presentation: We present the frst case of cerebral arterial air embolism after endobronchial electrocautery. A 56‑year‑old male with a pulmonary tumour in the right upper lobe received repeated endobronchial electrocautery. During the procedure, he experienced unresponsiveness, hypoxemia and bradycardia, and he developed tetraplegia. Brain computed tomography showed several cerebral arterial air emboli with low‑density spots in the right frontal lobe. He received hyperbaric oxygen therapy with almost full recovery, except for residual left‑sided weakness. Conclusions: General physicians should realize that CAAE may be a possible complication of endobronchial elec‑ trocautery. Several measures, including avoiding positive pressure, lowering ventilatory pressures if possible, avoid‑ ing advancing the bronchoscope to occlude the bronchus and using the non‑contact technique, should be used to prevent this devastating complication. Keywords: Air embolism, Bronchoscopy, Endobronchial electrocautery, Hyperbaric oxygen therapy Background arterial air embolism has been shown to be a complica- Terapeutic endoscopic treatment may be considered for tion of APC and thermal laser treatments [2], it has never use in malignant airway obstruction, such as endobron- been reported in electrocautery. Herein, we described chial electrocautery, argon plasma coagulation (APC), a patient who developed cerebral arterial air embolism and thermal lasers. Electrocautery is a common and safe (CAAE) after endobronchial electrocautery. bronchoscopy technique. Te main complications of electrocautery include bleeding and airway fre. Cerebral Case presentation arterial air embolism is an extremely rare but potentially A 56-year-old male, who never smoked, was transferred fatal complication of bronchoscopy. Azzola et al. [1] to our hospital. Approximately 16 years prior, he had reported a frequency of < 0.02% of cerebral air embolism been diagnosed with lung cancer and received lung sur- after bronchoscopy in their institution. Although cerebral gery and chemotherapy. Tree years ago, he developed a cough and underwent three endobronchial electro- cautery treatments in another hospital. As a result, the *Correspondence: [email protected] right middle lobe (RML) mass was debulked. With the †Yu‑Ping He and Yuan‑Ling Liu should be considered joint frst author 1 Department of Pulmonary and Critical Care Medicine, Yunfu People’s diagnosis of the recurrence of right lung endobronchial Hospital, Huanshi Dong Lu No.120, Yuncheng DistrictYunfu 527300, China adenocarcinoma, the patient was admitted for the fourth Full list of author information is available at the end of the article bronchoscopic thermal ablation procedure to relieve © The Author(s) 2021. This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://crea‑ tivecommons.org/licenses/by/4.0/. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdo‑ main/zero/1.0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data. He et al. BMC Pulm Med (2021) 21:222 Page 2 of 6 airway obstruction. Bronchoscopy revealed an endobron- after bronchoscopy and showed no signs of air embolism chial tumour emanating from the posterior segment of (Fig. 3). Te patient received intensive rehabilitation. His the right upper lobe (RUL) bronchus, causing complete mental status subsequently improved, but he still had obstruction of the bronchus (Fig. 1a). Te patient was in mild left-sided hemiparesis with muscle strength of 3/5 the supine position without intravenous sedation. Te in the left upper limb and muscle strength of 4/5 in the tumour was debulked using endobronchial electrocau- left lower limb. tery, and blunt dissection of devitalized tissues with tooth forceps was performed (Fig. 1b, c). Te electrocautery cut Discussion and conclusions mode was set at an intensity of 40 W, and the coagulation CAAE is a rare but potentially fatal complication of both mode was set at an intensity of 30 W for a duration of 3 s. diagnostic and therapeutic bronchoscopy, and it is often Te bronchoscopy operation took approximately iatrogenic [3]. Because knowledge about the aetiology of 30 min in total, including 15 min of endobronchial elec- CAAE is limited, case reports are therefore important trocautery therapy. Fifteen incinerations were performed. sources to obtain information [4]. To our knowledge, During the procedure, the patient showed no cough and only four cases of CAAE after thermal ablation have been no obvious bleeding. At the end of the operation, he sud- reported [5–8]. Te profles of the reported patients, the denly became unresponsive, hypoxemic (SpO2 = 88%) examination procedures undertaken, the treatments, and bradycardic (heart rate = 58/min). High-fow oxy- and the outcomes are shown in Table 1. Tis is the frst gen administration with a mask and fuid resuscitation reported case in the literature of CAAE developing after were quickly performed. His heart rate and SpO 2 recov- endobronchial electrocautery. ered quickly, and his consciousness gradually improved Te possible mechanisms responsible for the develop- 30 min later. However, he presented with obvious abnor- ment of CAAE during therapeutic bronchoscopy include mal neurological symptoms, including slurred speech, the formation of a broncho-vascular fstula, the occlusion right gaze and paralysis in both extremities. Te muscle of a bronchus by bronchoscopy and paradoxical embo- strength in the left limbs was 0/5, while it was 2/5 in the lization [3, 4, 8, 9]. A broncho-vascular fstula can form right limbs. His left Babinski sign was positive. Hypogly- due to infammation or heat coagulation and mechanical caemia was excluded. Emergency brain computerized destruction of the tumour and adjacent tissue [7, 10]. In tomography (CT) revealed the presence of rounded cer- this case, electrocautery ablation of the tumour accompa- ebral gas embolisms that were several millimetres in size nied by mechanical debridement of the bronchus might and low-density spots in the right frontal lobe (Fig. 2). have resulted in the formation of the broncho-vascular Hyperbaric oxygen therapy (HBO2) was initiated within fstula [1, 11]. Gas can enter the circulation through the 2 h after bronchoscopy. He was transferred to the inten- fstula, and a gas embolism can easily enter a broncho- sive care unit. Tat night, he received another hyper- vascular fstula if the internal airway pressure goes up baric oxygen therapy. After this treatment, the patient with the bronchoscopy process or when the patient is experienced generalized tonic–clonic seizures that were accepting positive pressure ventilation, coughing or aborted using phenytoin, phenobarbitone and sodium taking a deep breath during the procedure [7, 12–15]. valproate. A repeated brain CT was performed 24 h Paradoxical embolization occurs when the gas migrates Fig. 1 The bronchoscopy showed that the posterior segment of the RUL bronchus was completely obstructed by the tumour (a, arrow). Endobronchial electrocautery was used to debulk the tumour (b). Bronchoscopy showed the posterior segment after ablation (c) He et al. BMC Pulm Med (2021) 21:222 Page 3 of 6 Fig. 2 The cerebral CT scan following bronchoscopy showed multifocal cerebral air embolisms in the right frontal lobe (arrows) Fig. 3 The repeated cerebral CT scan performed 24 h after bronchoscopy demonstrated no signs of air embolism from the venous circulation into the arterial system via lead to vascular air embolism during the use of a contact an intracardiac shunt (patent foramen ovale)[16]. Te air probe [10]. Other possible risk factors for CAAE include can be eliminated through difusion into the alveoli, but patients with chronic obstructive pulmonary disease, a if the capacity of the air exceeds 50 mL, it easily enters cavity inside the mass, lesions in the upper lobe, left lat- the pulmonary veins [16, 17]. In an animal study, Feller- eral position, semi-recumbent position and bleeding [1, 7, Kopman et al. [10, 13] found that bronchoscopic thermal 18]. In this case, the tumour was located in the posterior ablation with gas fow is associated with the occurrence segment of the right upper lobe, completely obstructing of gas embolism in a dose-dependent
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