The patient, 33-year-old male, was admitted to Shanghai Public Health Clinical Center on November 22, 2019, with the complaint of "human immunodeficiency virus (HIV) infection for more than 5 months, cough and expectoration for 1 month, aggravation and shortness of breath for 2 days." He was found HIV positive 5 months ago. There were no symptoms such as fever, cough, expectoration, nausea, vomiting, and he refused to accept any antiviral agents. Four month ago, he began to have anorexia and dysphagia. Gradually, he could only take liquid food and drink water. Two month ago, he began to accept antiretroviral drugs, but irregularly. Cough, yellowish white sticky sputum with blood in sputum occurred 1 month ago. Chest CT in local hospital showed that the right upper lung cavity was accompanied by multiple consolidation, and soft tissue density shadows in the trachea. He felt the above symptoms aggravated 2 days ago accompanied with severe shortness of breath, therefore he came to our hospital for further treatment and was admitted through Emergency.
Physical examination after admission found this patient extremely thin. With dyspnea gradually exacerbated, he received nasal catheter oxygen inhalation, transnasal high flow oxygen inhalation (HFNC) and non-invasive ventilator successively. On the 8th day after admission, the patient occurred obvious respiratory distress. Laboratory findings included WBC 12.63 x 10^9/L, HB 125 g/L, PLT 414 x 10^9/L, N 78.4%, L 13.1%, HS-CRP 65.4 mg/L, PCT 0.08 ng/ml, ALT 20 U/L, AST 18 U/L, TBIL 6.1 umol/L, ALB 36 g/L, K 3.7 mmol/L, CL 100 mmol/L, Na 138 mmol/L, UREA 2.95 mmol/L, Cr 49.5 umol/L, Glu 4.83 mmol/L, PT 13.7 S, APTT 41.8 S, FDP 7.1 mug/mL, D-D 2.76 mug/ml, TNI 0.01 ng/ml, pro-BNP 32 pg/ml, CK 40 U/L, HBsAg (-), anti-HCV (-), Anti-TP (-), T-SPOT.TB (-), CD4 195 cell/mul, CD8 597 cell/mul, CEA 0.87 ng/ml, CA125 122 U/ml, G test < 10 pg/ml, HIV 266 copy/ml (reference value < 40). Sputum smear found some coccus and bacillus, but culture was negative. His finger pulse oxygen saturation (SpO2) fluctuated obviously between 85 and 99%. Blood gas analysis showed pH 7.26, PaCO2 9.6 kpa and lactic acid 7.65 mmol/L. He was supported by non-invasive ventilation with driving force of 14 cm H2O and inhaled oxygen concentration of 1.0 and transferred to ICU immediately.
In order to clarify the cause of dyspnea, emergency CT was carried out and showed cavitary lesions in the right upper lung, new organisms in the main trachea near to the carina which almost completely blocked the lumen (the narrowest part is about 2 mm), mediastinal lymph nodes swelling, obvious thickening of the wall of the middle esophagus and obvious expansion of the upper segment (Figure 1). This revealed the patient's dyspnea was due to severe stenosis of the trachea and he needed emergent airway operation. An emergent consultation of multiple disciplinary team (MDT) including anesthesia physician, intervention and ECMO team suggested that the patient's vital signs were unstable, and the risk of preoperative anesthesia induction was very high. Meanwhile, due to airway severe obstruction, the conventional endotracheal intubation could not ensure sufficient ventilation. Extracorporeal membrane oxygenation (ECMO) was then considered to start. Bedside ultrasound evaluation found that the diameter of inferior vena cava was 13 mm, the variability 50%, the filling of right ventricle poor, and left ventricular systolic function normal. Fluid resuscitation was carried out and norepinephrine was continuously pumped intravenously (0.3 mug/kg/min) to maintain the stability of blood pressure.
After evaluation of blood vessels with ultrasound, we used Seldinger's method to percutaneously puncture and put the catheters in the right femoral vein and right internal jugular vein. The tube sizes were Fr 21 and Fr 17, respectively. Initial setting of ECMO were rotating speed 3,200 rpm, blood flow 4.0 L/min and air flow 4.0 L/min (FiO2 1.0). Low dose heparin was used for anticoagulation during catheterization, but anticoagulant agents were not given during ECMO running. With the oxygen supply from ECMO, the SpO2 increased rapidly from 75 to 100%. With the significant improvement of oxygenation, the real-time invasive arterial blood pressure stabilized at about 120/75 mmHg.
Next, we began to solve the airway obstruction. By inserting the rigid bronchoscope, we found that the neoplastic tissue in the lower part of the trachea lead to severe lumen stenosis. After circumcision of the tumor, a small amount of tissue infiltration could be seen at the opening of the left and right bronchia, and the distal lumen was basically unobstructed. After measuring the length of the neoplastic focus, a Y-shaped silicone stent was cut, sent to the carina, then released and adjusted. The fiberoptic bronchoscopy confirmed that the stent was stable and fit well with the tracheal wall. Withdrew the two scopes, followed by endotracheal intubation and mechanical ventilation. ECMO was weaned off when the operation finished and had been running for a total of 6 h. Ventilator and tracheal cannula were removed another 6 h later. The patient's symptoms were significantly improved. Three days after the operation, bronchoscopy was carried out again and found the stent was in place and the lumen was normal. Pathological examination of excised tissue showed lung squamous cell carcinoma. Laboratory tests showed WBC 16.9 x 10^9/L, N 76.4%, L 15.3%, HS-CRP 95.3 mg/L, PCT 0.89 ng/ml. BALF culture for bacterial (-), fungal (-), tuberculosis (-), and he was treated with antibiotics, expectorants, and atomization therapy. The patient was discharged 1 week later and returned to local hospital for further treatment.