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Endobronchial Resection of a Tracheal Leiomyoma in a Parturient
Abstract Number: SAT-72
Abstract Type: Case Report/Case Series
Bronchoscopy in pregnancy is generally avoided if possible because of the risks related to the procedure and sedation to both mother and fetus, which include aspiration, hypoxemia, barotrauma, and pulmonary hemorrhage. Delay of intervention to the postpartum period should be considered if possible without effect to the course of pregnancy or disease. Nonemergent bronchoscopies may be indicated and should be performed after consideration among multidisciplinary teams of the clinical setting, stage of pregnancy, and patient’s status.
A 38 yo G4P3003 at 31w6d presented for abnormal CXR showing left middle and lower lung opacification. She complained of moderate cough with sputum for 1 week though was afebrile on room air. CT suggested active granulomatous disease with a soft tissue lesion of the left main bronchus, mediastinal shift, and post obstructive pneumonia, consistent with tuberculosis. However once TB work up was negative, the patient was scheduled for bronchoscopy with biopsy to evaluate the lung lesion of unknown cause. We planned for general anesthesia with continuous FHR monitoring and an obstetrics team available for emergent cesarean delivery. Betamethasone was administered for fetal lung maturity.
We performed an RSI with fentanyl, lidocaine, propofol and succinylcholine, and an 8.0 ETT was easily placed via direct laryngoscopy. A pedunculated near obstructing mass was noted in the left main bronchus during bronchoscopy. Cardiothoracic surgery was consulted and recommended resection due to risk of significant purulent drainage distal to the lesion. A 1.5cm mass was resected via endobronchial electrocautery snare, which required intermittent decreases in FiO2 to 30%. The patient remained hemodynamically stable with oxygen saturations >93% and peak inspiratory pressure <35 cmH2O. The patient was extubated, afterwards continued to improve on CXR and clinically, and was then discharged stable on room air. Biopsy results ultimately revealed leiomyoma. The patient later presented in active labor at 35w5d and delivered a healthy baby vaginally, which was otherwise uneventful.
Endobronchial leiomyomas are rare benign tumors from smooth muscle cells of the bronchial tree and occur in the 3rd-4th decade of life in females. Patients usually present with symptoms due to obstruction of the affected bronchus, such as wheezing, orthopnea, hemoptysis, recurrent pneumonia and subsequent bronchiectasis. Bronchoscopic intervention is an option for pedunculated lesions that avoids surgical resection required of broad-based lesions which recur. In this case of a parturient reporting a cough with sputum discovered to be an endobronchial leiomyoma, bronchoscopy with electrocautery snare resection was performed safely and effectively because of multidisciplinary coordination between pulmonary, obstetric, thoracic surgery, and anesthesia services.
J Bronchology Interv Pulmonol 2015;22(1):90-3.
Chest 2004; 126:1974-81.