The Endoscopic Technique
Two pulmonologists and one respiratory therapist were present at the
time of cryoextraction. Two bronchoscopes (Olympus BF-P180, Olympus,
Tokyo, Japan) were utilized and each controlled by a separate
pulmonologist. A single Olympus endoscope video cart was used. An Erbe
(Tubingen, Germany) 1.9-mm multi-use cryoprobe was inserted through the
2.0 mm working channel of 1 bronchoscope and advanced into the center of
the thrombus. Freeze times of 5 - 15 seconds were utilized to adhere to
the proximal end of the thrombus, being mindful to avoid contact with
the ETT or tracheobronchial wall. The bronchoscope and cryoprobe (with
attached thrombus) were withdrawn en bloc. Immediately following
bronchoscope removal, the assisting respiratory therapist disconnected
the bronchoscope-cryoprobe from the video cart and connected the second
bronchoscope, already in the hands of the other pulmonologist. This
second bronchoscope, with a clean lens and patent suction channel, was
inserted into the ETT to assess the airway and control bleeding. Once
bleeding was controlled, any fresh blood obfuscating the remaining
thrombus was cleared in preparation for repeat cryoextraction. The
bronchoscopes were then disconnected-reconnected in the same fashion
until the entire thrombus extending from the distal trachea to the left
subsegmental bronchi was removed [Figures 1B and 1D]. Due to
increasing degrees of active bleeding at the proximal portion of the
right main bronchus, dilute epinephrine was instilled near the carina.
The procedure was then terminated with plans for cryoextraction of the
right side at a later date. The second procedure was performed 7 days
later in the same manner, and the entire tracheobronchial tree was
subsequently cleared of obstruction [Figure 2]. Roughly 1 week
following cryotherapy, the patient was taken off of ECMO and ultimately
extubated to non-invasive positive pressure ventilation.