Respiratory support including emergent extracorporeal membrane oxygenation as a bridge to airway dilatation following perioperative bronchial occlusion.

During the perioperative period, various factors may lead to intraoperative and postoperative respiratory failure including upper airway obstruction, bronchospasm, acid aspiration, laryngospasm, and pulmonary hypertension. Regardless of the etiology, prompt recognition with treatment of the inciting event is required to ensure a successful recovery. We report the intraoperative development of respiratory insufficiency and failure in a 17-year-old girl who was status post lung transplant undergoing bronchoscopy. During bronchoscopy, complete left main stem obstruction occurred due to a fibrinous mass near the bronchial anastomosis site. Various modalities were used to support the patient intraoperatively and then postoperatively including low tidal volume/high PEEP ventilation, inhaled nitric oxide (iNO), and high frequency oscillatory ventilation (HFOV). In the CTICU, emergent bedside venovenous extracorporeal membrane oxygenation (ECMO) was used as a bridge to the recovery of respiratory function which was achieved with removal of the occluding fibrinous airway tissue followed by balloon dilatation and stenting of the left main stem bronchus. The potential perioperative causes of respiratory failure are reviewed and support techniques including conventional ventilator strategies, iNO, HFOV and ECMO discussed.