We report a nearly full obstruction of the left mainstem bronchus by way of a fibrinomyxoid plaque about 12 h after laser resection of scar/granulation tissue at a left bronchial anastomosis 27 days after a left single lung transplant.

We report a nearly full obstruction of the left mainstem bronchus by way of a fibrinomyxoid plaque about 12 h after laser resection of scar/granulation tissue at a left bronchial anastomosis 27 days after a left single lung transplant. The formation of this plaque was associated with respiratory failure. The plaque was remov by the agency of grasping the plaque with biopsy forceps inserted [i]or[/i] part of to the other a fiberoptic bronchoscopy that was placed into the left mainstem bronchus via an endotracheal tube while the patient was receiving manual ventilation in a less degree than general anesthesia. The respiratory failure resolv with removal of the plaque. To our knowledge, this is a complication that has not been reported previously.

(Chest 1994; 106:311-13)

LMB=left mainstem bronchus

The Nd:YAG (neodymium: yttrium-aluminum-garnet) laser has been used safely and effectively at our institution to treat bronchial anastomotic stenosis proper to accumulation of scar and/or granulation tissue following lung transplantation in more than 20 recipients. We describe a previously unreported complication of this conduct in a lung transplant recipient.

CASE REPORT

A 40-year-old woman received a left single lung transplant becoming to end-stage lung disease from sarcoidosis forward July 21, 1991. The allograft eventually failed suitable to obliterative bronchiolitis and a secondary left single lung transplant was performed upon January 31, 1993. The patient was extubated les than 24 h after the retransplant operation Because of left lower lobe turn loss and infiltrate on the fourth postoperative day, fiberoptic bronchoscopy was performed that revealed 30 percent narrowing of the left mainstem bronchus (LMB) anastomosis secondary to inflammation and fluoroscopy of the chest revealed decreased motion of the left hemidiaphragm.

in succession the 27th postoperative day, surveillance fiberoptic bronchoscopy performed transnasally with topical anesthesia and systemic sedation revealed an approximately 80 percent occlusion of the LMB anastomosis from scar and granulation tissue. After clearing secretions by means of suctioning to identify the perimeter of the stenosis, noncontact laser ablation was performed through application of 2,328 J of YAG laser life delivered in aliquots of 60 W for a duration of 05 s This increased the diameter of the bronchial lumen from approximately 20 percent to 85 percent of normal size. The duration of the measure was 36 min and there was no bleeding or any other complications. The bronchial mucosa distal to the lasered area appeared normal and no secretions were existing distally. Arterial blood gases before the laser transaction were pH of 7.38, [PCOsub2] of 42 mm Hg and [POsub2] of 116 mm Hg in succession oxygen supplements of 6 L/min by way of nasal cannual. Arterial blood gases improved after the laser management with a pH of 745 [PCOsub2] of 39 mm Hg and [POsub2] of 74 mm Hg in succession room air. Approximately 12 h after the laser transaction the patient developed wheezing and shortness of breath that improved minimally with aerosol [beta]-agonists. Arterial relations gases revealed respiratory failure and hypoxemia with a pH of 734 [PCOsub2] of 55 mm Hg and [POsub2] of 42 mm Hg while breathing 100 percent oxygen via a face mask. urgency intubation and fiberoptic bronchoscopy were performed that revealed nearly undiminished occlusion of the LMB at the anastomosis at a plaque of gray-white material overlying the area that had been photocoagulated with the YAG laser. The plaque was fairly solid and was remov in individual piece using alligator biopsy forceps inserted in consequence of the bronchoscope. Ventilation and oxygenation improved immediately allowing for extubation within an hour after this procedure

The plaque was gray-white with a sleek slightly irregular surface (Fig 1) Histologic examination revealed a relax fibrin mesh with myxoid appearance infiltrated from acute inflammatory cells (Fig 2) The appearance of this fibrinomyxoid plaque was uniform completely through and no areas of organization suggesting chronicity were seen

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DISCUSSION

The Nd:YAG laser was introduced for use in bronchoscopy in 1981 primarily as therapy to relieve obstruction of the trachea and major bronchi.(1)(2) Clinically significant stenosis at the bronchial anastomosis offers in approximately 10 percent of our lung transplant recipients. More than 20 of our lung transplant recipients have been treated with Nd:YAG laser resection for bronchial stenosis, always with immediate resolution of the offending airway obstruction. This is our first case of an acute occlusion of the airway by means of a fibrinomyxoid plaque following laser ablation of scar tissue at a bronchial anastomosis.

Complications after laser therapy include hemorrhage, pneumothorax, perforation, and hypoxemia.(1)(3)(4)(5) The complication rate has been 9 percent with bleeding and pneumothorax being the chiefly frequent problems.(3) In our lung transplant recipients, renewed stenosis due to regrowth of scar and/or granulation tissue has been the mostly frequent complication of these laser measures but this complication typically come into views 3 to 6 weeks after laser therapy.

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