Respiratory Medicine CME
Volume 2, Issue 1 , Pages 27-30, 2009

Broncholithiasis causing acute respiratory failure: Successfully treated by flexible bronchoscopy

  • Andre G. Melendez

      Affiliations

    • University of Colorado, Department of Medicine, Denver, CO, USA
    • ,
  • Maya Hosein

      Affiliations

    • Indiana University, Pulmonary-Critical Care Medicine, Indianapolis, IN, USA
    • ,
  • Francis Sheski

      Affiliations

    • Indiana University, Pulmonary-Critical Care Medicine, Indianapolis, IN, USA
    • ,
  • Kenneth S. Knox

      Affiliations

    • University of Arizona, SAVAHCS, Tucson, AZ, USA
    • ,
  • Chadi A. Hage

      Affiliations

    • Pulmonary-Critical Care and Infectious Diseases, Roudebush VA Medical Center and Indiana University, 1481W. 10th St., 111P-IU, Indianapolis, IN 46202, USA
    • Corresponding Author InformationCorresponding author. Tel.: +1 317 988 3811; fax: +1 317 988 3976.

Received 2 September 2008; accepted 15 October 2008.

Article Outline

Keywords: Broncholithiasis, Bronchoscopy, Respiratory failure

 

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Patient summary 

A 65-year-old male with history of COPD presented to our institution with a two-month history of worsening dyspnea, cough, and wheezing and with occasional blood-tinged sputum. He had been recently evaluated in the emergency room for these symptoms, at which time chest radiograph revealed a right lung density (Fig. 1A). A chest CT scan demonstrated a large calcified lymph node involving the bronchus intermedius, resulting in collapse of the right middle and lower lobes (Fig. 1B). Bronchoscopy showed broncholithiasis that subtotally occluded the bronchus intermedius. The broncholith was firmly imbedded in the bronchial wall. He was treated for acute exacerbation of COPD with azithromycin and a tapering course of corticosteroids. His symptoms improved, but not fully resolved, at the time of discharge.

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  • Figure 1 

    Serial radiographs; 1A: PA view of a chest radiograph showing a density in the hilum of the right lung. 1B: A chest CT scan showing large calcified lymph nodes surrounding the bronchus intermedius (arrowheads). 1C: Chest CT scan showing a broncholith in the left main bronchus (arrow). 1D: A chest CT scan showing band like atelectasis in the left lung. 1E: improved aeration of the left lung immediately and 2 days (1F) after removal of the broncholith.

The patient returned within one month with worsening symptoms. In the emergency room he experienced severe paroxysmal coughing, after which he became acutely dyspneic. On exam he had localized wheezing in the left lung. He required increased inspired oxygen and eventually noninvasive ventilation (BIPAP 18/8cm, with 60% oxygen). Chest CT scan revealed a broncholith in the left main bronchus, a patent bronchus intermedius, and left lung atelectasis (Fig. 1C, D). Flexible bronchoscopy performed after endotracheal intubation showed a one-centimeter, mobile broncholith in the left main bronchus (Fig. 2). An attempt to retrieve the broncholith using a cryotherapy probe failed because the broncholith was too large to pass through the endotracheal tube. Therefore a decision was made to extubate the patient as the broncholith was removed. To better secure the broncholith, it was snared by a wire basket and withdrawn with the bronchoscope as the patient was extubated. The patient's respiratory status rapidly improved following removal of the broncholith (Fig. 3). Bronchoscopic examination of the right bronchial tree revealed several non-obstructing broncholiths that had partially eroded into the bronchus intermedius, accompanied by minimal bleeding, and that were not occluding the airway. Pathologic examination of the broncholith revealed a calculus consistent with a broncholith with adherent mucus containing acute inflammatory cells. Follow-up chest radiograph showed improved aeration in all lung fields (Fig. 1E, F). The patient was discharged home the following day with no need for oxygen supplementation. In 12-months since discharge, the patient remains well with no recurrence of these same symptoms.

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Discussion 

Broncholithiasis is a condition characterized by calcified mediastinal lymph nodes that either compress or erode into the airways or adjacent structures. Broncholiths are commonly caused by chronic granulomatous processes, with pulmonary tuberculosis being the most common cause worldwide, while histoplasmosis being the most common cause in the United States. The calcified lymph node gradually begins to impinge and erode into the tracheobronchial tree or adjacent vascular structures as a result of constant cardiothoracic movement within the chest cavity, thereby causing clinical manifestations.

Broncholithiasis typically presents with symptoms of chronic cough, dyspnea, wheezing, hemoptysis, or recurrent pneumonias. Rarely do patients complain of lithoptysis, a pathognomonic sign characterized by the expectoration of small stones or gritty material. Depending on the site of erosion, broncholiths can lead to a variety of complications including airway obstruction, massive hemoptysis, or bronchoesophageal fistulas.1

Broncholithiasis can be managed in a number of ways, depending on the extent of disease and the comorbidities of the patient. Options include observation, bronchoscopic removal, and surgery. Infrequently, lithoptysis can lead to a resolution of symptoms. Bronchoscopic broncholithectomy can be performed using either a flexible or rigid bronchoscope. Success rates have been reported to be higher with a rigid bronchoscope.2, 3 Olson et al. in large retrospective series concluded that bronchoscopy is a safe and effective therapy for broncholiths, reporting a 100% success rate for loose broncholiths and a 48% success rate for partially eroding broncholiths.2 Laser therapy (Nd-YAG and holmium-YAG lasers) has been used to fragment mobile broncholiths that would otherwise be too hard or large to be removed by bronchoscopy.4, 5 There has also been one report that describes the use of cryotherapy during bronchoscopy to remove a partially attached broncholith.6 Complications of bronchoscopic broncholithectomy include bleeding and acute dyspnea due to broncholith fragments remaining in airway.2

Surgical management is indicated when a patient fails bronchoscopic broncholithectomy, presents with massive hemoptysis or has developed chronic suppurative disease or bronchoesophageal fistula. The surgical options depend on the location and extent of disease and include broncholithectomy without pulmonary resection, broncholithectomy with bronchoplasty, sleeve resection, segmentectomy, lobectomy, or pneumonectomy.7, 8, 9 Complications include bleeding, fistula formation, infections, and injury to pulmonary vessels, esophagus, and bronchi.

We report the case of a broncholith that became dislodged from the airway of one lung and migrated into the other, leading to respiratory distress due to atelectasis. The patient improved dramatically after removal of the broncholith. Although flexible bronchosocpy with a basket was able to remove the broncholith while the patient was extubated, bronchoscopy with cryotherapy probably could have accomplished the same result, if the patient had been extubated simultaneously with removal of the bronchoscope-probe-broncholith complex, as the broncholith was adherent to the probe. With the patient in a somewhat tenuous medical status, we felt that using the basket – if possible – would minimize the chance of the broncholith becoming dislodged from the device as it was drawn through the airway and passed the vocal cords and re-generating respiratory distress. Dislodgement of the foreign body from the cryoprobe can occur upon withdrawal of the probe from the airway, especially at the vocal cord level. Indications for cryotherapy include removal of foreign bodies, blood clots, mucous plugs, granulation tissue, and tumor when they cause airway compromise.10 Wire baskets or snares and forceps can be used to extract foreign bodies as well. These modalities are complimentary. Some times one mode will work when another will not. Our extraction was complicated by the large size of the broncholith, which ultimately required concomitant extubation. Fortunately, the patient did well.

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Conflict of interest statement 

This manuscript has been approved by all of the authors. None of the authors have any conflict of interest to declare in relation to this work.

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References 

  1. Conces DJ, Tarver RD, Vix VA. Broncholithiasis: CT features in 15 patients. AJR Am J Roentgenol. 1991;157:249–253
  2. Olson EJ, Utz JP, Prakash UB. Therapeutic bronchoscopy in broncholithiasis. Am J Respir Crit Care Med. 1999;160:766–770
  3. Dixon GF, Donnerberg RL, Schonfeld SA, Whitcomb ME. Advances in the diagnosis and treatment of broncholithiasis. Am Rev Respir Dis. 1984;129:1028–1030
  4. Miks VM, Kvale PA, Riddle JM, Lewis JW. Broncholith removal using the YAG laser. Chest. 1986;90:295–297
  5. McCaughan JS, Heinzmann HG, McMahon D. Impacted broncholiths removed with the holmium: YAG laser. Lasers Surg Med. 1996;19:230–232
  6. Reddy AJ, Govert JA, Sporn TA, Wahidi MM. Broncholith removal using cryotherapy during flexible bronchoscopy: a case report. Chest. 2007;132:1661–1663
  7. Faber LP, Jensik RJ, Chawla SK, Kittle CF. The surgical implication of broncholithiasis. J Thorac Cardiovasc Surg. 1975;70:779–789
  8. Minami H, Sano I, Matsuo S, Oikawa M, Takagi K. Broncholithiasis managed by surgical resection. Gen Thorac Cardiovasc Surg. 2007;55:138–142
  9. Potaris K, Miller DL, Trastek VF, Deschamps C, Allen MS, Pairolero PC. Role of surgical resection in broncholithiasis. [erratum appears in Ann Thorac Surg 2001 Dec;72(6):2188] Ann Thorac Surg. 2000;70:248–251[discussion 51–2]
  10. Mathur PN, Wolf KM, Busk MF, Briete WM, Datzman M. Fiberoptic bronchoscopic cryotherapy in the management of tracheobronchial obstruction. [see comment] Chest. 1996;110:718–723

PII: S1755-0017(08)00086-9

doi:10.1016/j.rmedc.2008.10.015

Respiratory Medicine CME
Volume 2, Issue 1 , Pages 27-30, 2009

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