case_images: PMC11246608_01
case_images: Chest radiography (A) does not clearly reveal any abnormalities at first glance. Although the carina appears indistinct, the positioning of the tip of the tracheal tube seems to be appropriate. However, closer inspection reveals a decrease in transparency of the left lung and a mild leftward mediastinal shift, suggestive of left lung atelectasis. Furthermore, there is an absence of the radiolucent image of the airways originating from the carinal bifurcation extending into both bronchi. Additionally, the left diaphragm is elevated. Bronchoscopic findings on the day of admission (B). Infiltration and compression of the carina (a blue arrow), right main bronchus (a white arrowhead), and left main bronchus (a blue arrowhead) by the lung tumor. We attempted to place an endobronchial stent falter owing to severe airway compression and infiltration. Chest computed tomography (CT) on the day of admission (C) shows a large mediastinal mass compressing the carina and both main stem bronchi. The tumor's compression and infiltration have rendered the carina indistinct. The right main bronchus (a white arrowhead) is significantly stenotic, and the left main bronchus (a blue arrowhead) is obstructed. Furthermore, a consolidation is observed in the dorsal region of the left lung caused by the obstruction of the left main bronchus. Subsequent CT following radiotherapy (D) showed a reduction in the tumor size, with decreased compression of the carina and both main stem bronchi.
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case_images: Chest radiography showed no clear abnormalities; although the carina was indistinct, the tracheal tube tip was appropriately positioned (Figure 1A). Computed tomography (CT) revealed a large mediastinal mass compressing and infiltrating the carina and both bronchi, causing complete left main stem bronchus occlusion (Figure 1C). Endobronchial stent placement was unsuccessful owing to severe airway compression (Figure 1B). On hospital day 12, bronchoscopy and CT scans showed substantial tumor reduction (Figure 1D).
case_images: Clinical time course on the first day of hospitalization. Inhalation of beta-stimulants and intramuscular injections of adrenaline were ineffective, necessitating intubation. As the arterial CO2 partial pressure continued to increase, venovenous extracorporeal membrane oxygenation was initiated. Attempts to place a stent were unsuccessful.
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case_images: With ECMO blood flow at 2.8 L/min, arterial CO2 concentration significantly decreased (Figure 2).
case_images: Points of ingenuity in radiotherapy under venovenous extracorporeal membrane oxygenation (VV-ECMO). (A) Extended ECMO circuit and (B) closed-circuit television (CCTV). We adjusted the length of the ECMO circuit (a blue arrowhead) and monitored the patient during the radiotherapy using CCTV (a blue arrow).
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case_images: Despite safety reservations about radiotherapy and possible disruption by breathing efforts, we implemented a 39 Gy radiotherapy regimen over 13 sessions (3 Gy each), beginning on the second hospital day, with adjustments to the ECMO circuit for safety (Figure 3A). CCTV monitored the radiotherapy (Figure 3B), and muscle relaxants were used to suppress spontaneous breathing and ensure effective tumor irradiation.