Framing Bias and Life-changing Decisions: A Rare Airway Neoplasm Presenting as a One-way Ball Valve During Emergent Bronchoscopy

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Abstract The estimated global incidence of non-hodgkin's lymphoma (NHL) in 2018 was 509,590. Fortunately for those affected by NHL, airway involvement is rare. There are, however, cases of secondary airway invasion, but less than thirty cases have been reported in the last five years. Due to this infrequency, presentations of NHL airway invasion are easily mistaken for cases of asthma or COPD exacerbations. Thus, it is crucial for those treating patients with asthma history to avoid framing bias when shortness of breath is a chief complaint and invasive neoplasms are under consideration. Here, we describe a case where a forty-four year old, obese, Spanish-speaking woman with a month-long history of coughing attributed to asthma, presented with shortness of breath refractory to steroids and bronchodilators. In the emergency department she discussed an abnormal feeling in her throat that prompted a chest x-ray (1A) and neck ultrasound (1B). These studies detected enlarged paratracheal and jugulodigastric lymph nodes that were not considered causative despite airway proximity. After eight hospital days the patient developed acute hypercarbic respiratory failure and stridor was heard. During transfer to the ICU a CT scan (1C,1H) revealed an endotracheal mass, but before this was reported, an emergent endotracheal intubation was completed. Surprisingly, this intubation failed to provide adequate ventilatory volumes. Due to this imminent life threat, a bronchoscopy was completed and a mass acting as a one-way ball valve was visualized (1F). Availability of interventional pulmonology limited management and in the evening a second emergent bronchoscopy was completed to guide advancement of the ET tube past the tumor and restore airway patency (1D). Ultimately, the patient was transferred to a facility with interventional pulmonology and subsequent resection of the tumor allowed for analysis, revealing a CD30+, Anaplastic Lymphoma Kinase – negative Anaplastic Large Cell Lymphoma (ALK-ALCL) (1E,1G). After resection the patient was discharged from the hospital with improved ventilation and plans for oncology follow up. This case represents a rare endotracheal presentation of ALK-ALCL. Crucially, while it highlights how framing-bias can prevent early diagnosis of NHL subtypes, it also illustrates how bias can contribute to high risk intubations. While this case is ongoing, recently reported local growth of the tumor may have been contributed to by the unplanned advancement of the ET tube. While such complications cannot always be avoided, it is possible that bias-awareness could help promote improved management choices in similar future cases.

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