Therapeutic rigid bronchoscopy allows level of care changes in patients with acute respiratory failure from central airways obstruction

Therapeutic bronchoscopy in lung cancer. Laser therapy, electrocautery, brachytherapy, stents, and photodynamic therapy

Therapeutic bronchoscopic techniques such as LPR, EC, brachytherapy, stents, and PDT are effective tools in the palliation and local control of lung cancer. Palliation of malignant tracheobronchial obstruction by LPR, stents, brachytherapy, PDT, or a combination thereof results in relief of dyspnea, hemoptysis, and postobstructive pneumonia. Importantly, it avoids intubation in patients with respiratory distress and facilitates the weaning of patients from MV. In the exciting field of lung cancer screening and treatment of early lung cancer, PDT, brachytherapy, EC, and LPR may represent treatment alternatives to surgical resection, especially in a select group of patients with high surgical risk or favorable endobronchial lesions. Clinicians await the results of future studies, which will (1) better define the impact of each treatment modality on patient care in terms of cost, survival, and improvement in quality of life, and (2) determine the optimal combination therapy relative to bronchoscopic and conventional treatment for effective palliation and cure of lung cancer.

Role of bronchoscopy in modern medical intensive care unit

This article gives a broad overview of the increasingly important applications of bronchoscopy, flexible (FOB) and rigid (RB), in a modern medical intensive care unit. Special emphasis is made to bronchoscopy use in mechanically ventilated patients. Therapies such as endobronchial stenting and Nd:YAG laser are being used to improve respiratory failure and facilitate weaning from mechanical ventilation. Practical applications of recent advancements in technology (endobronchial stenting, laser therapy, and so forth), the increasing use of rigid bronchoscopy, and the new generation of flexible bronchoscopes like battery bronchoscopes, and ultra-thin bronchoscopes, are also discussed. The risks, potential benefits, complications, and suggested technique of performing bronchoscopy in mechanically ventilated patients are reviewed.

The heat is on: impact of endobronchial electrosurgery on the need for Nd-YAG laser photoresection

STUDY OBJECTIVES

Advances in bronchoscopic electrosurgery have allowed its application in the outpatient setting in patients who otherwise would have required Nd-YAG laser photoresection (LPR) in the operating room. We intended to evaluate the impact of endobronchial electrosurgery (EBES) on the need for Nd-YAG LPR on patients with symptomatic airway lesions.

DESIGN

Prospective observational case series.

PARTICIPANTS

One hundred eighteen evaluations for LPR were performed. Forty-seven evaluations (40%) were considered to be amendable to EBES and were treated during the initial bronchoscopy. The remaining patients underwent LPR.

SETTING

Outpatient bronchoscopy suite at the Cleveland Clinic Foundation, Cleveland, OH.

RESULTS

Of the 47 procedures, 42 (89%) were successful in alleviating the obstruction, thus eliminating the need for LPR. No major complications were encountered.

CONCLUSION

EBES can be performed safely in the outpatient setting and is an effective procedure in treating select endobronchial lesions. EBES eliminated the need for LPR in 36% of such procedures with a potential for significant time and cost savings.

Surgical palliation of airway obstruction resulting from lung cancer

Bronchogenic carcinoma remains a relentless plague of modern society causing far more deaths than the well-popularized "AIDS epidemic" and secondary only to cardiovascular disease as a cause of death in America. Despite medical advances and treatment breakthroughs, only 40% of newly identified lung cancer patients are "potentially curable". Therefore, a large portion of this patient population will require palliative care and treatment. Surgical palliation is somewhat a misnomer in that most endobrachial lesions causing significant obstruction that result in dyspnea are not amenable to surgical intervention, i.e., operative resectional therapy. The palliative management options of airway obstruction resulting from advanced stage lung cancer will be reviewed, including the historical aspects, development and current use of laser resection, airway stenting, and endobrachial brachytherapy for management of unresectable airway tumors. These modalities frequently are used simultaneously in the same patient and may be used in conjunction with current chemotherapeutic and conventional external-beam radiation protocols.

Stenting of the tracheobronchial tree

Endoscopic treatment of endobronchial obstructions is becoming increasingly important. Tracheobronchial stents often are needed in the treatment of obstructions from submucosal or extrabronchial lesions. Tube stents have been available since the early 1960s but are underused because their insertion requires the use of a rigid bronchoscope. With the recent development of metallic stents, interventional radiologists increasingly are involved in the treatment of tracheobronchial obstructions. Metallic stents, easily placed with flexible bronchoscopy, are growing in popularity. All available tracheobronchial stents have been shown in various clinical series to be able to achieve immediate resolution of respiratory symptoms from various tracheobronchial obstructions. A stent's performance, however, should not be based solely on short-term response. Presently, there is no ideal stent because none is free of complications and none are able to consistently maintain life-long patency. Gianturco stents are associated with serious major complications (bronchial perforations and strut fractures) and are no longer recommended for use in the tracheobronchial tree. The Palmaz stent has also fallen into disfavor, because a strong external force, such as a vigorous cough, can recompress it. The Strecker stent can only be used in smaller airways, but may be useful in the accurate stenting of short segment stenoses because it does not foreshorten on deployment. The Wallstent and Ultraflex are our present metallic stents of choice. Both are easy to deploy, available in covered forms, exert adequate radial force, remain relatively stable in position, and have good longitudinal flexibility for use in tortuous airways. Disadvantages include excessive granulation tissue formation and difficulty of removal once the stent has been epithelialized. Metallic stents should be chosen very carefully for use in benign lesions with ongoing active local inflammation or when temporary stenting is needed. In the absence of an ideal stent, technologic advancements will continue. Potential developments include removable metallic stents, biodegradable stents, and chemically and radioactively coated stents. Unquestionably, the expanding stent market will drive scientific research toward the development of the ideal stent. Clearly, physicians need to be ready to assess these technologic advancements.

Pulmonary complications of mechanical ventilation

Although life-saving, mechanical ventilation may be associated with many complications, including consequences of positive intrathoracic pressure, the many aspects of volutrauma, and adverse effects of intubation and tracheostomy. Optimal ventilatory care requires implementing mechanical ventilation with attention to minimizing adverse hemodynamic effects, averting volutrauma, and effecting freedom from mechanical ventilation as quickly as possible so as to minimize the risk of airway complications.

Endobronchial laser therapy

We have sought to briefly outline the history and current role of laser therapy in airway obstruction. A primary goal in the use of laser therapy is the safe, effective, and rapid palliation of symptoms owing to tracheal or bronchial obstruction. This seems clearly supported in the literature despite some variation in definitions as to measurement of success. Objective criteria for improvement has also been studied, with authors noting improvement in walk tests, spirometric studies, and caliber of airways after treatment in significant percentages of patients. Patient survival, as noted by Ramser and Beamis, may not be the proper endpoint when discussing therapy, which for malignant causes, is meant to be palliative. Noting this, there are many benign conditions that may be effectively treated with laser therapy with a possible "cure" for some lesions defined as "carcinoma in situ." We believe laser therapy in the treatment of airway obstruction is an important tool that has proven beneficial in the therapy of benign and malignant lesions of the airway. Although future studies should prospectively examine survival characteristics, the current evidence firmly supports the use of laser as a useful modality of therapy in our endeavors to provide palliative and potentially curative care to our patients with lung disease.

Airway stenting in Japan

Various types of outstanding airway stents have been made commercially available. In Japan, a total of 1004 airway stents (Dumon stents (Novatech, Aubagne, France), Gianturco Z stents (Cook Ins, Bloomington, USA), Ultraflex stents (Boston Scientific Corp, Natick, MA, USA), and Dynamic Y stents (Ruesch AG, Kernen, Germany)) were implanted from July 1991 until February 1998. Of all the various stents, the Dumon stent has become the standard worldwide. Also, the Dumon stent has been replacing the Gianturco Z stent as the preferred stent throughout Japan. The Dumon stent was the first stent covered by Japanese National Health Insurance. Therefore, we present our 5-year experience with the Dumon stent at our institution. In our experience, stenting is effective for the immediate and lasting relief of symptoms in patients with severe malignant obstruction of major airways.