Bronchoscopic management of patients with symptomatic airway stenosis and prognostic factors for survival

Procedure-free survival after therapeutic bronchoscopy in patients with central airway obstruction

BACKGROUND

Central airway obstruction (CAO) poses a significant risk of respiratory failure, often necessitating urgent intervention. Therapeutic bronchoscopy is a well-established method for palliation or definitive management of CAO. Although similar therapeutic maneuvers are employed for benign and malignant CAO, the long-term effectiveness and influencing factors are not fully described. This retrospective cohort study compares the clinical outcomes of therapeutic bronchoscopy for both.

METHODS

This is a retrospective review of therapeutic bronchoscopies for initial CAO presentation at our tertiary center from January 1, 2019, to December 31, 2020. The primary outcome was procedure-free survival in both malignant and benign CAO cohorts. The impact of clinically relevant covariances on the primary outcome, reasons for follow-up bronchoscopies, and complications related to the procedures were also analyzed.

RESULTS

Ninety-six patients (66 % malignant, 34 % benign) underwent therapeutic bronchoscopy. The median procedure-free survival was 175 days in the benign cohort and 49 days in the malignant cohort. Airway prosthetics were associated with shorter procedure-free survival in both cohorts. Common reasons for follow-up bronchoscopies in both cohorts included disease recurrence or progression, stent complications, and surveillance. The median total number of procedures during the 2-year follow-up was 2 for both cohorts. Procedural complications were not common with more reported in the malignant cohort.

CONCLUSION

Therapeutic bronchoscopy effectively and safely treats both malignant and benign CAO, with longer-lasting effects observed in the benign group. Patients with airway prosthetics tend to require repeat procedures within a shorter timeframe in both cohorts.

World Association for Bronchology and Interventional Pulmonology (WABIP) guidelines on airway stenting for malignant central airway obstruction

Malignant Central Airway Obstruction (MCAO) encompasses significant and symptomatic narrowing of the central airways that can occur due to primary lung cancer or metastatic disease. Therapeutic bronchoscopy is associated with high technical success and symptomatic relief and includes a wide range of airway interventions including airway stents. Published literature suggests that stenting practices vary significantly across the world primarily due to lack of guidance. This document aims to address this knowledge gap by addressing relevant questions related to airway stenting in MCAO. An international group of 17 experts from 17 institutions across 11 countries with experience in using airway stenting for MCAO was convened as part of this guideline statement through the World Association for Bronchology and Interventional Pulmonology (WABIP). We performed a literature and internet search for reports addressing six clinically relevant questions. This guideline statement, consisting of recommendations addressing these six PICO questions, was formulated by a systematic and rigorous process involving the evaluation of published evidence, augmented with expert experience when necessary. Panel members participated in the development of the final recommendations using the modified Delphi technique.

Tumor-Related Factors Affecting the Success of Interventional Bronchoscopy in Malignant Airway Obstructions

BACKGROUND

It is difficult to select patients who will benefit from endobronchial treatment (ET) in malignant central airway obstruction (MCAO). We aimed to determine the tumor-related factors that affect the success of MCAO treatment.

METHODS

ETs for MCAO between March 2019 and June 2021 were analyzed retrospectively. The relationships between the success of the procedure and the percentage of endoluminal obstruction, tumor size, and type of lesion were evaluated.

RESULTS

Totally, 220 ETs were administered to 205 patients. Treatment was significantly more successful for the patients with pure endobronchial lesions than those with mixed lesions. The success rate was significantly lower when the tumor size was greater than 54.5 mm and the degree of endoluminal stenosis exceeded 92%; the area under the curve was 0.734 (0.625-0.842; P=0.001) and 0.733 (0.597- 0.870; P=0.001), respectively. There was no difference in the procedural success between lung cancer and extrathoracic malignancies and tumor treatment before the procedure.

CONCLUSION

Mixed lesions, tumor size over 54.5 mm, and a degree of stenosis over 92% are risk factors for unsuccessful endoluminal obstruction procedures. These parameters should be considered when selecting patients for ET interventions.

Risk-score model to predict prognosis of malignant airway obstruction after interventional bronchoscopy

Background

Interventional bronchoscopy exhibits substantial effects for patients with malignant airway obstruction (MAO), while little information is available regarding the potential prognostic factors for these patients.

Methods

Between October 31, 2016, and July 31, 2019, a total of 150 patients undergoing interventional bronchoscopy and histologically-confirmed MAO were collected, in which 112 eligible participants formed the cohort for survival study. External validation cohort from another independent institution comprised 33 MAO patients with therapeutic bronchoscopy. The least absolute shrinkage and selection operator regression (LASSO) was applied to the model development dataset for selecting features correlated with MAO survival for inclusion in the Cox regression from which we elaborated the risk score system. A nomogram algorithm was also utilized.

Results

In our study, we observed a significant decline of stenosis rate after interventional bronchoscopy from 71.7%±2.1% to 36.6%±2.7% (P<0.001) and interventional bronchoscopy dilated airway effectively. Patients in our study undergoing interventional bronchoscopy had a median survival time of 614.000 days (95% CI: 269.876–958.124). Patients receiving distinct therapeutic methods of interventional bronchoscopy had different prognosis (P=0.022), and patients receiving treatment of electrocoagulation in combination with stenting and electrosurgical snare had worse survival than those receiving other options. Multivariate Cox analysis revealed that nonsmoking status, adenoid cystic carcinoma, and low preoperative stenosis length, as independent predictive factors for better overall survival (OS) of MAO patients. Then, the nomogram based on Cox regression and risk score system based on results from LASSO regression were elaborated respectively. Importantly, this risk score system was proved to have better performance than the nomogram and other single biomarkers such as traditional staging system (area under the curve 0.855 vs. 0.392–0.739). Survival curves showed that patients with the higher risk-score had poorer prognosis than those with lower risk-score (third quantile of OS: 126.000 days, 95% CI: 73.588–178.412 vs. 532.000 days, 95% CI: 0.000–1,110.372; P<0.001).

Conclusions

Nonsmoking status, adenoid cystic carcinoma, and low preoperative stenosis length, were independent predictive factors for better OS of MAO patients. We proposed a nomogram and risk score system for survival prediction of MAO patients undergoing interventional bronchoscopy with good performance.

Long-term prognostic factors of clinical success after interventional bronchoscopy in patients with scarring central airway stenosis

Background

Scarring central airway stenosis (SCAS) is a potentially life-threatening condition with debilitating symptoms. Interventional bronchoscopy is increasingly used to relieve symptoms in patients with SCAS, but recurrent stenosis is frequently observed. Little data exist on the long-term prognosis of interventional bronchoscopy for SCAS. We aimed to assess the prognostic factors of bronchoscopic interventions in patients with SCAS to optimize treatment.

Methods

This was a retrospective study that enrolled 119 consecutive patients with SCAS from January 2010 to April 2019 at our institution. Long-term clinical success was defined as airway stenosis < 50%, no limitation of physical activity, and a stable condition for > 12 months after the last interventional procedure. We compared patients’ demographics, airway stenosis characteristics, and interventional procedures between the successful and unsuccessful groups, and identified significant predictors of long-term outcome with univariate and multivariate logistic regression.

Results

A total of 119 patients with 577 therapeutic bronchoscopies were included. Seventy-five (63%) patients were considered to have long-term clinical success. Older age, male gender, smoking, elevated C-reactive protein level, subglottic stenosis, stent or T-tube implantation, previous interventional treatment, and multiple procedures per year were potentially associated with unsuccessful long-term outcomes in the univariate analysis. Current smoker status (odds ratio [OR] 5.70, 95% confidence interval [CI] 1.35–24.17, P = 0.018), subglottic stenosis (OR 4.35, 95% CI 1.31–14.46, P = 0.017), and stent implantation (OR 4.96, 95% CI 1.33–18.48, P = 0.017) were associated with decreased odds of long-term success in the multivariate logistic regression analysis. Of note, there was no significant difference in odds of success between former smokers and nonsmokers.

Conclusions

Current smoker status, subglottic stenosis, and stent implantation are independent factors associated with reduced long-term efficacy of interventional bronchoscopy for SCAS. Smoking cessation should be encouraged to improve the outcome of therapeutic bronchoscopy.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12890-021-01434-5.

Successful rescue using tracheal intubation cannula for severe central airway stenosis after tracheotomy: A CARE compliant case report

INTRODUCTION

Central airway stenosis is a life-threating requiring immediate medical intervention. There are several options for treating central airway stenosis, including rigid bronchoscopy, bronchoscopic high-power laser therapy, high-frequency electric needle knife, and balloon-expanding stents. However, interventional techniques may be unavailable in an emergent situation or at smaller local hospitals. In this case report, we publicly demonstrate for the first time that a tracheal intubation catheter may be applied as a temporary alternative to interventional bronchoscopic treatment.

PATIENT CONCERNS

A 72-year old male patient was admitted with a 1-year history of intermittent dyspnea, which was exacerbated for one day. One day prior to admission to our hospital, the patient presented with cyanosis due to an exacerbation of dyspnea.A tracheotomy was performed and the patient had been carrying a tracheotomy cannula for 6 months.

DIAGNOSIS

The ventilator alarm indicated high airway resistance and the nurses were unable to insert the suction pipes into the airway. Immediate fiberoptic bronchoscopy showed diffuse edema and stenosis of the inferior tracheal airways.

INTERVENTIONS

Tracheal intubation was used to temporarily replace the tracheotomy cannula, which successfully expanded the narrowed airways.

OUTCOMES

The blood oxygen saturation returned to normal, and dyspnea was quickly relieved.

CONCLUSION

In emergent situations, tracheal intubation catheters may be used in patients with post-tracheotomy central airway stenosis, not only for surviving the most dangerous phase but for also prolonging the survival time for further treatments.

Comparison of clinical features and stent placement outcomes between airway stenosis caused by primary pulmonary malignancies and that caused by primary non-pulmonary malignancies

Background:

Primary pulmonary malignancies (PPMs) and non-pulmonary malignancies (PNPMs) may result in airway stenosis requiring stenting. This study aimed to compare and evaluate the clinical features and stent placement outcomes of airway stenosis caused by PPMs and PNPMs.

Methods:

A total of 141 patients with malignant airway stenosis who underwent Micro-Tech stent placements between January 2004 and October 2017 at Department of Respiratory Medicine, Beijing Tian Tan Hospital, Capital Medical University were divided into PPM (n = 100) and PNPM groups (n = 41). Patients’ clinical features and stent placement outcomes were collected and analyzed. Chi-square test was used to compare the categorical variables, while independent- or paired-sample t test was used to compare the continuous variables.

Results:

There were no significant differences in age, sex, treatment history, respiratory symptoms, and incidence of obstructive pneumonia between groups. Multiple airway involvement (63.0% vs. 31.7%; χ² = 11.459, P = 0.001) and atelectasis (17.0% vs. 2.4%; χ² = 5.536, P = 0.019) were more common in the PPM group, while extraluminal obstruction (24.4% vs. 6.0%; χ² = 8.033, P = 0.005) was more common in the PNPM group. Before stenting, the American Thoracic Society Dyspnea Index (ADI) and Karnofsky Performance Scale (KPS) scores showed no significant differences between groups (all P > 0.05). After stenting, a satisfactory rate of symptom improvement was achieved in both groups (98.0% and 100.0% in the PPM and PNPM groups, respectively; χ² = 0.016, P = 0.898); ADI and KPS scores, which showed no significant differences between groups (all P > 0.05), were significantly improved in each group (all P < 0.001). Complications after stenting could be effectively managed using bronchoscopic procedures.

Conclusions:

Among cases of malignant airway stenosis requiring stenting, those caused by PPM are more likely to involve multiple airways and are associated with atelectasis, while those caused by PNPM are more likely to cause extraluminal obstruction. Micro-Tech stent placement has the same immediate effect in terms of improvement in respiratory symptoms and performance status for both malignant airway stenosis caused by PPM and that caused by PNPM.

Scarring Airway Stenosis in Chinese Adults: Characteristics and Interventional Bronchoscopy Treatment

Background:

Scarring airway stenosis is commonly seen in China as compared to other developed countries, due to the high prevalence of tuberculosis. Nowadays, interventional bronchoscopy treatment has been widely used to treat this disease in China. This study demonstrated the characteristics of scarring airway stenosis in Chinese adults and retrospectively evaluated the efficacy of interventional bronchoscopy treatment of this disease.

Methods:

Patients with scarring airway stenosis from 18 tertiary hospitals were enrolled between January 2013 and June 2016. The causes, site, and length of scarring airway stenosis were analyzed, and the efficacy of the interventional bronchoscopy treatment was evaluated.

Results:

The final study cohort consisted of 392 patients. Endotracheobronchial tuberculosis (EBTB) was the most common cause of scarring airway stenosis (305/392, 77.8%) in Chinese adults with a high rate of incidence in young women. The left main bronchus was most susceptible to EBTB, and most posttuberculosis airway scarring stenosis length was 1.1–2.0 cm. The average clinical success rate of interventional bronchoscopy treatment for scarring airway stenosis in Chinese patients is 60.5%. The stent was inserted in 8.7% scarring airway stenosis in China.

Conclusions:

Scarring airway stenosis exhibits specific characteristics in Chinese patients. Interventional bronchoscopy is a useful and safe treatment method for the disease.

Magnetic resonance imaging of patients with airway stents

Airway stent implantation is a highly effective treatment for airway stenosis. However, it is presently unclear whether patients with airway stents can safely undergo magnetic resonance imaging (MRI). Such stents may be metallic or non-metallic, and MRI may induce stent dislodgment or heating and may be associated with stent-induced artifacts. We thoroughly reviewed the literature, experimental data, and manufacturer information on non-metallic, stainless steel (SS) and nickel-titanium alloy stents. Non-metallic stents are made of non-ferromagnetic materials associated with no MRI concerns. SS stents may shift in a magnetic field, generating significant artifacts. Nickel-titanium alloy stents are not at risk of dislodgement or heating, but may create some artifacts affecting image quality. Both non-metallic and nickel-titanium alloy stents are safe for patients who must undergo MRI. However, the safety of SS stents depends on the type of steel used.

Incidence and Risk Factors of Hypoxemia During Interventional Rigid Bronchoscopy Under Spontaneous-assisted Ventilation

BACKGROUND

Interventional rigid bronchoscopy for tracheobronchial stenosis can be performed under total intravenous anesthesia and spontaneous-assisted ventilation. Intraoperative hypoxemia can occur during this procedure, but the incidence and risk factors have not yet been determined.

METHODS

Medical records of patients who underwent rigid bronchoscopy for the treatment of tracheobronchial stenosis under total intravenous anesthesia and spontaneous-assisted ventilation during the study period from January 2011 to December 2012 were retrospectively reviewed.

RESULTS

There were 126 patients who underwent 263 procedures. The 2 main causes of tracheobronchial stenosis were tuberculosis (41.3%) and malignancy (35.7%). The 2 main locations of stenotic area were the trachea (58.6%) and the left main bronchus (46.4%). Tracheobronchial dilatation and stent insertion were performed in 78.7% and 21.3% of patients, respectively. The incidence of intraoperative hypoxemia was 25.5%. Independent risk factors for intraoperative hypoxemia were a degree of tracheal stenosis ≥75% (odds ratio: 2.48; 95% confidence interval, 1.19-5.17) and tumor removal procedure (odds ratio: 2.9; 95% confidence interval, 1.13-7.41).

CONCLUSIONS

Incidence of intraoperative hypoxemia during interventional rigid bronchoscopy for tracheobronchial stenosis under spontaneous-assisted ventilation was 25.5%. Risk factors for hypoxemia were a degree of tracheal stenosis ≥75% and tumor removal procedure.

Secondary tracheal tumors: a systematic review

BACKGROUND

Secondary tracheal tumors arise from mural invasion by primary tumors in adjacent organs, metastatic lymph nodes or blood-born metastasis from distant sites. This systematic review aims to assess the presentation, management options, and clinical outcomes of these uncommon non-tracheal malignancies.

METHODS

Electronic searches of the MEDLINE database were performed to identify case series and individual case reports of tracheal invasion by primary non-tracheal tumors or metastatic disease. All English-language studies with available abstracts or articles containing primary data were included.

RESULTS

From 1978 to 2017, a total of 160 case reports or case series identified 2,242 patients with invasion of the trachea by tumors of adjacent organs (n=1,853) or by metastatic lymph nodes or hematogenous spread (n=389). Common primary sites of origin were thyroid, esophagus, and lung, and the most common presentation was metachronous (range of interval: 0 to 564 months) with dyspnea, neck mass, voice change and/or hemoptysis. A majority of patients in case reports (77.9%) and case series (66.0%) underwent resection and the most common reported operation was segmental tracheal resection. Fewer patients underwent bronchoscopic intervention (21.7%) and radiation was used in 32.2% of patients. Complications after bronchoscopic treatment included bleeding, granulation tissue, and retained secretions, while anastomotic leak, unplanned tracheostomy, and new recurrent laryngeal nerve paralysis were observed after surgical resection. The rate of 30-day mortality was low (0.01-1.80%). Median survival was higher in patients with thyroid malignancy and in patients who underwent surgical management. Follow-up time ranged from 0.03 to 183 months.

CONCLUSIONS

Patients with tracheal invasion by metastatic or primary non-tracheal malignancies should be assessed for symptoms, tumor grade, tumor recurrence and concurrent metastases to decide on optimal surgical, bronchoscopic or noninterventional therapy. Clinical experience suggests that palliative endoscopic intervention for tracheal obstruction by metastasis-bearing lymph nodes is underreported.

A retrograde y-stenting of the trachea for treatment of mediastinal fistula in an unusual situation

INTRODUCTION

Stents have been used for quite some time for the treatment of benign and malignant airway stenosis. Silicon stents are preferred for benign situations, whereas metallic self-expanding stents are preferred for malignant comorbidities.

PATIENT AND METHODS

In general, stents can be placed in different approach directions, although in pulmonary medicine it is logical to apply only antegrade techniques - until now. A 63-year-old patient, 168 cm height and 53 kg weight on referral, suffered chronical diseases. The patient was diagnosed with a papillary thyroid carcinoma in 1989, which was treated by resection and radiotherapy. In the following years, she developed a stenosis of the esophagus. The decision to try endobronchial stenting was made upon the plan to close that fistula with a pedicled omentum majus replacement through the diaphragmal opening of the esophagus. This surgical plastic needed an abutment and a secured continuous airway replacement above the tracheostoma level. A Freitag stent (FS), 11 cm in length (110-25-40) and an inner diameter of 13 mm, was placed successfully retrograde into the trachea and completely bridged the big fistula. Unfortunately the patient passed away due to pulmonary infections after several weeks.

DISCUSSION

In this case report, a successful but unusual case of retrograde stent placement of a modified FS is presented.

MINIMALLY INVASIVE METHODS IN TREATMENT OF COMPLICATED FORMS OF CENTRAL LUNG CANCER

Despite certain achievements in lung cancer treatment, the essential number of patients is subjected to palliative and symptomatic treatment. Hemoptysis addition is the one of most heavy symptoms of unresectable lung cancer. No less heavy complication is an atelectasis and hypoventilation of a lobe or a whole lung, which clinical image is attended by respiratory failure phenomena or association of purulent-septic pneumonia. The combination of endoscopic hemostasis with roentgen endovascular embolization of bronchial arteries (REEBA) allows to increase patients’ live quality and to prolong it for some time. In the clinic REEBA has been done in 121 patients with unresectable forms of lung cancer. The causes of surgical treatment refusal were a widespread tumor process, age, and severity of associated pathology. Hemostasis was achieved in 112 patients. A relapse of pulmonary bleeding was observed in 11 patients, who underwent the repeated REEBA. Lethal outcome was observed in 5 cases. Hemostasis was ineffective in 9 patients. Thus, the experience of using REEBA and endoscopic hemostasis at complicated forms of unresectable lung cancer allows to increase the life quality and in further to realize chemoradial therapy that gives a possibility to prolong a patient’s life.

Palliation of Concomitant Tracheobronchial and Esophageal Disease Using a Combined Airway and Esophageal Approach

BACKGROUND

Neoplastic involvement of the mediastinum can contribute to both airway and esophageal pathology. That can manifest as combined esophageal and airway stenosis, or tracheobronchoesophageal fistula. Conventional palliative treatment of these problems consists of endoluminal stent insertion. The double stenting approach consists of insertion of a tracheobronchial and an esophageal stent in parallel and allows concomitant symptomatic relief of both the airway and esophageal pathology.

METHODS

The study consists of a retrospective case series of patients who underwent a double stenting procedure for concomitant airway and esophageal disease between August 2009 and September 2014. The type of airway stent chosen was determined based on the pathology and the level of the lesion (simple tubular in the mid trachea or mainstem bronchus, Y-stent for carina).

RESULTS

Thirty-nine patients were treated using the double stenting approach during a combined procedure over 5 years: 15 patients with tracheobronchoesophageal fistula and 24 with stenosis. Immediate relief of symptoms, defined as resuming oral intake and breathing without an external tracheal device, was observed in 25 patients (64%). Thirty-two patients (82%) were discharged from hospital, and 7 patients died in hospital (18%). Of these 7 deaths, 6 patients died of pulmonary complications. Inhospital complications occurred in 11 patients (28%). Of the patients discharged from the hospital, 14 died during a mean follow-up period of 54 days. Mean and median survival were 49 and 24 days, respectively (range, 1 to 448), and median hospital stay was 3 days (range, 1 to 46).

CONCLUSIONS

Treatment of combined airway and esophageal pathology using a double stenting approach is safe, feasible, provides reasonable immediate palliation of symptoms, and is associated with acceptable morbidity. It is a palliative procedure that allows for early hospital discharge of patients who are diagnosed with an incurable malignancy.

Reporting of central airway obstruction on radiology reports and impact on bronchoscopic airway interventions and patient outcomes

BACKGROUND

Central airway obstruction (CAO) is a serious condition that affects patients with both benign and malignant diseases. Timely recognition of CAO is crucial for prompt intervention aimed at improving the symptoms and quality of life of these patients. The aim of this study is to evaluate the formal radiology reporting of CAO and its impact on patients' outcomes.

METHODS

The medical records of patients who underwent advanced therapeutic bronchoscopy for CAO from August 2013 to September 2014 were retrospectively reviewed. Three researchers each reviewed 14 of the 42 formal radiology reports that were performed at 16 different medical and radiology centers.Patient characteristics were reported as means, medians, and standard deviations for continuous variables, and as frequencies and relative frequencies for categorical variables.

RESULTS

Out of 42 patients who underwent advanced bronchoscopy for planned therapeutic intervention, only 30 had radiology and pulmonology concordance about the airway findings of CAO. This is an agreement rate of 71.4% [95% confidence interval (CI): 56.7-83.3%] or a disagreement rate of 28.6% (95% CI: 16.7-43.3%). The radiology reports did not mention 31% of CAO on CT scans. The median time from CT imaging to bronchoscopy was significantly longer in patients with CAO not reported by the radiologists (21 versus 10 days; p = 0.011). Most patients improved postoperatively with no significant difference between the two groups.

CONCLUSIONS

Findings of CAOs were not described in a significant proportion of radiology reports. This results in significant delay in bronchoscopic airway management.