An Overview of Treatment Options for Lower Airway Obstruction

Dilatation for Assisted Ventilation-Induced Laryngotracheal Stenosis

OBJECTIVE

To assess the long-term results of dilatation and our experience with dilatation for assisted ventilation-induced laryngotracheal stenosis.

DESIGN

A retrospective study of 32 patients primarily treated with dilatation for assisted ventilation-induced laryngotracheal stenosis between 1977 and 2002.

SETTING

A tertiary care center and university teaching hospital.

PATIENTS

There were 19 men and 13 women aged 15 to 76 years. The stenosis was cicatricial with some inflammatory process in 27 patients and completely mature in 5 patients. The stenosis involved the cricoid and the trachea in four patients. In 28 patients, the stenosis involved only the trachea.

METHODS

Dilatation was performed with serially sized rigid bronchoscopes. Endoscopic laser vaporization was never performed in this series. Six patients were treated with only one dilatation. The 26 remaining patients were treated with successively 2 to 10 dilatations (mean, 3.3 dilatations). The dilatation success rate was analyzed using the Kaplan-Meier method.

RESULTS

Median duration of follow-up was 1.8 years. Mortality rate was 9.4%. The overall failure rate was 71.8%. Twenty patients presented with recurrent stenosis. The treatment of recurrent stenosis consisted of tracheal resection with end-to-end anastomosis (11 patients, 55%), cricotracheal anastomosis (5 patients, 25%), tracheal endoprosthesis (2 patients, 10%), and tracheotomy (1 patient, 5%). All patients who underwent tracheal or cricotracheal anastomosis were successfully treated. None of the variables under analysis (sex, age, medical history, cause for intubation, intubation type and duration, delay from initial injury, degree of stenosis, length of trachea involved, number of dilatations) were statistically related to the incidence of complications and the success rate of dilatations.

CONCLUSIONS

We do not recommend dilatation technique as the sole treatment for assisted ventilation-induced laryngotracheal stenosis. This technique is helpful in case of emergency to restore an airway and useful for the assessment of stenosis.

Surgisis patch tracheoplasty in a rodent model for tracheal stenosis

BACKGROUND

Tracheal stenosis is a challenging surgical problem that can require reconstruction using autologous grafts or artificial stents. In this study, we evaluate the efficacy of Surgisis, a commercially available, biocompatible, acellular matrix, in the repair of a critical-size tracheal defect.

METHODS

A full-thickness defect (2 mm x 6 mm) was created in tracheal rings 4 through 6 in adult rats. A piece of 8-ply Surgisis (Cook; Bloomington, IN) was sutured to the edges of the defect with interrupted 8-0 polypropylene sutures. In control animals, the defect was closed primarily. The trachea was harvested at 4 weeks and prepared for histologic evaluation using conventional techniques. Cross-sectional area and perimeters were calculated using imaging software.

RESULTS

Tracheal defects without patch repair (n = 3) resulted in tracheal stenosis and immediate death. Animals that underwent Surgisis patch repair of tracheal defects (n = 10) tolerated the procedure well and had no audible stridor or evidence of respiratory distress. Eight of ten animals survived 4 weeks. The tracheal lumen was patent with no evidence of contracture or degradation of the Surgisis. Histologically, neovascularization of the Surgisis was noted with moderate inflammation. The surface of the Surgisis patch was covered ith a lining of ciliated epithelial cells.

CONCLUSION

In the rodent model, Surgisis appears to be an efficacious method for the patch repair of partial circumferential tracheal defects. Surgisis appears to be a safe and promising means of facilitating neovascularization and tissue regeneration. The long-term use of Surgisis warrants further investigation.

A correção das estenoses traqueobrônquicas mediante o emprego de órteses

O tratamento cirúrgico do paciente com estenose traqueobrônquica exige uma avaliação individualizada em razão da complexidade de sua origem, sendo a traqueoplastia considerada a modalidade ideal. As causas mais comuns de estenose são devidas à intubação traqueal e ao desenvolvimento de neoplasias e estas condições são justamente as que mais se beneficiam com o tratamento endoscópico quando a correção cirúrgica não está indicada. Na atualidade, os meios endoscópicos incluem a aplicação de diversos tipos de laser e sondas de dilatação, habitualmente com o uso de broncoscópio rígido, e emprego de radioterapia e órteses, separadamente ou em associação. Basicamente, as órteses são de dois tipos: metálicas e de silicone. As metálicas têm sua indicação mais freqüente para os casos de traqueomalacia e estenoses por compressão neoplásica extrínseca. Nos casos de obstrução da via aérea por inflamação aguda, restrita à sua luz ou sem envolvimento mais profundo da parede traqueobrônquica, ou em presença de neoplasia endoluminal, é recomendável a órtese de silicone. Embora em algumas situações essas diversas formas de tratamento possam ser intercambiáveis, não costumam ser a regra. Portanto, a estratégia terapêutica visando à resolução mais eficaz da estenose traqueobrônquica baseia-se na seleção dos métodos empregados desde o primeiro tratamento.

Multidisciplinary airway stent team: a comprehensive approach and protocol for tracheobronchial stent treatment

Tracheobronchial stents are being used with increasing frequency to treat major airway obstruction from both malignant and benign processes. Traditionally, stents have been placed via rigid bronchoscopy, flexible bronchoscopy, or fluoroscopy by members of various individual disciplines. We describe a novel multidisciplinary airway stent team (MAST) protocol for tracheobronchial stent placement and endoscopic management of major airway obstruction. A patient with symptoms of airway obstruction is generally first evaluated with a computed tomography scan and a videotaped flexible bronchoscopy. These studies are reviewed by the team otolaryngologist, pulmonologist, and interventional radiologist. A treatment plan, including the type and location of stents and the need for adjuvant therapies, is formulated. Stent placement is performed in the operating room under general anesthesia. Rigid bronchoscopy, with flexible bronchoscopy and fluoroscopy as needed, allows precise stent placement and the best use of various therapeutic methods. The MAST protocol combines the skills, knowledge, and unique therapeutic options of specialists from otolaryngology, pulmonology, and interventional radiology. This approach allows optimal stent placement and the use of other endobronchial therapies, including laser ablation, balloon dilation, photodynamic therapy, cryotherapy, and brachytherapy. A protocol with representative case reports is presented, along with a review and comparison of several of our most commonly used stents. Otolaryngologists who practice bronchoesophagoscopy, by virtue of their operative skill and knowledge of airway management, are well equipped to become leaders of MASTs and are encouraged to initiate MASTs at their institutions.

Transbronchial Palmaz stent placement for tracheo-bronchial stenosis

PURPOSE

Evaluation of the efficacy of transbronchial Palmaz stent placement in the treatment of tracheo-bronchial narrowing.

MATERIALS AND METHODS

Twelve patients with stenoses of the tracheo-bronchial tree were treated with balloon-expandable Palmaz stents. Etiology was anastomotic stenosis after lung transplantation (n = 3), bronchogenic carcinoma (n = 2), external compression from thoracic aortic aneurysm (n = 2), Mycobacterium tuberculosis (n = 1), esophageal carcinoma (n = 1), after lobectomy (n = 1), after lobectomy and endobronchial radiation (n = 1), and lye ingestion (n = 1). All patients had respiratory symptoms, radiologic findings of persistent atelectasis, or worsening pulmonary function tests. Bronchoscopy was used to delineate the stenosis prior to intervention. With use of fluoroscopic guidance, stents were placed in the mainstem bronchus (n = 11), lower lobe bronchus (n = 5), bronchus intermedius (n = 5), trachea (n = 3), and middle lobe bronchus (n = 1).

RESULTS

Initial technical success was achieved in all patients. Ten of the 12 patients (83%) had improvement of clinical pulmonary signs or symptoms. During follow-up, five patients died. One was lost to follow-up and was presumed dead. The 30-day mortality rate was 17% (two of 12 patients). The two complications were superficial laceration of the bronchial mucosa during balloon dilation in one patient and compression of stents by a thoracic aortic aneurysm in another patient.

CONCLUSION

Initial results suggest that transbronchial Palmaz stent placement is a feasible and effective method of treating tracheo-bronchial stenosis.

Clinical features and therapeutic management of subglottic stenosis in patients with Wegener's granulomatosis

OBJECTIVE

To determine the clinical features and optimal treatment of subglottic stenosis (SGS) in patients with-Wegener's granulomatosis (WG).

METHODS

Review of 43 patients with SGS and treatment of 20 patients with intratracheal dilation-glucocorticoid injection therapy.

RESULTS

SGS developed in 43 of 189 patients with WG who were followed up at the National Institutes of Health Clinical Center. The diagnosis of SGS occurred in the absence of other features of active. WG in 21 of 43 patients (49%). In 21 patients (49%), SGS began while the patient was receiving systemic immunosuppressive therapy for disease activity involving other sites. Tracheostomy was required in 10 of 18 patients (56%) who were treated with systemic immunosuppressive therapy. In 20 patients treated with intratracheal therapy, none required tracheostomy and 6 with previous tracheostomies were decannulated.

CONCLUSION

SGS often occurs independently of other features of active WG and is frequently unresponsive to systemic immunosuppressive therapy. Intratracheal dilation-injection therapy provides a safe and effective treatment for WG-associated SGS and, in the absence of major organ disease activity, should be used without concomitant systemic immunosuppressive agents.