Bronchoscopic dilatation in the management of benign (non-transplant) tracheobronchial stenosis

Superior Strategy in Benign Tracheal Stenosis Treatment: Surgery or Endoscopy?

INTRODUCTION

 Due to the variations in (laryngeal) tracheal stenosis (TS) patient groups, there is still no consensus on which patient should be treated with endoscopy or surgery. The aim of the present study was to generate an algorithm in the light of the related literature and the data obtained from a clinic where both endoscopic and surgical treatments are conducted.

METHOD

 A retrospective analysis was performed on the data of a total of 56 patients during 2013 to 2019. A total of 38 patients were subject to surgery with 31 as a first treatment option and 7 due to the unsatisfactory results of endoscopic treatments. Endoscopic approaches were tried on a total of 29 patients with 25 as initial treatment and 4 due to postsurgical recurrence.

RESULTS

 Symptomatic full control ratio was determined as 69% with endoscopic treatments, 89.5% in subglottic stenosis (SGS) surgery (n = 19), and 89.5% in trachea surgery (n = 19). However, success rates with no recurrence were determined, respectively, as 40.0, 36.4, and 36.4% for patients subject to dilatation, stent, or T tube treatment. Dilatation was observed to be successful in patients with stenotic segment lengths of less than 1.5 cm (p = 0.02). Failure rates increased in SGS (p = 0.03) and TS (p = 0.12) in the surgical group with increasing stenotic segment length. The presence of comorbidities was not effective on treatment success.

CONCLUSION

 Endoscopic methods are preferred in cases of web-like stenosis. Surgical methods should first be considered for other patients and endoscopic methods should be used on patients who are not suited for surgery or in cases of postsurgical recurrence.

Indications and complications of rigid bronchoscopy

INTRODUCTION

Rigid bronchoscopy is an invaluable tool for the management of airway disorders and an essential skill for an interventional pulmonologist. Since its introduction in the late 19th century, it has remained an important technique for the management of central airway obstruction, foreign body aspiration and massive hemoptysis. Areas covered: This article will review the history, indications, contraindication, technique and complications of rigid bronchoscopy. We will also briefly discuss the methods of anesthesia and ventilation and finally our perspective on the future of rigid bronchoscopy. Expert commentary: Although the rise of flexible bronchoscopy in the 1960s led to a decline in the use of rigid bronchoscopy, the last two decades have witnessed resurgence in its popularity. We anticipate that it will remain an important tool used by interventional pulmonologists for decades to come. We suggest that interventional pulmonologists must have training and develop expertise in this technique.

Comparison between traditional and small-diameter tube-assisted bronchoscopic balloon dilatation in the treatment of benign tracheal stenosis

OBJECTIVE

To compare the safety and efficacy between using a small-diameter tube-assisted bronchoscopic balloon dilatation (BBD) and the traditional BBD in the treatment of benign tracheal stenosis.

METHODS

A retrospective study included 58 patients with benign tracheal stenosis from August 2009 to December 2014 was made. The patients who underwent traditional BBD were divided into group A, and who underwent a small-diameter tube-assisted BBD were divided into group B. The tracheal diameter, dyspnea index and blood gas analysis results were detected before and after BBD. Efficacy and complications were evaluated after BBD.

RESULTS

There were significant differences in oxygen saturation (PaO₂ ) during the operations comparing with before and after operations in group A (P = .005), while there was no significant difference in group B (P = .079). The tracheal diameter obviously increased (in group A, from 4.16 ± 1.43 mm to 12.47 ± 1.41 mm, P = .000; in group B: from 4.94 ± 1.59 mm to 12.61 ± 1.41 mm, P = .000). Dyspnea index obviously decreased (group A: from 3.21 ± 0.93 to 0.50 ± 0.59, P = .000; group B: from 3.24 ± 0.89 to 0.65 ± 0.69, P = .000). The immediately cure rate in both groups was 100%. Long-term effect was significantly better in group B than that in group A (85.3% vs 59.1%, P = .021), at the end of the follow-up period.

CONCLUSIONS

Small-diameter tube-assisted BBD obtains better safety and long-term efficacy than the traditional BBD in the treatment of benign tracheal stenosis. However, close attention should be given to the risk of the adverse effects caused by carbon dioxide retention.

Bronchoscopic balloon dilatation for tuberculosis-associated tracheal stenosis: a two case report and a literature review

Background

Bronchoscopic balloon dilatation (BBD) is a common strategy in the treatment of bronchostenosis. However, the longer dilating time in each inflation cycle (approximately 3–5 min) without mechanical ventilation is not possible for the treatment of tracheal stenosis.

Case presentation

In this study, we reported our experience of BBD with shorter dilating time (10 s or 1 min) and intermittent ventilation for the repair of tuberculous-associated tracheal stenosis in two cases of our hospital. After the surgeries, the physical examinations and pulmonary function were tested. In case 1, the cough and dyspnea syndromes subsided, wheeze and strid or in lungs were remarkably reduced, tracheal lumen was considerably expanded and pulmonary function was improved following the treatment. For the case 2, her chest tightness, shortness of breath symptoms were alleviated after the treatment. The middle and lower trachea stenosis was dilated and patent, but the right main bronchus stenosis was slightly improved. No restenosis occurred in the two patients in 1 year outpatient follow-up.

Conclusions

These findings suggest that our modification in BBD is safe and effective for treating this patient with tracheal stenosis caused by tuberculosis, but the longer-term effect of the surgery in a large number of patients with longer follow-up remains to be seen.

Electronic supplementary material

The online version of this article (doi:10.1186/s13019-016-0417-z) contains supplementary material, which is available to authorized users.

From electrocautery, balloon dilatation, neodymium-doped:yttrium-aluminum-garnet (Nd:YAG) laser to argon plasma coagulation and cryotherapy

Over the past decade, there has been significant advancement in the development/application of therapeutics in thoracic diseases. Ablation methods using heat or cold energy in the airway is safe and effective for treating complex airway disorders including malignant and non-malignant central airway obstruction (CAO) without limiting the impact of future definitive therapy. Timely and efficient use of endobronchial ablative therapies combined with mechanical debridement or stent placement results in immediate relief of dyspnea for CAO. Therapeutic modalities reviewed in this article including electrocautery, balloon dilation (BD), neodymium-doped:yttrium-aluminum-garnet (Nd:YAG) laser, argon plasma coagulation (APC), and cryotherapy are often combined to achieve the desired results. This review aims to provide a clinically oriented review of these technologies in the modern era of interventional pulmonology (IP).

Characteristics and risk factor analysis of 410 cases of tracheobronchial tuberculosis

The present study analyzed the characteristics and risk factors associated with tracheobronchial tuberculosis (TBTB) in 410 patients with TBTB. Retrospective analysis was performed on the clinical features, bronchoscopy performance, bacteriological examination, imaging and treatment of 410 patients who were diagnosed with TBTB using bronchoscopy. Among the 410 patients, 10 patients underwent chest X-ray which revealed two cases of atelectasis, eight cases of patch or spot shadows, three cases of cavity, one case of nodule and one case with no abnormalities. The remaining 400 patients underwent computed tomography chest scans and/or airway reconstruction examinations. Among all the lesion types, the cavity type was found to be the most likely to cause bronchial stenosis or obstruction, with statistically significant differences when compared with the congestion, stenosis or scar lesion types (P<0.01). Moreover, for the cavity type, there were 194 sites of obstruction prior to therapy; however, only 23 sites of obstruction remained following therapy. Furthermore, there were 34 sites without stenosis prior to therapy and 205 sites without stenosis following therapy. The number of sites of obstruction was significantly decreased and the number of sites without stenosis was increased upon therapy. These findings suggest that the cavity type is the most sensitive type to therapy among the five types of TBTB lesion.

Non-malignant central airway obstruction

The most common causes of non-malignant central airway obstruction are post-intubation and post-tracheostomytracheal stenosis, followed by the presence of foreign bodies, benign endobronchial tumours and tracheobronchomalacia. Other causes, such as infectious processes or systemic diseases, are less frequent. Despite the existence of numerous classification systems, a consensus has not been reached on the use of any one of them in particular. A better understanding of the pathophysiology of this entity has allowed us to improve diagnosis and treatment. For the correct diagnosis of nonspecific clinical symptoms, pulmonary function tests, radiological studies and, more importantly, bronchoscopy must be performed. Treatment must be multidisciplinary and tailored to each patient, and will require surgery or endoscopic intervention using thermoablative and mechanical techniques.

Managing obstruction of the central airways

Lung cancer is the most common cause of cancer death in Australia, Europe and the USA. Up to 20-30% of these cancers eventually affect the central airways and result in reduced quality of life, dyspnoea, haemoptysis, post-obstructive pneumonia and ultimately death. Non-malignant processes may also lead to central airway obstruction and can have similar symptoms. With the development of newer technologies, the last 20 years have seen the emergence of the field of interventional pulmonology to deal specifically with the diagnosis and management of thoracic malignancy, including obstruction of the central airways. This review discusses the pathology, pre-procedure work-up and management options for obstructing central airway lesions. Several treatment modalities exist for dealing with endobronchial pathology with local availability and expertise guiding choice of treatment. While the literature lacks large, multicentre, randomized studies defining the optimal management strategy for a given problem, there is growing evidence from numerous case studies of improved physiology, of quality of life and possibly of survival with modern interventional techniques.

Update on lung transplantation

Lung transplantation is a suitable treatment to improve the quality of life and the prognosis of patients with various end-stage pulmonary diseases. There is a shortage of organs and the number of patients on waiting list is exceeding the number of transplants per year approximately two-fold in most countries. Strategies to increase the donor pool are therefore crucial. The long-term prognosis after lung transplantation is not yet as good as for other transplantation procedures and special complications should be taken into account. Aside from infections chronic organ dysfunction is the main cause of death and the most important prognosis limiting factor. Other typical problems are rejection, bronchus complications, and primary transplant dysfunction. However, the results of large centers show promising improvements in recent years.

Rhinoscleroma: eight Peruvian cases

Rhinoscleroma is a rare infection in developed countries; although, it is reported with some frequency in poorer regions such as Central Africa, Central and South America, Eastern and Central Europe, Middle East, India and Indonesia. Nowadays, rhinoscleroma may be erroneously diagnosed as mucocutaneos leishmaniasis, leprosy, paracoccidioidomycosis, rhinosporidiasis, late syphilis, neoplasic diseases or other upper airway diseases. From 1996 to 2003, we diagnosed rhinoscleroma in eight patients attended in the Dermatologic and Transmitted Diseases service of "Cayetano Heredia" National Hospital, in Lima, Peru. The patients presented airway structural alterations producing nasopharyngeal, oropharyngeal and, in one patient, laryngeal stenosis. Biopsy samples revealed large vacuolated macrophages (Mikulicz cells) in all patients. Ciprofloxacin 500 mg bid for four to 12 weeks was used in seven patients and oxytetracycline 500 mg qid for six weeks in one patient. After follow-up for six to 12 months the patients did not show active infection or relapse, however, all of them presented some degree of upper airway stenosis. These cases are reported because of the difficulty diagnosing the disease and the success of antibiotic treatment.

Therapeutic Bronchoscopy Interventions Before Surgical Resection of Lung Cancer

BACKGROUND

Therapeutic bronchoscopy is used for endobronchial staging of lung cancer and symptomatic relief of central airway obstruction or postobstructive pneumonia. The aim of this study was to assess the utility of therapeutic bronchoscopy as a complementary tool in the combined bronchoscopic and surgical management of malignant airway lesions before curative lung surgery.

METHODS

Seventy-four consecutive patients with nonsmall cell lung carcinoma undergoing a therapeutic bronchoscopy procedure followed by surgery with a curative intent were included.

RESULTS

A single interventional bronchoscopic method was used in 27 patients (36%) and a combination of methods in 47 patients (64%). Median forced expiratory volume in 1 second (FEV1) before and after bronchoscopy were 1.7 L and 2.2 L, respectively, and forced vital capacity (FVC) was 2.5 L and 3.3 L, respectively. Sleeve upper lobectomy was performed in 22 patients (30%), sleeve upper bilobectomy in 16 patients (22%), lower bilobectomy in 2 patients (3%), pneumonectomy with sleeve resection in 2 patients (3%), and pneumonectomy in 28 patients (38%). The following surgeries were performed in 1 patient each: sleeve middle lobectomy, sleeve lower lobectomy, carina resection and complex reconstruction, and exploratory thoracotomy. Overall, parenchyma-sparing surgery (lobectomy or bilobectomy) could be performed in 57% patients after therapeutic bronchoscopy. There were no in-hospital deaths or deaths in the first 30 days after surgery.

CONCLUSIONS

Therapeutic bronchoscopy can be used as a complementary tool in the combined bronchoscopic and surgical management of malignant airway obstruction before curative lung surgery. Therapeutic bronchoscopy might permit parenchyma-sparing surgery in patients with lung cancer.

Successful Bronchoscopic Balloon Dilation of Nonmalignant Tracheobronchial Obstruction Without Fluoroscopy

OBJECTIVE

To evaluate the safety and efficacy of bronchoscopic balloon dilation (BBD) without fluoroscopy for relief of tracheobronchial obstruction.

METHODS

We performed a retrospective study of all adult patients who underwent BBD without fluoroscopy at the Tulane University Hospital and Clinic between July 1, 1997, and June 30, 2002.

RESULTS

Twenty-four patients (mean [+/- SD] age, 58 +/- 14 years; 80% men) underwent 59 BBD procedures without fluoroscopy for the following conditions: iatrogenic tracheal stenosis (80%); saber-sheath trachea (4%); bronchial stenosis resulting from lung transplantation (4%); sarcoidosis (4%); Wegener granulomatosis (4%); and idiopathic stenosis (4%). All BBD procedures were performed via a rigid bronchoscope (61%) or a flexible bronchoscope (39%) without fluoroscopy. BBD was often combined with mechanical debridement (64%), stent placement (47%), or laser photoresection (19%), although in 26% of cases BBD was the only intervention. During the 59 procedures, 71 different balloon catheters were deployed a total of 112 times (deployment was defined as any use of balloon dilation in a different location, for a different purpose, or to a different inflation diameter). These 112 deployments were performed for primary dilation (49%), dilation prior to stent placement (28%), and stent seating (22%). Improvement in stenosis was achieved immediately postprocedure in all 59 procedures (100%). One balloon ruptured during inflation without clinically significant effect, and no other complications occurred.

CONCLUSION

BBD without fluoroscopy for the relief of nonmalignant tracheobronchial obstruction can be safely performed through a rigid or flexible bronchoscope. It can be used alone or as an adjunct to other therapeutic modalities. In this series, 100% of airway obstructions were improved, and there were no clinically significant complications. BBD of a tracheobronchial obstruction without fluoroscopy is safe, efficacious, and cost-effective.

Management of hypoxemia during flexible bronchoscopy

Under controlled conditions, FB is a safe procedure that has few significant adverse events. Significant hypoxemia may sometimes occur during FB despite the use of supplemental oxygen. UAO has been shown to be the dominant cause of hypoxemia during FB, and this is successfully managed with nasopharyngeal tube insertion. Other strategies that may need to be implemented include oxygen supplementation with intratracheal catheter, administration of sedation reversal medication, removal of the bronchoscope, bag-and-mask ventilation, and, rarely, endotracheal intubation and ventilation. Access to an anesthetist, availability of propofol, backup rigid bronchoscopy, and fluoroscopy are optional but desirable components in the bronchoscopy suite.

Ultraflex stents for the management of airway complications in lung transplant recipients

OBJECTIVE

We present our experience with the use of the Ultraflex (nitinol) stents in the management of airway complications in lung transplant (LT) recipients.

METHODOLOGY

Nine LT recipients underwent insertion of uncovered Ultraflex stents. Mean change in FEV1, duration to formation of granulation tissue and follow-up post-stent insertion were compared with results obtained in LT recipients who had undergone Gianturco stent (n = 10) and Wallstent insertion (n = 16).

RESULTS

Mean improvement in FEV1 after insertion of Gianturco, Wallstent and Ultraflex stents was 670 +/- 591 mL, 613 +/- 221 mL and 522 +/- 391 mL, respectively. No patient with an Ultraflex stent developed mucus plugging or stenosis at stent extremity at a follow up of 263 +/- 278 days. The mean and median duration to stenosis at stent extremity for patients with Gianturco stents was 102 +/- 85 days and 73 days, respectively, compared with 132 +/- 87 days and 142 days, respectively, for patients with Wallstents. Stricture formation in the middle of the Ultraflex stent occurred bilaterally, at the level of anastomosis in one patient in whom stent placement was undertaken in the presence of inflammation. Stent migration in one patient was related to undersizing of the stent diameter relative to the airway diameter. A larger diameter relative stent was subsequently inserted successfully.

CONCLUSION

Ultraflex stents appear to have fewer long-term complications when used in the management of airway complications following LT.

Tracheobronchial stenosis from acid aspiration presenting as asthma

We report a case of a 42-year-old man who fell in a vat of hydrochloric acid, resulting in ingestion and aspiration of acid. Initially, he suffered from a chemical pneumonitis and GI burns. He was released from the hospital without complications, only to return with signs and symptoms consistent with asthma. Evaluation revealed multiple areas of large airway stenosis, resulting from the chemical burns. The stenoses were treated with multiple stents.