Endobronchial stenting in the management of large airway pathology

Role of interventional bronchoscopy and chemotherapy in the treatment of patients with small-cell lung cancer: A case report

Most of the small-cell lung cancer patients are of the central type of lung cancer. Small-cell lung cancer often intrudes into the atmospheric tract and large blood vessels, thus causing severe tracheobronchial stenosis and superior vena cava syndrome. In addition, patients with malignant tumors, especially those with respiratory failure and severe hypoxia, can be complicated with thromboembolic diseases. We reported a 65-year-old woman with severe stenosis of the trachea, and right main bronchus complicated with acute respiratory failure was treated with bronchoscopy and stent implantation to improve the patient's dyspnea, thus successfully receiving chemotherapy and timely treatment. After chemotherapy, the tumor shrank and the stenosis of the trachea and right main bronchus improved. We removed the right main bronchus stent and the tracheal stent successively to improve the quality of life of the patients. We managed both the cancer and exacerbation-related factors to improve the patient's medical conditions so that the patient could receive timely and suitable treatment.

Beware of spurious tracheo-bronchial stents

OBJECTIVE

To present a case of accidental sheath removal of tracheo-bronchial self-expandable metallic airway stent in a patient with endotracheal tumour.

METHODS

Design: Case Report; Setting: Tertiary care hospital; Patient: One.

RESULTS

A 65 years male, follow up case of endotracheal tumor with tracheo-bronchial self-expandable metallic stenting done presented with dry cough and difficulty in breathing since 8-10 days and suddenly coughed out thin whitish paper-like material 2 days back (which later proved as sheath of metallic stent). Direct laryngoscopy with flexible videobronchoscopy was done which showed tracheal stent well placed and intact, coughed out sheath couldn't be replaced back. Procedure was uneventful and patient was discharged in satisfactory condition and is doing well on regular follow up.

CONCLUSION

Self-expandable metallic airway stents (SEMAS) represents a standard method of airways stenting especially when employed for the management of malignant central airway obstruction. Despite the obvious stenting advantages, it may be complicated with stent migration and accidental removal or coughing out of stent especially in high tracheal stenosis. In our case, as a peculiar complication there was accidental removal of the tracheal stent sheath which couldn't be replaced back whereas stent was well in place and intact. We need to be beware of such spurious tracheo-bronchial stents.

Use of an Insulation-Tipped Knife during Rigid Bronchoscopic Treatment of Benign Tracheobronchial Stenosis

Background and Objectives: Tracheal or bronchial tears are potential complications of rigid bronchoscopy. This study aimed to investigate the acute complications and outcomes of using an insulation-tipped (IT) knife in combination with rigid bronchoscopic dilatation for treating benign tracheobronchial stenosis. Materials and Methods: We conducted a chart review of patients with benign tracheobronchial stenosis who were treated with rigid bronchoscopy and an IT knife at two referral centers. Treatment success was defined as a clinically stable state without worsening symptoms after 3 months of treatment. Results: Of the 23 patients with benign tracheobronchial stenosis, 15 had tracheal stenosis and 6 had main bronchial stenosis. Among them, three cases were of simple stenosis (13%), while the others were of complex stenosis (87%). The overall treatment success rate was 87.0%. Pneumomediastinum and subcutaneous emphysema occurred due to bronchial laceration in two cases of distal left main bronchial stenosis (8.7%), and no other significant acute complications developed. Silicone stents were inserted in 20 patients, and successful stent removal was possible in 11 patients (55.0%). Six of the seven stents inserted in patients with post-intubation tracheal stenosis were removed successfully (85.7%). However, most of the patients with post-tracheostomy tracheal stenosis required persistent stenting (80%). Pulmonary function was significantly increased after treatment, and the mean increase in the forced expiratory volume in 1 s was 391 ± 171 mL (160–700 mL). Conclusion: The use of an IT knife can be suggested as an effective and safe modality for rigid bronchoscopic treatment of benign tracheobronchial stenosis.

Internal fixation of the proximal tracheal self-expandable metallic stent (SEMS): migration prevention in high risk patients

Airway stenting provides an important treatment option for patients with proximal tracheal stenosis. However, the risk of migration remains a major challenging problem. In our report we describe the internal fixation of SEMS in 3 patients with proximal tracheal stenosis due to variable causes. The fixation was performed in different situations including: prophylaxis to prevent the stent migration, fixation due to displacement of the stent during insertion and finally internal fixation of migrated tracheal stent.

Long-term management and outcomes of tracheobronchial stent by flexible bronchoscopy in infants <5 kg: A 13-year single-center experience

BACKGROUND

Tracheobronchial (TB) lumen narrowing may require prolonged positive-pressure ventilation, endotracheal tube intubation or even surgical interventions. Therapeutic flexible bronchoscopy (TFB) of balloon-expandable metallic stent (BEMS) placement and subsequent forceps, laser and balloon dilatation management might be less invasive and helpful. This study aimed to analyse the placement, follow-up management with TFB and long-term outcomes in small infants with BEMS.

METHODS

This retrospective study reviewed the medical records and associated TFB videos of infants with a maximum body weight (BW) of 5.0 kg who had TB BEMS placement from January 2005 to December 2017 at our institution. All TFB procedures were supported with a novel noninvasive ventilation, nasopharyngeal oxygen with intermittent nose closure and abdominal compression.

RESULTS

Forty-one BEMSs were placed in 24 infants. The mean BW and mean age were 4.0 ± 0.7 kg and 4.9 ± 2.4 months, respectively. There were 20, 8 and 13 stents located in trachea, carina and main-stem bronchi, respectively. Seven infants with 13 stents died without obvious stent-related mortality. Seven stents in five infants were successfully retrieved by rigid endoscopy (RE). At placement, the diameters of 28 tracheal and 21 bronchial stents were 7.5 ± 1.1 (4-10) and 5.4 ± 0.9 (4-8) mm, respectively. These implanted BEMSs could be gradually and significantly (p < 0.01) expanded. At the end of the follow-up period, all the remaining 21 stents in 12 infants were functional. The diameters of the 14 remaining tracheal and 13 remaining bronchial stents were 9.6 ± 2.0 (8-14) and 7.2 ± 1.4 (4-10) mm, respectively.

CONCLUSION

BEMSs are practical and effective in selected small infants with benign TB narrowing and can be safely implanted and managed with TFB, and finally retrieved by RE.

Tracheobronchial stents in palliative care: a case series and literature review

Objective

To evaluate the outcomes of tracheobronchial stenting in patients with malignant central airway obstruction and assist practitioners in palliative settings in understanding the indications, contraindications and management of tracheobronchial stents.

Methods

This retrospective study involved a consecutive case series of palliative patients with central airway obstruction secondary to inoperable cancers who underwent tracheobronchial stenting at a single institution. The European Cooperative Oncology Group (ECOG) scale was used to evaluate patient functional status before and after tracheobronchial stenting.

Results

Twenty-three patients underwent tracheobronchial stenting for malignant central airway obstruction. The majority of patients presented with symptoms of worsening dyspnoea (21 of 23; 91%). Postoperatively, there was a significant improvement in mean ECOG performance status from 2.88±0.34 to 1.58±0.50 (p<0.01). There was no intraoperative mortality resulting from tracheobronchial stenting. Five patients (21.74%) re-presented to hospital due to worsening symptoms and required emergency bronchoscopy. Two patients had stent migration, requiring stent replacement. One patient restenosed from tumour granulation, requiring microdebrider to debulk the mass. Two patients had stent failure secondary to external tumour compression, leading to death.

Conclusion

Tracheobronchial stenting is a safe and effective procedure that offers rapid palliation of symptoms and improvement in patient functional status.

A novel simple external fixation for securing silicone stent in patients with upper tracheal stenosis

Upper tracheal stenosis is considered as a potentially life-threatening condition. Silicone stenting is an attractive treatment option for patients with upper tracheal stenosis. However, its use has been compromised by a major complication, stent migration. In the report, we introduced a novel external fixation of silicone stent which only needed one puncture site and involved a silicon chip as an anchoring device. All equipment and materials including the silicon chip were available in routine bronchoscopy suite. The method had been successfully performed in three patients with upper tracheal stenosis at our institution. And the patients were monitored for over 20 months after the intervention, and no spontaneous stent migration occurred. Therefore, we believe this is a simple and reliable approach for improving the outcome of silicone stenting in patients with upper tracheal stenosis and should be introduced in clinical practice.

Flexible endoscopy for pediatric tracheobronchial metallic stent placement, maintenance and long-term outcomes

OBJECTIVES

To assess the placement, surveillance management and long-term outcomes of the tracheobronchial (TB) balloon expandable metallic stent (BEMS) managed by therapeutic flexible endoscopy (TFE).

METHODS

This is a retrospective review and analysis of all computerized medical records and related flexible endoscopy videos of pediatric patients who received TB BEMS during 20 years period, from January 1997 to December 2016. TFE techniques with forceps debridement, balloon dilatation and laser ablation were used to implant stents, perform regular surveillance, maintain their functions, and expand the diameters of BEMS. Short-length (30cm-36cm) endoscopes of OD 3.2mm to 5.0mm coupled with the noninvasive ventilation, without ventilation bag, mask or airway tube, supported the whole procedures.

RESULTS

146 BEMS were implanted in 87 consecutive children, including 84 tracheal, 15 carinal and 47 bronchial stents. At the time of placement, the mean age was 35.6 ± 54.6 month-old (range 0.3-228) and the mean body weight was 13.9 ± 10.6 kg (range 2.2-60). Surveillance period was 9.4 ± 6.7 years (range, 0.3-18.0). Satisfactory clinical improvements were noted immediately in all but two patients. Seventy-two (82.8%) patients were still alive with stable respiratory status, except two patients necessitating TFE management every two months. Fifty-one stents, including 35 tracheal and 16 bronchial ones, were successfully retrieved mainly with rigid endoscopy. Implanted stents could be significantly (< .001) further expanded for growing TB lumens. The final stent diameters were positively correlated to the implanted duration. Altogether, 33 stents expired (15 patients), 51 were retrieved (40 patients), and 62 remained and functioning well (38 patients), with their mean duration of 7.4 ± 9.5, 34.9 ± 36.3 and 82.3 ± 62.5 months, respectively.

CONCLUSION

In pediatric patients, TFE with short-length scopes coupled with this NIV support has provided a safe, feasible and effective modality in placing and subsequently managing TB BEMS with acceptable long-term outcomes.

Practical anesthetic considerations in patients undergoing tracheobronchial surgeries: a clinical review of current literature

Tracheobronchial surgeries require close cooperation and extensive communication between the anesthesia providers and the surgeons. Anesthetic management of tracheal and bronchial pathologies differ basically from regular upper airways management, due access to the patients airway is limited, mostly even practically impossible for the anesthesia providers. As a consequence, the surgeon overtakes responsibility for the airway access from the anesthesia provider in the variety of the cases. Preoperative recognition of a difficult airway, detailed planning and being aware of plan B and plan C are the elementary keys to success. Providers have to be aware, that preoperative airway assessment does not always correlate with the ease of oxygenation and ventilation. Therefore, various methods have been described in the literature and several authors have adopted unique ways to manage the airways in a successful manner. With the advancement of surgical techniques over the years, anesthetic management has also evolved tremendously to match the needs. The commonly encountered conditions requiring surgical interventions include post-intubation stenosis and foreign body aspiration. In this review we will discuss the most common pathologies of tracheobronchial lesions and specific anesthetic management considerations related to them.

A Novel Method for Insertion of the Straight Metallic Tracheal Stent

A straight metallic tracheal stent can be inserted either during flexible or rigid bronchoscopy. However, in patients with significant airway obstruction or those requiring tumor debulking, rigid bronchoscopy is the method of choice. A tracheoscope size 12 or larger is generally required for the introduction of the straight metallic tracheal stent. Herein, we describe a novel method that facilitates the introduction of the straight metallic tracheal stent through a size 8.5 tracheoscope by using the introducer tube of the silicone stent applicator.

Mechanical properties of different airway stents

Airway stents improve pulmonary function and quality of life in patients suffering from airway obstruction. The aim of this study was to compare main types of stents (silicone, balloon-dilated metal, self-expanding metal, and covered self-expanding metal) in terms of their mechanical properties and the radial forces they exert on the trachea. Mechanical measurements were carried out using a force gauge and specially designed adaptors fabricated in our lab. Numerical simulations were performed for eight different stent geometries, inserted into trachea models. The results show a clear correlation between stent diameter (oversizing) and the levels of stress it exerts on the trachea. Compared with uncovered metal stents, metal stents that are covered with less stiff material exert significantly less stress on the trachea while still maintaining strong contact with it. The use of such stents may reduce formation of mucosa necrosis and fistulas while still preventing stent migration. Silicone stents produce the lowest levels of stress, which may be due to weak contact between the stent and the trachea and can explain their propensity for migration. Unexpectedly, stents made of the same materials exerted different stresses due to differences in their structure. Stenosis significantly increases stress levels in all stents.

Use of combined suspension laryngoscopy and jet ventilation for Y-shaped airway stents delivery

Airway stenting is a common endoscopic procedure that is used to treat a variety of central airway lesions. Obstructions or fistulas involving the carina or nearby tracheobronchial structures require the use of specially designed stents, commonly referred to as Y-stents. Conventional methods of endobronchial Y-stent delivery are all characterized by a blind and apneic period during the procedure that carries the risk of stent misplacement or ventilation/oxygenation problems or both. Using combined suspension laryngoscopy, flexible bronchoscopy, and jet ventilation, we describe a technique that makes challenging bronchoscopic interventions--such as self-expandable Y-shaped airway stent delivery--easy, precise, and safe.

Indications and interventional options for non-resectable tracheal stenosis

Non-specific presentation and normal examination findings in early disease often result in tracheal obstruction being overlooked as a diagnosis until patients present acutely. Once diagnosed, surgical options should be considered, but often patient co-morbidity necessitates other interventional options. Non-resectable tracheal stenosis can be successfully managed by interventional bronchoscopy, with therapeutic options including airway dilatation, local tissue destruction and airway stenting. There are common aspects to the management of tracheal obstruction, tracheomalacia and tracheal fistulae. This paper reviews the pathogenesis, presentation, investigation and management of tracheal disease, with a focus on tracheal obstruction and the role of endotracheal intervention in management.

Endoscopic removal of a self-expanding metallic airway stent: A case report

Self-expanding metallic stents are sometimes placed for the management of obstructing airway lesions or conditions such as airway wall malacia or tracheal stenosis. However, endoscopic removal of these devices from the airway can pose extreme challenges for both clinical airway management as well as for the administration of general anesthesia. We report on a 61-year-old man with a complex cardiac history presenting for endoscopic stent removal necessitated by the formation of extensive granulation tissue. Comorbidities included a history of myocardial infarction, an ischemic cardiomyopathy with severe left heart failure (ejection fraction of 25%), mild right heart failure, 2+ tricuspid regurgitation status post tricuspid valve repair, and atrial fibrillation. An automatic external (wearable) cardiac defibrillator (Zoll Life Vest) was also in place. Induction of anesthesia was carried out using etomidate, with maintenance of anesthesia carried out with a propofol infusion (total intravenous anesthesia). Rocuronium was used for neuromuscular blockade. A size 4 iGel supraglottic airway and, later, rigid bronchoscopy formed the basis for airway management. Stable conditions were met through the 2-h procedure, and the patient recovered uneventfully. Our successful experience in this case leads us to propose further use of a supraglottic airway in conjunction with total intravenous anesthesia for these procedures.

Endobronchial valves for advanced emphysema: an endobronchial follow-up

Lung volume reduction surgery is a therapeutic option for selected patients with advanced emphysema. However, it is an invasive procedure benefitting only a selected group of patients with heterogeneous upper lobe predominant disease and limited exercise capacity. The most widely studied alternatives are endobronchial valves. Hundreds of patients worldwide have undergone endobronchial valve placement. Although short-term outcomes have been described, little is known about the long-term side effects following this treatment, and endoscopic follow-up is virtually nonexistent. The images, biopsies, and microbiologic evidence accrued from this patient are witnesses to the natural evolution of endobronchial valves in the airways and should offer a word of caution with regard to valve placement in patients with life expectancies exceeding those typical of severe chronic obstructive lung disease.

Dynamic Y stent fractures in crescentic tracheobronchomalacia

Endobronchial stents have been used occasionally to treat benign conditions such as tracheobronchomalacia (TBM). This report describes a unique case of a patient with crescentic TBM in whom Dynamic Y stent was placed on 2 separate occasions to control symptoms and resulted in identical posterior wall stent fractures within a year of stent placement, both times. A silicone Y stent was substituted for the dynamic stent, and it has been effective in controlling symptoms for 9 months without complications. A literature review of cases of fractured Dynamic Y stents is made and factors affecting the choice of stent type for crescentic TBM are explored.

Multidetector CT and postprocessing in planning and assisting in minimally invasive bronchoscopic airway interventions

A widening spectrum of increasingly advanced bronchoscopic techniques is available for the diagnosis and treatment of various bronchopulmonary diseases. The evolution of computed tomography (CT)-multidetector CT in particular-has paralleled these advances. The resulting development of two-dimensional and three-dimensional (3D) postprocessing techniques has complemented axial CT interpretation in providing more anatomically familiar information to the pulmonologist. Two-dimensional techniques such as multiplanar recontructions and 3D techniques such as virtual bronchoscopy can provide accurate guidance for increasing yield in transbronchial needle aspiration and transbronchial biopsy of mediastinal and hilar lymph nodes. Sampling of lesions located deeper within the lung periphery via bronchoscopic pathways determined at virtual bronchoscopy are also increasingly feasible. CT fluoroscopy for real-time image-guided sampling is now widely available; electromagnetic navigation guidance is being used in select centers but is currently more costly. Minimally invasive bronchoscopic techniques for restoring airway patency in obstruction caused by both benign and malignant conditions include mechanical strategies such as airway stent insertion and ablative techniques such as electrocauterization and cryotherapy. Multidetector CT postprocessing techniques provide valuable information for planning and surveillance of these treatment methods. In particular, they optimize the evaluation of dynamic obstructive conditions such as tracheobronchomalacia, especially with the greater craniocaudal coverage now provided by wide-area detectors. Multidetector CT also provides planning information for bronchoscopic treatment of bronchopleural fistulas and bronchoscopic lung volume reduction for carefully selected patients with refractory emphysema.

Anesthesia for Tracheobronchial Surgery

The airway is a crucial dynamic structure that spans different anatomical zones, including the intrathoracic, extrathoracic, tracheal, bronchial, and alveolar zones. Because of its vital role as the sole oxygen-conducting pathway to the alveoli, and hence to the human body, surgery involving any portion requires careful and specific planning by both the surgeon and the anesthesiologist. The review covers essential management points for proximal and distal tracheal procedures, including a discussion of tracheal stenting and tracheoplasty.

Clinical experience of rigid bronchoscopy in single center

Background

The aim of this study was to analyze clinical situations requiring rigid bronchoscopy and evaluate usefulness of rigid bronchoscopic intervention in benign or malignant airway disorders.

Methods

We retrospectively reviewed 29 patients who underwent rigid bronchoscopy from November 2007 to February 2011 at St. Paul's Hospital, The Catholic University of Korea School of Medicine.

Results

Of the 29 patients, the most frequent underlying etiology was benign stenosis of trachea (n=20). Of those 20 patients, 16 had post-intubation tracheal stenosis (PITS), 2 had tracheal stenosis due to inhalation burn (IBTS) and other 2 had obstructive fibrinous tracheal pseudomembrane (OFTP). Other etiologies were airway malignancy (n=6), endobronchial stenosis due to tuberculosis (n=2), and foreign body (n=1). For treatment, silicone stent insertion was done in 16 cases of PITS and IBTS and mechanical removal was performed in 2 cases of OFTP. In 6 cases of malignant airway obstruction mechanical debulking was performed and silicone stents were inserted additionally in 2 cases. Balloon dilatation and electrocautery were used in 2 cases of endobronchial stenosis due to tuberculosis. In all cases of stent, airway obstructive symptom improved immediately. Granulation tissue formation was the most common complication.

Conclusion

Tracheal stenosis was most common indication and silicone stenting was most common procedure of rigid bronchoscopy in our center. Rigid bronchoscopic procedures, at least tracheal silicone stenting, should be included in pulmonary medicine fellowship programs because it is a very effective and indispensable method to relieve critical airway obstruction which needs training to learn.

Airway fire injury during rigid bronchoscopy in a patient with a silicon stent -A case report-

Therapeutic bronchoscopy is widely employed as an effective first-line treatment for patients with central airway obstructions. Airway fires during rigid bronchoscopy are rare, but can have potentially devastating consequences. Pulmonologist and anesthesiologist undertaking this type of procedure should be aware of this serious problem and be familiar with measures to avoid this possibly fatal complication. We report the case of a 24-year-old patient with a silicone stent who experienced an electrocautery-induced airway fire during rigid bronchoscopy.

Interventional management of tracheobronchial strictures

Tracheobronchial balloon dilation and stent placement have been well used in the treatment of patients with benign and/or malignant diseases. Balloon dilation is the first option in the treatment of benign airway stenosis. Although balloon dilation is simple and fast, recurrence rate is high. Stent placement promptly relieves acute airway distress from malignant extraluminal and intraluminal airway obstruction. Temporary stent placement may be an alternative for benign airway strictures refractory to balloon dilation. This article reviews the indications, pre-procedure evaluation, technique, outcomes and complications of balloon dilation and stent placement with regard to benign and malignant tracheobronchial stenoses.