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Omori H, Wakasaki T, Hongo T, Rikimaru F, Toh S, Higaki Y, Masuda M. Acquired tracheobronchomalacia developed following voice prosthesis implantation. Auris Nasus Larynx 2024; 51:433-436. [PMID: 38520973 DOI: 10.1016/j.anl.2023.12.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2023] [Revised: 12/06/2023] [Accepted: 12/20/2023] [Indexed: 03/25/2024]
Abstract
Acquired tracheobronchomalacia (ATBM) is a condition in which the tracheobronchial wall and cartilage progressively lose their rigidity, resulting in dynamic collapse during exhalation. In this report, we present a case of ATBM that developed following voice prosthesis implantation. To the best of our knowledge, this is the first documented case of such a condition in the medical English literature based on a PubMed search. A 63-year-old man was referred to National Kyushu Cancer Center in Japan with complaints of pharyngeal pain and a laryngeal tumor. The tumor was diagnosed as laryngeal cancer, and the patient underwent laryngectomy. Three months after the surgery, we implanted a voice prosthesis through a tracheoesophageal puncture. Two months after implantation, the patient experienced dyspnea. This condition was subsequently diagnosed as ATBM through computed tomography and bronchofiberscope examinations. After the removal of the voice prosthesis, there has been no progression of ATBM for over five years. While ATBM may not be a common occurrence in the practice of head and neck surgeons, it should be considered as a potential complication when patients report dyspnea following voice prosthesis implantation.
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Affiliation(s)
- Hirofumi Omori
- Department of Head and Neck Surgery, National Kyushu Cancer Center, 3-1-1 Notame, Minami-ku, Fukuoka 811-1395, Japan.
| | - Takahiro Wakasaki
- Department of Head and Neck Surgery, National Kyushu Cancer Center, 3-1-1 Notame, Minami-ku, Fukuoka 811-1395, Japan
| | - Takahiro Hongo
- Department of Head and Neck Surgery, National Kyushu Cancer Center, 3-1-1 Notame, Minami-ku, Fukuoka 811-1395, Japan
| | - Fumihide Rikimaru
- Department of Head and Neck Surgery, National Kyushu Cancer Center, 3-1-1 Notame, Minami-ku, Fukuoka 811-1395, Japan
| | - Satoshi Toh
- Department of Head and Neck Surgery, National Kyushu Cancer Center, 3-1-1 Notame, Minami-ku, Fukuoka 811-1395, Japan
| | - Yuichiro Higaki
- Department of Head and Neck Surgery, National Kyushu Cancer Center, 3-1-1 Notame, Minami-ku, Fukuoka 811-1395, Japan
| | - Muneyuki Masuda
- Department of Head and Neck Surgery, National Kyushu Cancer Center, 3-1-1 Notame, Minami-ku, Fukuoka 811-1395, Japan
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Geraci TC, Chan J, Angel L, Chang SH. Concurrent tracheobronchoplasty and bilateral lung transplant for obstructive lung disease. JTCVS Tech 2024; 23:182-183. [PMID: 38351993 PMCID: PMC10859567 DOI: 10.1016/j.xjtc.2023.11.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2023] [Revised: 10/22/2023] [Accepted: 10/30/2023] [Indexed: 02/16/2024] Open
Affiliation(s)
- Travis C. Geraci
- Division of Thoracic Surgery, Department of Cardiothoracic Surgery, NYU Langone Health, New York, NY
| | - Justin Chan
- Division of Thoracic Surgery, Department of Cardiothoracic Surgery, NYU Langone Health, New York, NY
| | - Luis Angel
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, NYU Langone Health, New York, NY
| | - Stephanie H. Chang
- Division of Thoracic Surgery, Department of Cardiothoracic Surgery, NYU Langone Health, New York, NY
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3
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Santos Portela AM, Radu DM, Onorati I, Peretti M, Freynet O, Uzunhan Y, Jerbi S, Martinod E. [Interventionnal bronchoscopy for the treatment of tracheobronchomalacia]. Rev Mal Respir 2023; 40:700-715. [PMID: 37714754 DOI: 10.1016/j.rmr.2023.07.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2023] [Accepted: 07/18/2023] [Indexed: 09/17/2023]
Abstract
Tracheobronchomalacia is usually characterized by more than 50% expiratory narrowing in diameter of the trachea and the bronchi. The expiratory collapse includes two entities: (1) the TBM related to the weakness of the cartilaginous rings, and (2) the Excessive Dynamic Airway Collapse (EDAC) due to the excessive bulging of the posterior membrane. Patients have nonspecific respiratory symptoms like dyspnea and cough. Diagnosis is confirmed by dynamic tests: flexible bronchoscopy and/or computed tomographic scan of the chest. There are different forms of tracheobronchomalacia in adults: primary (genetic, idiopathic) or secondary to trauma, tracheotomy, intubation, surgery, transplantation, emphysema, infection, inflammation, chronic bronchitis, extrinsic compression; or undiagnosed in childhood vascular rings. Some management algorithms have been proposed, but no specific recommendation was established. Only symptomatic patients should be treated. Medical treatments and noninvasive positive pressure ventilation should be the first line therapy, after evaluation of various quality measures (functional status, performance status, dyspnea and quality of life scores). If symptoms persist, therapeutic bronchoscopy permits: (1) patient's selection by stent trial to determine whether patient benefit for surgical airway stabilization; (2) malacic airways stenting in patients who are not surgical candidates, improving QOL despite a high complication rate; (3) the management of stent-related complication (obstruction, plugging, migration granuloma); (4) alternative therapeutics like thermo-ablative solution. Lasty, the development of new types of stents would reduce the complication rates. These different options remained discussed.
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Affiliation(s)
- A M Santos Portela
- Département de chirurgie thoracique et vasculaire, faculté de médecine SMBH, Assistance publique-Hôpitaux de Paris, hôpitaux universitaires Paris Seine-Saint-Denis, hôpital Avicenne, université Sorbonne Paris Nord, Bobigny, France
| | - D M Radu
- Département de chirurgie thoracique et vasculaire, faculté de médecine SMBH, Assistance publique-Hôpitaux de Paris, hôpitaux universitaires Paris Seine-Saint-Denis, hôpital Avicenne, université Sorbonne Paris Nord, Bobigny, France
| | - I Onorati
- Département de chirurgie thoracique et vasculaire, faculté de médecine SMBH, Assistance publique-Hôpitaux de Paris, hôpitaux universitaires Paris Seine-Saint-Denis, hôpital Avicenne, université Sorbonne Paris Nord, Bobigny, France
| | - M Peretti
- Département de chirurgie thoracique et vasculaire, faculté de médecine SMBH, Assistance publique-Hôpitaux de Paris, hôpitaux universitaires Paris Seine-Saint-Denis, hôpital Avicenne, université Sorbonne Paris Nord, Bobigny, France
| | - O Freynet
- Département de pneumologie, faculté de Médecine SMBH, Assistance publique-Hôpitaux de Paris, hôpitaux universitaires Paris Seine-Saint-Denis, hôpital Avicenne, université Sorbonne Paris Nord, Bobigny, France
| | - Y Uzunhan
- Département de pneumologie, faculté de Médecine SMBH, Assistance publique-Hôpitaux de Paris, hôpitaux universitaires Paris Seine-Saint-Denis, hôpital Avicenne, université Sorbonne Paris Nord, Bobigny, France
| | - S Jerbi
- Département d'anesthésie, faculté de médecine SMBH, Assistance publique-Hôpitaux de Paris, hôpitaux universitaires Paris Seine-Saint-Denis, hôpital Avicenne, université Sorbonne Paris Nord, Bobigny, France
| | - E Martinod
- Département de chirurgie thoracique et vasculaire, faculté de médecine SMBH, Assistance publique-Hôpitaux de Paris, hôpitaux universitaires Paris Seine-Saint-Denis, hôpital Avicenne, université Sorbonne Paris Nord, Bobigny, France.
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4
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Lazzaro R, Kontopidis I, Medina BD. Just breathe: 12-step robotic tracheobronchoplasty. JTCVS Tech 2023; 21:239-243. [PMID: 37854802 PMCID: PMC10579873 DOI: 10.1016/j.xjtc.2023.05.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2023] [Revised: 05/22/2023] [Accepted: 05/26/2023] [Indexed: 10/20/2023] Open
Affiliation(s)
- Richard Lazzaro
- Division of Thoracic Surgery, Department of Surgery, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ
| | - Ioannis Kontopidis
- Division of Thoracic Surgery, Department of Surgery, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ
| | - Benjamin D. Medina
- Division of Thoracic Surgery, Department of Surgery, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ
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5
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Lazzaro R, Inra ML. Tracheobronchoplasty: Indications and Best Approaches. Thorac Surg Clin 2023; 33:141-147. [PMID: 37045483 DOI: 10.1016/j.thorsurg.2023.01.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/14/2023]
Abstract
Tracheobronchomalacia (TBM) is an increasingly recognized abnormality of the central airways in patients with respiratory symptoms. Severe TBM in symptomatic patients warrants screening dynamic CT of the chest and/or awake dynamic bronchoscopy. The goal of surgical repair is to restore the C-shaped configuration of the airway lumen and splint or secure the lax posterior membrane to the mesh to ameliorate symptoms. Robotic tracheobronchoplasty is safe and associated with improvements in pulmonary function and subjective improvement in quality of life.
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Affiliation(s)
- Richard Lazzaro
- Thoracic Surgery, Southern Region Robert Wood Johnson Barnabas Health, 1 Robert Wood Johnson Pl, New Brunswick, NJ 08901, USA.
| | - Matthew L Inra
- 130 East 77th Street, 4th Floor, New York, NY 10075, USA
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Aslam A, De Luis Cardenas J, Morrison RJ, Lagisetty KH, Litmanovich D, Sella EC, Lee E, Agarwal PP. Tracheobronchomalacia and Excessive Dynamic Airway Collapse: Current Concepts and Future Directions. Radiographics 2022; 42:1012-1027. [PMID: 35522576 DOI: 10.1148/rg.210155] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Tracheobronchomalacia (TBM) and excessive dynamic airway collapse (EDAC) are airway abnormalities that share a common feature of expiratory narrowing but are distinct pathophysiologic entities. Both entities are collectively referred to as expiratory central airway collapse (ECAC). The malacia or weakness of cartilage that supports the tracheobronchial tree may occur only in the trachea (ie, tracheomalacia), in both the trachea and bronchi (TBM), or only in the bronchi (bronchomalacia). On the other hand, EDAC refers to excessive anterior bowing of the posterior membrane into the airway lumen with intact cartilage. Clinical diagnosis is often confounded by comorbidities including asthma, chronic obstructive pulmonary disease, obesity, hypoventilation syndrome, and gastroesophageal reflux disease. Additional challenges include the underrecognition of ECAC at imaging; the interchangeable use of the terms TBM and EDAC in the literature, which leads to confusion; and the lack of clear guidelines for diagnosis and treatment. The use of CT is growing for evaluation of the morphology of the airway, tracheobronchial collapsibility, and extrinsic disease processes that can narrow the trachea. MRI is an alternative tool, although it is not as widely available and is not used as frequently for this indication as is CT. Together, these tools not only enable diagnosis, but also provide a road map to clinicians and surgeons for planning treatment. In addition, CT datasets can be used for 3D printing of personalized medical devices such as stents and splints. An invited commentary by Brixey is available online. Online supplemental material is available for this article. ©RSNA, 2022.
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Affiliation(s)
- Anum Aslam
- From the Department of Radiology, Division of Cardiothoracic Imaging (A.A., E.C.S., E.L., P.P.A.), Division of Pulmonary and Critical Care Medicine, Department of Medicine, Section of Thoracic Surgery, Department of Surgery (J.D.L.C.), Department of Otolaryngology-Head and Neck Surgery (R.J.M.), Department of Surgery (K.H.L.), Michigan Medicine, 1500 E Medical Center Dr, Ann Arbor, MI 48109; Department of Surgery, Ann Arbor Veterans Hospital, Ann Arbor, Mich (K.H.L.); and Department of Radiology, Division of Cardiothoracic Imaging, Beth Israel Deaconess Medical Center, Boston, Mass (D.L.)
| | - Jose De Luis Cardenas
- From the Department of Radiology, Division of Cardiothoracic Imaging (A.A., E.C.S., E.L., P.P.A.), Division of Pulmonary and Critical Care Medicine, Department of Medicine, Section of Thoracic Surgery, Department of Surgery (J.D.L.C.), Department of Otolaryngology-Head and Neck Surgery (R.J.M.), Department of Surgery (K.H.L.), Michigan Medicine, 1500 E Medical Center Dr, Ann Arbor, MI 48109; Department of Surgery, Ann Arbor Veterans Hospital, Ann Arbor, Mich (K.H.L.); and Department of Radiology, Division of Cardiothoracic Imaging, Beth Israel Deaconess Medical Center, Boston, Mass (D.L.)
| | - Robert J Morrison
- From the Department of Radiology, Division of Cardiothoracic Imaging (A.A., E.C.S., E.L., P.P.A.), Division of Pulmonary and Critical Care Medicine, Department of Medicine, Section of Thoracic Surgery, Department of Surgery (J.D.L.C.), Department of Otolaryngology-Head and Neck Surgery (R.J.M.), Department of Surgery (K.H.L.), Michigan Medicine, 1500 E Medical Center Dr, Ann Arbor, MI 48109; Department of Surgery, Ann Arbor Veterans Hospital, Ann Arbor, Mich (K.H.L.); and Department of Radiology, Division of Cardiothoracic Imaging, Beth Israel Deaconess Medical Center, Boston, Mass (D.L.)
| | - Kiran H Lagisetty
- From the Department of Radiology, Division of Cardiothoracic Imaging (A.A., E.C.S., E.L., P.P.A.), Division of Pulmonary and Critical Care Medicine, Department of Medicine, Section of Thoracic Surgery, Department of Surgery (J.D.L.C.), Department of Otolaryngology-Head and Neck Surgery (R.J.M.), Department of Surgery (K.H.L.), Michigan Medicine, 1500 E Medical Center Dr, Ann Arbor, MI 48109; Department of Surgery, Ann Arbor Veterans Hospital, Ann Arbor, Mich (K.H.L.); and Department of Radiology, Division of Cardiothoracic Imaging, Beth Israel Deaconess Medical Center, Boston, Mass (D.L.)
| | - Diana Litmanovich
- From the Department of Radiology, Division of Cardiothoracic Imaging (A.A., E.C.S., E.L., P.P.A.), Division of Pulmonary and Critical Care Medicine, Department of Medicine, Section of Thoracic Surgery, Department of Surgery (J.D.L.C.), Department of Otolaryngology-Head and Neck Surgery (R.J.M.), Department of Surgery (K.H.L.), Michigan Medicine, 1500 E Medical Center Dr, Ann Arbor, MI 48109; Department of Surgery, Ann Arbor Veterans Hospital, Ann Arbor, Mich (K.H.L.); and Department of Radiology, Division of Cardiothoracic Imaging, Beth Israel Deaconess Medical Center, Boston, Mass (D.L.)
| | - Edith Carolina Sella
- From the Department of Radiology, Division of Cardiothoracic Imaging (A.A., E.C.S., E.L., P.P.A.), Division of Pulmonary and Critical Care Medicine, Department of Medicine, Section of Thoracic Surgery, Department of Surgery (J.D.L.C.), Department of Otolaryngology-Head and Neck Surgery (R.J.M.), Department of Surgery (K.H.L.), Michigan Medicine, 1500 E Medical Center Dr, Ann Arbor, MI 48109; Department of Surgery, Ann Arbor Veterans Hospital, Ann Arbor, Mich (K.H.L.); and Department of Radiology, Division of Cardiothoracic Imaging, Beth Israel Deaconess Medical Center, Boston, Mass (D.L.)
| | - Elizabeth Lee
- From the Department of Radiology, Division of Cardiothoracic Imaging (A.A., E.C.S., E.L., P.P.A.), Division of Pulmonary and Critical Care Medicine, Department of Medicine, Section of Thoracic Surgery, Department of Surgery (J.D.L.C.), Department of Otolaryngology-Head and Neck Surgery (R.J.M.), Department of Surgery (K.H.L.), Michigan Medicine, 1500 E Medical Center Dr, Ann Arbor, MI 48109; Department of Surgery, Ann Arbor Veterans Hospital, Ann Arbor, Mich (K.H.L.); and Department of Radiology, Division of Cardiothoracic Imaging, Beth Israel Deaconess Medical Center, Boston, Mass (D.L.)
| | - Prachi P Agarwal
- From the Department of Radiology, Division of Cardiothoracic Imaging (A.A., E.C.S., E.L., P.P.A.), Division of Pulmonary and Critical Care Medicine, Department of Medicine, Section of Thoracic Surgery, Department of Surgery (J.D.L.C.), Department of Otolaryngology-Head and Neck Surgery (R.J.M.), Department of Surgery (K.H.L.), Michigan Medicine, 1500 E Medical Center Dr, Ann Arbor, MI 48109; Department of Surgery, Ann Arbor Veterans Hospital, Ann Arbor, Mich (K.H.L.); and Department of Radiology, Division of Cardiothoracic Imaging, Beth Israel Deaconess Medical Center, Boston, Mass (D.L.)
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Ratwani AP, Davis A, Maldonado F. Current practices in the management of central airway obstruction. Curr Opin Pulm Med 2022; 28:45-51. [PMID: 34720097 DOI: 10.1097/mcp.0000000000000838] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
PURPOSE OF REVIEW Airway obstruction continues to cause substantial pulmonary morbidity and mortality. We present a review of classic, current, and evolving management techniques, highlighting recently published studies on the topic. Recommendations have historically been primarily based on anecdotal experience, case reports, and retrospective studies, but more solid evidence has emerged in the last decade. RECENT FINDINGS Novel endobronchial stents are being developed to mitigate the issues of stent migration, mucus plugging, fracture, and granulation tissue formation. Endobronchial drug delivery has become an active area of translational and clinical research, especially with regards to antineoplastic agents used for malignant airway stenosis. Even classic or updated techniques such as spray cryotherapy, injections of mitomycin-c, and balloon dilation have recently been examined in methodologically sound studies. Finally, recently published data have confirmed that patient breathlessness and quality of life improve significantly with therapeutic airway interventions. A multimodal and multidisciplinary approach to patient care is key to achieving the best outcomes. SUMMARY The treatment of central airway stenosis is often multimodal and should focus on patient-centric factors, taking into account risks and benefits of the procedure, operator, and center expertise, and always occur in the context of a multidisciplinary approach. Evidence-based clinical research is increasingly driving patient management.
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Affiliation(s)
| | - Andrea Davis
- Department of Internal Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
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Crespo MM. Airway complications in lung transplantation. J Thorac Dis 2021; 13:6717-6724. [PMID: 34992847 PMCID: PMC8662498 DOI: 10.21037/jtd-20-2696] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2021] [Accepted: 07/13/2021] [Indexed: 12/03/2022]
Abstract
Airway complications (ACs) after lung transplantation remain an important source of morbidity and mortality despite significant advances in the surgical technics, leading to increased cost, and decrease quality of life. The incidences of ACs after lung transplantation range from 2% to 33%, even though most transplant centers have reported rates in the range of 7% to 8%. However, the reported rate of ACs has been inconsistent as a result of a lack of standardized airway definitions and grading protocols before the recent 2018 International Society for Heart and Lung Transplantation (ISHLT) proposed consensus guidelines on ACs after lung transplantation. The ACs include stenosis, perioperative and postoperative bronchial infections, bronchial necrosis and dehiscence, excess granulation tissue, and tracheobronchomalacia (TBM). Anastomosis infection, necrosis, or dehiscence typically develops within the first month after lung transplantation. The most frequent AC after lung transplantation is bronchial stenosis. Several risk factors have been proposed to the development of ACs after lung transplantation, including surgical anastomosis techniques, hypoperfusion, infections, donor and recipient factors, immunosuppression agents, and organ preservation. ACs might be prevented by early recognition of the airway pathology, using advance medical management, and interventional bronchoscopy procedures. Balloon bronchoplasty, cryotherapy, laser photo resection, electrocautery, high-dose endobronchial brachytherapy, and bronchial stents placement are the most frequent interventional bronchoscopic procedures utilized for the management of ACs.
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Affiliation(s)
- Maria M Crespo
- Pulmonary, Allergy and Critical Care Division, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
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Lazzaro RS, Patton BD, Wasserman GA, Karp J, Cohen S, Inra ML, Scheinerman SJ. Robotic-assisted tracheobronchoplasty: Quality of life and pulmonary function assessment on intermediate follow-up. J Thorac Cardiovasc Surg 2021; 164:278-286. [PMID: 34340852 DOI: 10.1016/j.jtcvs.2021.07.012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2020] [Revised: 07/01/2021] [Accepted: 07/07/2021] [Indexed: 12/30/2022]
Abstract
OBJECTIVE The initial description of robotic tracheobronchoplasty for the treatment of tracheobronchomalacia demonstrated feasibility, safety, and short-term symptomatic and functional improvement. The purpose of the current study was to demonstrate intermediate outcomes in postoperative pulmonary function and quality of life after robotic tracheobronchoplasty. METHODS We retrospectively reviewed prospectively collected clinical data from 42 patients who underwent robotic tracheobronchoplasty from May 2016 to December 2017. The Institutional Review Board or equivalent ethics committee of the Northwell Health approved the study protocol and publication of data. Patient written consent for the publication of the study data was waived by the Institutional Review Board. RESULTS A total of 42 patients underwent robotic tracheobronchoplasty during the study period. Median total follow-up is 40 months. There was 1 death since surgery from an unrelated disease. Significant decreases in St George's Respiratory Questionnaire total score (preoperative mean: 64.01, postoperative mean: 38.91, P = .002), St George's Respiratory Questionnaire symptom score (preoperative median: 82.6, postoperative median: 43.99, P < .001), and St George's Respiratory Questionnaire impact score (preoperative median: 55.78, postoperative median: 25.95, P < .001) were apparent at a median follow-up of 13 months. Comparison of preoperative and postoperative pulmonary function tests revealed a significant increase in percent predicted forced expiratory volume in 1 second (preoperative median: 74% vs postoperative median: 82%, P = .001), forced vital capacity (preoperative median: 68.5% vs postoperative median: 80.63%, P < .001), and peak expiratory flow (preoperative median: 61.5% vs postoperative median: 75%, P = .02) measured at a median follow-up of 29 months. CONCLUSIONS Robotic tracheobronchoplasty is associated with low intermediate-term mortality. Robotic tracheobronchoplasty results in significant improvement in quality of life and postoperative pulmonary function. Longer-term follow-up is necessary to continue to elucidate the effect of robotic tracheobronchoplasty on halting pathologic progression of tracheobronchomalacia and to determine the long-term impact of tracheobronchoplasty on symptomatic and functional improvement.
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Affiliation(s)
- Richard S Lazzaro
- Department of Cardiovascular and Thoracic Surgery, Northwell Health Lenox Hill Hospital, New York, NY; Donald and Barbara Zucker School of Medicine at Hofstra Northwell, Hempstead, NY.
| | - Byron D Patton
- Department of Cardiovascular and Thoracic Surgery, Northwell Health Lenox Hill Hospital, New York, NY; Donald and Barbara Zucker School of Medicine at Hofstra Northwell, Hempstead, NY
| | - Gregory A Wasserman
- Department of Cardiovascular and Thoracic Surgery, Northwell Health Lenox Hill Hospital, New York, NY
| | - Jason Karp
- Department of Cardiovascular and Thoracic Surgery, Northwell Health Lenox Hill Hospital, New York, NY; Department of Pulmonary Medicine, North Shore University Hospital, Manhasset, NY
| | - Stuart Cohen
- Department of Cardiovascular and Thoracic Surgery, Northwell Health Lenox Hill Hospital, New York, NY; Department of Radiology, Northwell Health, North Shore University Hospital, Manhasset, NY
| | - Matthew L Inra
- Department of Cardiovascular and Thoracic Surgery, Northwell Health Lenox Hill Hospital, New York, NY; Donald and Barbara Zucker School of Medicine at Hofstra Northwell, Hempstead, NY
| | - S Jacob Scheinerman
- Department of Cardiovascular and Thoracic Surgery, Northwell Health Lenox Hill Hospital, New York, NY; Donald and Barbara Zucker School of Medicine at Hofstra Northwell, Hempstead, NY
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10
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Lui NS, Guo HH, Sung AW, Peterson A, Kulkarni VN. Single-Lumen Endotracheal Tube and Bronchial Blocker for Airway Management During Tracheobronchoplasty for Tracheobronchomalacia: A Case Report. A A Pract 2020; 13:236-239. [PMID: 31385817 PMCID: PMC6749959 DOI: 10.1213/xaa.0000000000001076] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
We present a case of a 69-year-old man who underwent tracheobronchoplasty for tracheobronchomalacia using a single-lumen endotracheal tube and a Y-shaped bronchial blocker for airway management. Tracheobronchoplasty is performed by sewing mesh to plicate the posterior, membranous wall of the distal trachea and main bronchi through a right posterolateral thoracotomy. The goals of airway management include continuous left-lung ventilation and lung protection from aspiration. Ideally, only conventional airway management tools are used. This case demonstrates that a single-lumen endotracheal tube with a bronchial blocker can be a straightforward strategy for airway management during tracheobronchoplasty.
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Affiliation(s)
| | | | | | - Ashley Peterson
- Anesthesiology, Perioperative and Pain Medicine, Stanford University, Stanford, California
| | - Vivekanand N Kulkarni
- Anesthesiology, Perioperative and Pain Medicine, Stanford University, Stanford, California
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11
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A successful surgical tracheobronchoplasty in a case of expiratory collapse of central airways associated with tracheobronchomalacia in a severely deformed single lung patient. Gen Thorac Cardiovasc Surg 2020; 69:756-761. [PMID: 33164133 DOI: 10.1007/s11748-020-01542-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2020] [Accepted: 10/25/2020] [Indexed: 10/23/2022]
Abstract
A 67-year-old male with a severe body deformity and a total collapse of the left lung due to infantile paralysis was admitted to a regional hospital for a spinal fracture. He suffered from cardiopulmonary arrest during the hospitalization. Although extubation was tried several times after resuscitation, he went into cardiopulmonary arrest repeatedly. The expiratory collapse of the central airways due to tracheobronchomalacia was suspected, requiring tracheostomy with persistent positive pressure ventilation. He was transferred to our hospital after several unsuccessful endobronchial interventions. Severe tracheobronchomalacia was diagnosed with dynamic bronchoscopy, and surgical tracheobronchoplasty using a polypropylene mesh was performed. A modified surgical approach was utilized to stabilize the intraoperative respiratory status in this particular patient with a severely deformed body and a single lung. Consequently, the tracheobronchoplasty was completed without intraoperative complications. The postoperative course was also uneventful, and the patient was ventilator-free on postoperative day 7.
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12
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Thoracoscopic plication of the membranous portion of crescent-type tracheobronchomalacia in an elderly patient: a case report. Surg Case Rep 2020; 6:65. [PMID: 32253512 PMCID: PMC7136378 DOI: 10.1186/s40792-020-00831-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2020] [Accepted: 03/31/2020] [Indexed: 11/10/2022] Open
Abstract
Background It is presumed that tracheobronchomalacia in adults is caused by airway pressure-induced injury due to chronic cough related to pulmonary emphysema or chronic bronchitis. Commonly, a posterolateral approach using stabilizing materials is the surgical technique of choice for treating tracheobronchomalacia. We report a case in which thoracoscopic plication of the membranous portion was performed instead of airway stent placement for tracheobronchomalacia in an elderly individual. Case presentation An 87-year-old man who had been treated for bronchial asthma, pulmonary emphysema, and tracheobronchomalacia was admitted to our hospital with acute exacerbation of dyspnea. The patient underwent tracheal intubation, which was followed by tracheostomy 16 days later. Insertion of the tip of the adjustable-length tracheostomy tube to the end of the stenotic lesion enabled him to breathe spontaneously. However, conservative management failed due to recurrent pneumonia caused by the tracheobronchomalacia. Crescent-type tracheobronchomalacia (Johnson’s classification grade III) was diagnosed, and the main narrowed area of the trachea was assumed to be approximately 3–10 cm from the tracheal bifurcation. A thoracoscopic approach was selected because a posterolateral approach was considered too invasive considering the patient’s age and general condition. We placed eight stitches on the tracheal membranous portion and four stitches on the membranous portion of the right main bronchus, using the horizontal mattress suture technique. The use of foreign materials was avoided because meropenem-resistant Pseudomonas aeruginosa was cultured in a tracheal specimen. Immediately after the operation, the expiratory airway stenosis improved, and subsequently, spontaneous ventilation was possible using a normal type of tracheostomy tube instead of an adjustable-length tracheostomy tube. Conclusions Tracheobronchomalacia is not a rare condition in patients with chronic obstructive pulmonary disease. The thoracoscopic approach is less invasive than the posterolateral approach and is suitable in cases that are otherwise refractory to medical treatment. We believe that thoracoscopy may be a useful treatment option in cases where conservative treatment is not appropriate.
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Diaz Milian R, Foley E, Bauer M, Martinez-Velez A, Castresana MR. Expiratory Central Airway Collapse in Adults: Corrective Treatment (Part 2). J Cardiothorac Vasc Anesth 2019; 33:2555-2560. [DOI: 10.1053/j.jvca.2018.09.009] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2018] [Indexed: 02/06/2023]
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Abstract
Tracheobronchomalacia (TBM) and excessive dynamic airway collapse (EDAC) are more frequently being recognized as the etiology of multiple types of respiratory complaints from chronic cough to exertional syncope to recurrent infections. Identification of these conditions requires a high suspicion, as well as a thorough history and physical examination. Dynamic computed tomography imaging and bronchoscopic evaluation are integral in achieving an accurate diagnosis. Once recognized, treatment ranges from addressing underlying contributing conditions to surgical stabilization of the airway. Referral to an institution familiar with the evaluation and treatment of TBM/EDAC is essential for the appropriate management of these conditions.
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Affiliation(s)
- Kendra Hammond
- Division of Pulmonary and Critical Care Medicine, National Jewish Health, 1400 Jackson Street, Denver, CO 80206, USA
| | - Uzair K Ghori
- Division of Pulmonary, Critical Care, and Sleep Medicine, Medical College of Wisconsin, 9200 W Wisconsin Avenue, Suite 5200, Milwaukee, WI 53226, USA
| | - Ali I Musani
- Division of Pulmonary Sciences and Critical Care, University of Colorado Medical Center, 12605 E 16th Avenue, Aurora, CO 80045, USA; Interventional Pulmonology, Division of Pulmonary Sciences and Critical Care Medicine, University of Colorado School of Medicine, Denver, Academic Office 1, 12631 East 17th Avenue, M/S C323, Office # 8102, Aurora, CO 80045, USA.
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First series of minimally invasive, robot-assisted tracheobronchoplasty with mesh for severe tracheobronchomalacia. J Thorac Cardiovasc Surg 2018; 157:791-800. [PMID: 30669239 DOI: 10.1016/j.jtcvs.2018.07.118] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2018] [Revised: 07/13/2018] [Accepted: 07/22/2018] [Indexed: 12/11/2022]
Abstract
OBJECTIVE Tracheobronchomalacia is a progressive, debilitating disease with limited treatment options. Open tracheobronchoplasty (TBP) is an accepted surgical option for management of severe tracheobronchomalacia. This study examined the outcomes of the first reported series of robot-assisted TBP (R-TBP). METHODS We retrospectively reviewed the records of patients with clinical suspicion for tracheobronchomalacia who had dynamic computed tomography scan and subsequent R-TBP from May 2016 to December 2017. RESULTS Four hundred thirty-five patients underwent dynamic computed tomography scan for suspicion of tracheobronchomalacia. Of this group, 42 patients underwent R-TBP. In the surgery group, the median age was 66 years (interquartile range, 39-72 years) and there were 30 women (71%). Respiratory comorbidities included asthma (88%) and chronic obstructive pulmonary disease (52%). The median operative time was 249 minutes (interquartile range, 266-277 minutes). Median hospital length of stay was 3 days (interquartile range, 2-4.75 days), and there were 19 postoperative complications (11 minor and 8 major). There were no mortalities at 90 days. Comparison of preoperative and postoperative pulmonary function testing demonstrated improvement in forced expiratory volume at 1 second by 13.5% (P = .01), forced vital capacity by 14.5% (P < .0001), and peak expiratory flow rate by 21.0% (P < .0001). Quality of life questionnaires also showed improvement with 82% reporting overall satisfaction with the procedure. CONCLUSIONS R-TBP can be performed with low morbidity and mortality. Early follow-up reveals significant improvement in pulmonary function testing and high patient satisfaction when compared with preoperative baseline. Long-term follow-up is needed to demonstrate the durability of R-TBP and substantiate its role in the management of patients with symptomatic, severe tracheobronchomalacia.
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Fielding DI, Travers J, Nguyen P, Brown MG, Hartel G, Morrison S. Expiratory reactance abnormalities in patients with expiratory dynamic airway collapse: a new application of impulse oscillometry. ERJ Open Res 2018; 4:00080-2018. [PMID: 30443553 PMCID: PMC6230814 DOI: 10.1183/23120541.00080-2018] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2018] [Accepted: 09/02/2018] [Indexed: 11/09/2022] Open
Abstract
Expiratory dynamic airways collapse (EDAC) is a condition that affects the central airways; it is not well characterised physiologically, with relatively few studies. We sought to characterise impulse oscillometry (IOS) features of EDAC in patients with normal spirometry. Expiratory data were hypothesised to be the most revealing. In addition, we compared IOS findings in chronic obstructive pulmonary disease (COPD) patients with and without EDAC. EDAC was identified at bronchoscopy as 75–100% expiratory closure at the carina or bilateral main bronchi. Four patient groups were compared: controls with no EDAC and normal lung function; lone EDAC with normal lung function; COPD-only patients; and COPD patients with EDAC. 38 patients were studied. Mean IOS data z-scores for EDAC compared to controls showed significantly higher reactance (X) values including X at 5 Hz, resonance frequency and area under the reactance curve (AX). EDAC showed significantly greater expiratory/inspiratory differences in all IOS data compared to controls. Stepwise logistic regression showed that resonant frequency best discriminated between EDAC and normal control, whereas classification and regression tree analysis found AX ≥3.523 to be highly predictive for EDAC in cases with normal lung function (14 out of 15 cases, and none out of eight controls). These data show a new utility of IOS: detecting EDAC in patients with normal lung function. Central airway expiratory dynamic airway collapse can be “silent” on breathing tests, but impulse oscillometry can reveal ithttp://ow.ly/9oIb30lIOka
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Affiliation(s)
- David I Fielding
- Dept of Thoracic Medicine, Royal Brisbane and Women's Hospital, Herston, Australia
| | - Justin Travers
- Dept of Thoracic Medicine, Hutt Valley District Health Board, Lower Hutt, New Zealand
| | - Phan Nguyen
- The Dept of Thoracic Medicine, The Royal Adelaide Hospital, Adelaide, Australia
| | - Michael G Brown
- Dept of Thoracic Medicine, Royal Brisbane and Women's Hospital, Herston, Australia
| | | | - Stephen Morrison
- Dept of Thoracic Medicine, Royal Brisbane and Women's Hospital, Herston, Australia
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Wood DE. Giants in Chest Medicine: Douglas J. Mathisen, MD. Chest 2018; 154:476-478. [PMID: 30195340 DOI: 10.1016/j.chest.2018.04.048] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2018] [Accepted: 04/16/2018] [Indexed: 11/26/2022] Open
Affiliation(s)
- Douglas E Wood
- Douglas E. Wood is from the Department of Surgery, University of Washington, Seattle, WA.
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Abstract
Tracheobronchomalacia is an uncommon acquired disorder of the central airways. Common symptoms include dyspnea, constant coughing, inability to raise secretions and recurrent respiratory infections. Evaluation includes an inspiratory-expiratory chest computed tomography (dynamic CT), an awake functional bronchoscopy and pulmonary function studies. Patients with significant associated symptoms and severe collapse on CT and bronchoscopy are offered membraneous wall plication. Tracheobronchoplasty is performed through a right thoracotomy. The posterior airway is exposed after the azygous vein is ligated. The posterior wall of the trachea (and usually both main bronchi) is plicated to a sheet of thick acellular dermis (or polypropylene mesh) with a series of 4 mattress sutures of 4-0 sutures from the thoracic inlet to the bottom of the trachea to re-shape the trachea and restore the normal D shape. Patients report generally good results with improvement of their symptoms. Quality of life is usually improved while pulmonary function tests usually are not improved.
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Affiliation(s)
- Cameron D Wright
- Division of Thoracic Surgery, Massachusetts General Hospital, Boston, MA, USA
| | - Douglas J Mathisen
- Division of Thoracic Surgery, Massachusetts General Hospital, Boston, MA, USA
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Crespo MM, McCarthy DP, Hopkins PM, Clark SC, Budev M, Bermudez CA, Benden C, Eghtesady P, Lease ED, Leard L, D'Cunha J, Wigfield CH, Cypel M, Diamond JM, Yun JJ, Yarmus L, Machuzak M, Klepetko W, Verleden G, Hoetzenecker K, Dellgren G, Mulligan M. ISHLT Consensus Statement on adult and pediatric airway complications after lung transplantation: Definitions, grading system, and therapeutics. J Heart Lung Transplant 2018; 37:548-563. [PMID: 29550149 DOI: 10.1016/j.healun.2018.01.1309] [Citation(s) in RCA: 91] [Impact Index Per Article: 15.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2018] [Accepted: 01/31/2018] [Indexed: 11/18/2022] Open
Abstract
Airway complications remain a major cause of morbidity and mortality after cardiothoracic transplantation. The reported incidence of airway ischemic complications varies widely, contributed to by the lack of a universally accepted grading system and standardized definitions. Furthermore, the majority of the existing classification systems fail to integrate the wide range of possible bronchial complications that may develop after lung transplant. Hence, a Working Group was created by the International Society for Heart and Lung Transplantation with the aim of elaborating a universal definition of adult and pediatric airway complications and grading system. One such area of focus is to understand the problem in the context of a more standardized consensus of classifying airway ischemia. This consensus definition will have major clinical, therapeutics, and research implications.
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Affiliation(s)
- Maria M Crespo
- Division of Pulmonary, Allergy and Critical Care Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania.
| | - Daniel P McCarthy
- Division of Cardiothoracic Surgery, University of Wisconsin School of Medicine, Madison, Wisconsin
| | | | | | - Marie Budev
- Respiratory Institute, Cleveland Clinic, Cleveland, Ohio
| | - Christian A Bermudez
- Division of Cardiothoracic Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Christian Benden
- Department of Pulmonary Medicine, University Hospital of Zurich, Zurich, Switzerland
| | - Pirooz Eghtesady
- Division of Pediatric Cardiothoracic Surgery, Washington University School of Medicine, St. Louis, Missouri
| | - Erika D Lease
- Division of Pulmonary and Critical Care Medicine, University of Washington, Seattle, Washington
| | - Lorriana Leard
- Division of Pulmonary and Critical Care Medicine, University of California, San Francisco Medical Center, San Francisco, California
| | - Jonathan D'Cunha
- Department of Cardiothoracic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | | | - Marcelo Cypel
- Division of Thoracic Surgery, Toronto General Hospital UHN, Toronto, Ontario, Canada
| | - Joshua M Diamond
- Division of Pulmonary, Allergy and Critical Care Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - James J Yun
- Division of Cardiothoracic Surgery, Yale University School of Medicine, New Haven, Connecticut
| | - Lonny Yarmus
- Division of Pulmonary and Critical Care, The John Hopkins University Hospital, Baltimore, Maryland
| | | | - Walter Klepetko
- Department of Thoracic Surgery, Vienna Medical University, Vienna, Austria
| | - Geert Verleden
- Department of Respiratory Diseases, University Hospital of Gasthuisberg, Leuven, Belgium
| | | | - Göran Dellgren
- Cardiothoracic Department, Sahlgrenska University Hospital, Göteborg, Sweden
| | - Michael Mulligan
- Division of Cardiothoracic Surgery, University of Washington, Seattle, Washington
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Teflon Injection into the Trachea Causes Predictable Fibroblastic Response and Collagen Deposition: A Pilot Study. J Bronchology Interv Pulmonol 2017; 23:283-287. [PMID: 27764007 DOI: 10.1097/lbr.0000000000000290] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Expiratory central airway collapse is an increasingly recognized abnormality of the central airways and may be present in as many as 22% of patients evaluated for chronic obstructive pulmonary disease and/or asthma. Many current treatment options require invasive procedures that have been shown to cause significant morbidity and mortality. To test the hypothesis that Teflon injection will induce sufficient fibroblast proliferation and collagen deposition, we evaluated the time course on the effect of Teflon injection in the posterior membranous trachea on the histopathology of the tracheobronchial tree. METHODS Six Yucatan Pigs were assigned to undergo general anesthesia and injection of 0.3 to 0.5 mL of sterile Teflon paste in 50% glycerin into the posterior membranous tracheal wall. A control pig received an equivalent volume of glycerin. Animals were euthanized in predefined intervals and tracheas were excised and examined under light microscopy for identifying fibroblast proliferation and collagen deposition. RESULTS Compared with the control pig, the Teflon injection site showed tissue reaction of fibrohistiocytic proliferation and subsequent collagen deposition in all animals. Furthermore, the increased fibroblast proliferation and collagen deposition were time dependent (P<0.01). CONCLUSION This pilot study demonstrates histopathologic changes in the trachea after Teflon injection, comprised of increased fibroblast activity and collagen deposition that could be of potential use in creating greater airway rigidity in patients with sever diffuse excessive dynamic airway collapse.
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McLaurin S, Whitener GB, Steinburg T, Finley A, Heinke T, Nelson E, Guldan III G, Klapper J, Slinger P, Abernathy JH. A Unique Strategy for Lung Isolation During Tracheobronchoplasty. J Cardiothorac Vasc Anesth 2017; 31:731-737. [DOI: 10.1053/j.jvca.2016.11.027] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/04/2016] [Indexed: 12/30/2022]
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Tsukioka T, Takahama M, Nakajima R, Kimura M, Inoue H, Yamamoto R. Efficacy of Surgical Airway Plasty for Benign Airway Stenosis. Ann Thorac Cardiovasc Surg 2015; 22:27-31. [PMID: 26567879 DOI: 10.5761/atcs.oa.15-00271] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Long-term patency is required during treatment for benign airway stenosis. This study investigated the effectiveness of surgical airway plasty for benign airway stenosis. METHODS Clinical courses of 20 patients, who were treated with surgical plasty for their benign airway stenosis, were retrospectively investigated. RESULTS Causes of stenosis were tracheobronchial tuberculosis in 12 patients, post-intubation stenosis in five patients, malacia in two patients, and others in one patient. 28 interventional pulmonology procedures and 20 surgical plasty were performed. Five patients with post-intubation stenosis and four patients with tuberculous stenosis were treated with tracheoplasty. Eight patients with tuberculous stenosis were treated with bronchoplasty, and two patients with malacia were treated with stabilization of the membranous portion. Anastomotic stenosis was observed in four patients, and one to four additional treatments were required. Performance status, Hugh-Jones classification, and ventilatory functions were improved after surgical plasty. Outcomes were fair in patients with tuberculous stenosis and malacia. However, efficacy of surgical plasty for post-intubation stenosis was not observed. CONCLUSION Surgical airway plasty may be an acceptable treatment for tuberculous stenosis. Patients with malacia recover well after surgical plasty. There may be untreated patients with malacia who have the potential to benefit from surgical plasty.
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Affiliation(s)
- Takuma Tsukioka
- Department of General Thoracic Surgery, Osaka City General Hospital, Osaka, Osaka, Japan
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Bairdain S, Smithers CJ, Hamilton TE, Zurakowski D, Rhein L, Foker JE, Baird C, Jennings RW. Direct tracheobronchopexy to correct airway collapse due to severe tracheobronchomalacia: Short-term outcomes in a series of 20 patients. J Pediatr Surg 2015; 50:972-7. [PMID: 25824437 DOI: 10.1016/j.jpedsurg.2015.03.016] [Citation(s) in RCA: 46] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2015] [Accepted: 03/10/2015] [Indexed: 10/23/2022]
Abstract
PURPOSE Tracheobronchomalacia (TBM) is associated with esophageal atresia, tracheoesophageal fistulas, and congenital heart disease. TBM results in chronic cough, poor mucous clearance, and recurrent pneumonias. Apparent life-threatening events or recurrent pneumonias may require surgery. TBM is commonly treated with an aortopexy, which indirectly elevates trachea's anterior wall. However, malformed tracheal cartilage and posterior tracheal membrane intrusion may limit its effectiveness. This study describes patient outcomes undergoing direct tracheobronchopexy for TBM. METHODS The records of patients that underwent direct tracheobronchopexy at our institution from January 2011 to April 2014 were retrospectively reviewed. Primary outcomes included TBM recurrence and resolution of the primary symptoms. Data were analyzed by McNemar's test for matched binary pairs and logistic regression modeling to account for the endoscopic presence of luminal narrowing over multiple time points per patient. RESULTS Twenty patients were identified. Preoperative evaluation guided the type of tracheobronchopexy. 30% had isolated anterior and 50% isolated posterior tracheobronchopexies, while 20% had both. Follow-up was 5 months (range, 0.5-38). No patients had postoperative ALTEs, and pneumonias were significantly decreased (p=0.0005). Fewer patients had tracheobronchial collapse at postoperative endoscopic exam in these anatomical regions: middle trachea (p=0.01), lower trachea (p<0.001), and right bronchus (p=0.04). CONCLUSION The use of direct tracheobronchopexy resulted in ALTE resolution and reduction of recurrent pneumonias in our patients. TBM was also reduced in the middle and lower trachea and right mainstem bronchus. Given the heterogeneity of our population, further studies are needed to ascertain longer-term outcomes and a grading scale for TBM severity.
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Affiliation(s)
- Sigrid Bairdain
- Department of Pediatric Surgery, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Charles Jason Smithers
- Department of Pediatric Surgery, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Thomas E Hamilton
- Department of Pediatric Surgery, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - David Zurakowski
- Department of Pediatric Surgery, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA; Department of Anesthesiology, Perioperative and Pain Medicine, Boston Children's Hospital, Boston, MA, USA
| | - Lawrence Rhein
- Department of Pulmonology, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | | | - Christopher Baird
- Department of Cardiovascular Surgery, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Russell W Jennings
- Department of Pediatric Surgery, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA.
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Tsukioka T, Takahama M, Nakajima R, Kimura M, Tei K, Yamamoto R. Surgical reconstruction for tuberculous airway stenosis: management for patients with concomitant tracheal malacia. Gen Thorac Cardiovasc Surg 2015; 63:379-85. [PMID: 25802123 DOI: 10.1007/s11748-015-0536-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2015] [Accepted: 03/09/2015] [Indexed: 11/27/2022]
Abstract
OBJECTIVES Surgical reconstruction is commonly recommended for the treatment of tuberculous airway stenosis. The clinical conditions underlying tuberculous airway stenosis often involve both cicatricial stenosis and malacia. Surgical reconstruction alone may not improve the respiratory symptoms of patients with both types of airway stenosis. This study retrospectively reviewed patients who underwent surgical reconstruction for tuberculous airway stenosis to investigate the most appropriate treatment for this complicated condition. METHODS Twelve patients with tuberculous airway stenosis underwent surgical reconstruction at our institute from January 2003 to December 2013. The clinical courses of these patients were retrospectively reviewed. RESULTS The 12 patients were 2 men and 10 women with a mean age of 36 years (range 17-61 years). The site of stenosis was the left main bronchus in six patients, trachea in four patients, and right main bronchus in two patients. The procedure performed was sleeve lobectomy in five patients, bronchial resection in four patients, and tracheal resection in three patients. Additional airway stenting was performed in two patients with concomitant malacia of the lower trachea. The performance status and Hugh-Jones classification improved postoperatively in all patients. The forced expiratory volume in 1 s as a percent of forced vital capacity and percent of forced expiratory volume in 1 s improved significantly. CONCLUSION Surgical reconstruction is an acceptable treatment for tuberculous airway stenosis. Additional airway stenting may be needed in patients with symptomatic malacia.
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Affiliation(s)
- Takuma Tsukioka
- Department of General Thoracic Surgery, Osaka City General Hospital, 2-13-22 Miyakojima Hondori, Miyakojima-ku, Osaka, 534-0021, Japan,
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Gani MAD, Rogers VJC, Sachak KH, Marzouk JFK. Flat trachea syndrome: a rare condition with symptoms similar to obstructive airway disease. BMJ Case Rep 2015; 2015:bcr-2014-207063. [PMID: 25721828 DOI: 10.1136/bcr-2014-207063] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Flat trachea syndrome, commonly known as 'tracheobronchomalacia', is a central airway disease characterised by excessive expiratory collapse of the tracheobronchial posterior membrane due to weakness in the airway walls. Patients present with symptoms such as chronic cough, dyspnoea and recurrent respiratory tract infections, which are often attributed to more common conditions such as asthma and chronic obstructive pulmonary disease (COPD). The term 'Flat Trachea Syndrome' was first proposed by Niranjan and Marzouk in 2010 following a retrospective study of 28 patients with the condition who underwent surgery for it. The authors advocated the term due to the primary abnormality being collapse of the posterior membranous wall of the central airways as opposed to softening of the tracheal cartilage (tracheobronchomalacia), which they proposed is a misnomer. We present a rare case of a patient with flat trachea syndrome on a history of COPD who initially presented with recurrent respiratory tract infections.
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Affiliation(s)
| | | | | | - Joseph F K Marzouk
- Department of Cardiothoracic Surgery, University Hospital Coventry and Warwickshire, Coventry, UK
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Kitaoka H, Cok S. Estimation of the site of wheezes in pulmonary emphysema: airflow simulation study by the use of A 4D lung model. ANNUAL INTERNATIONAL CONFERENCE OF THE IEEE ENGINEERING IN MEDICINE AND BIOLOGY SOCIETY. IEEE ENGINEERING IN MEDICINE AND BIOLOGY SOCIETY. ANNUAL INTERNATIONAL CONFERENCE 2013; 2013:449-452. [PMID: 24109720 DOI: 10.1109/embc.2013.6609533] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
Abstract
Adventitious lung sounds in pulmonary emphysema, wheezes, are continuous musical sounds during expiration with 400 Hz or more. The textbook tells that expiratory airflow limitation in emphysema occurs at the peripheral airways and that wheezes are generated there. We have recently proposed a novel hypothesis based on image analysis and theoretical consideration that expiratory airflow limitation in emphysema occurs at the intra-mediastinal airway (trachea, main bronchi, and right lobar bronchi) due to compression by overinflated lungs. We performed expiratory airflow simulation by the use of a 4D finite element lung model, and found periodical vortex release with 300-900 Hz at the end of protrusion of the the tracheal posterior wall. Relationship between the peak frequency of pressure fluctuation and airflow velocity was in agreement with Strahal's law either in normal or emphysematous condition. Contrarily, airflow simulation in a small bronchus (1.5 mm in diameter) indicated no apparent periodic vortex release.
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Wilkey BJ, Alfille P, Weitzel NS, Puskas F. Anesthesia for Tracheobronchial Surgery. Semin Cardiothorac Vasc Anesth 2012; 16:209-19. [DOI: 10.1177/1089253212464715] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
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.
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Affiliation(s)
| | - Paul Alfille
- Harvard Medical School, Massachusetts General Hospital, Boston, MA, USA
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Abstract
Tracheobronchomalacia (TBM) refers to a weakening of the anterior tracheal rings leading to splaying and collapse of the central airways. In this report, we review the treatment of TBM, including preoperative workup, intraoperative anesthesia management, and surgical technique for posterior splinting tracheobronchoplasty. Imperative in the preoperative preparation is a stent trial in which an airway stent is placed to temporarily relieve the TBM and reassess for improvement in symptoms. Definitive therapy is then carried out with posterior splinting tracheoplasty or tracheobronchoplasty. Surgical results are generally excellent with the majority of patients having significant improvements in breathing.
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Affiliation(s)
- Sagar S. Damle
- University of Colorado School of Medicine, Aurora, CO, USA
| | - John D. Mitchell
- University of Colorado School of Medicine, Aurora, CO, USA
- National Jewish Health, Denver, CO, USA
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Tracheobronchoplasty for the treatment of tracheobronchomalacia. J Thorac Cardiovasc Surg 2012; 144:S58-9. [DOI: 10.1016/j.jtcvs.2012.05.025] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2011] [Revised: 05/10/2012] [Accepted: 05/15/2012] [Indexed: 11/21/2022]
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[Tracheobronchomalacia in adults: breakthroughs and controversies]. Rev Mal Respir 2012; 29:1198-208. [PMID: 23228678 DOI: 10.1016/j.rmr.2012.06.008] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2012] [Accepted: 06/05/2012] [Indexed: 11/23/2022]
Abstract
Tracheobronchomalacia (TBM) in adults is a disease defined by a reduction of more than 50% of the airway lumen during expiration. It encompasses many etiologies that differ in their morphologic aspects, pathophysiological mechanisms and histopathologies. TBM is encountered with increasing frequency, as it is more easily diagnosed with new imaging techniques and diagnostic bronchoscopy, as well as because of its frequent association with Chronic Obstructive Pulmonary Disease (COPD), which represents the most frequent etiology for acquired TBM in adults. A distinction between TBM in association with failure of the cartilaginous part of the airways and TBM affecting only the posterior membranous part is emerging since their physiopathology and treatment differ. The therapeutic management of TBM should be as conservative as possible. Priority should be given to identification and treatment of associated respiratory diseases, such as asthma or COPD. Surgery addressing extrinsic compression (thyroid goiter or tumor, for example) may be necessary. Noninvasive ventilation can be considered in patients with increasing symptoms. Endoscopic options, such as the placement of stents, should only be used as palliative or temporary solutions, because of the high complication rates. Symptomatic improvement after stenting might be helpful in selecting patients in whom a surgical management with tracheobronchoplasty can be useful.
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Video-assisted thoracoscopic surgical tracheobronchoplasty for tracheobronchomalacia. J Thorac Cardiovasc Surg 2011; 142:714-6. [DOI: 10.1016/j.jtcvs.2010.11.037] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2010] [Revised: 11/10/2010] [Accepted: 11/23/2010] [Indexed: 11/21/2022]
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Ernst A, Odell DD, Michaud G, Majid A, Herth FFJ, Gangadharan SP. Central airway stabilization for tracheobronchomalacia improves quality of life in patients with COPD. Chest 2011; 140:1162-1168. [PMID: 21868463 DOI: 10.1378/chest.10-3051] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
BACKGROUND Tracheobronchomalacia (TBM) is characterized by excessive collapsibility of the central airways, typically during expiration. TBM may be present in as many as 50% of patients evaluated for COPD. The impact of central airway stabilization on symptom pattern and quality of life is poorly understood in this patient population. METHODS Patients with documented COPD were identified from a cohort of 238 patients assessed for TBM at our complex airway referral center. Pulmonary function testing, exercise tolerance, and health-related quality-of-life (HRQOL) measures were assessed at baseline and 2 to 4 weeks following tracheal stent placement/operative tracheobronchoplasty (TBP). Severity of COPD was classified according to the GOLD (Global Initiative for Chronic Obstructive Lung Disease) staging system. RESULTS One hundred three patients (48 women) with COPD and moderately severe to severe TBM were identified. Statistically and clinically significant improvements were seen in HRQOL measures, including the transitional dyspnea index (stent, P = .001; TBP, P = .008), the St. George Respiratory Questionnaire (stent, P = .002; TBP, P < .0001), and the Karnofsky performance score (stent, P = .163; TBP, P < .0001). The improvement appeared greatest following TBP and was seen in all GOLD stages. Clinical improvement was also seen in measured FEV(1) and exercise capacity as assessed by 6-min walk test. CONCLUSIONS Central airway stabilization may provide symptomatic benefit for patients with severe COPD and concomitant severe airway malacia. Operative airway stabilization appears to impart the greatest advantage. Long-term follow-up study is needed to fully ascertain the ultimate efficacy of both stenting and surgical airway stabilization in this patient group.
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Affiliation(s)
- Armin Ernst
- Department of Pulmonary, Critical Care, and Sleep Medicine, St. Elizabeth's Medical Center, Boston, MA.
| | - David D Odell
- Division of Thoracic Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Gaetane Michaud
- Division of Interventional Pulmonology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Adnan Majid
- Division of Interventional Pulmonology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | | | - Sidhu P Gangadharan
- Division of Thoracic Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
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Odell DD, Shah A, Gangadharan SP, Majid A, Michaud G, Herth F, Ernst A. Airway stenting and tracheobronchoplasty improve respiratory symptoms in Mounier-Kuhn syndrome. Chest 2011; 140:867-873. [PMID: 21493699 DOI: 10.1378/chest.10-2010] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
BACKGROUND Mounier-Kuhn syndrome (MKS) is a condition characterized by tracheobronchomegaly resulting from the loss or atrophy of musculoelastic fibers within the airway wall. Concomitant tracheobronchomalacia is seen in most patients with MKS, often leading to significant respiratory compromise due to bronchiectasis, increased dead space, and impaired secretion clearance. METHODS We report a series of 12 patients with MKS and tracheobronchomalacia who were evaluated at our institution for significant respiratory problems. Stent trials were conducted in 10 patients, with seven proceeding to operative tracheobronchoplasty (TBP) and one continuing with long-term stent placement. One patient underwent TBP without prior stent placement. Of the remaining three patients, two had no improvement with trials of stent placement, and a stent could not be placed in the third because of a large tracheal diameter. RESULTS Compared with baseline values, clinically significant improvements in health-related quality-of-life measures and pulmonary function testing were seen in patients who underwent central airway stabilization (n = 9). Complications of both stent placement and TBP were generally mild. However, one death was reported in the surgical group secondary to an exacerbation of preexisting interstitial pneumonia. CONCLUSIONS An aggressive approach that targets central airway stabilization may improve outcomes for patients with MKS. TRIAL REGISTRY ClinicalTrials.gov; No.: NCT00550602; URL: www.clinicaltrials.gov.
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Affiliation(s)
- David D Odell
- Division of Thoracic Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Archan Shah
- Division of Interventional Pulmonology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Sidhu P Gangadharan
- Division of Thoracic Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA; Division of Interventional Pulmonology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Adnan Majid
- Division of Interventional Pulmonology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | | | - Felix Herth
- Thoraxklinik, University of Heidelberg, Heidelberg, Germany
| | - Armin Ernst
- Pulmonary, Critical Care and Sleep Medicine, St. Elizabeth's Medical Center, Boston, MA.
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Gangadharan SP. Tracheobronchomalacia in adults. Semin Thorac Cardiovasc Surg 2011; 22:165-73. [PMID: 21092895 DOI: 10.1053/j.semtcvs.2010.07.001] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/25/2010] [Indexed: 11/11/2022]
Abstract
Severe, diffuse tracheobronchomalacia (TBM) is an underrecognized cause of dyspnea, recurrent respiratory infections, cough, secretion retention, and even respiratory insufficiency. Patients often have comorbidities, such as asthma or chronic obstructive pulmonary disease, and inappropriate treatment for these conditions may precede eventual recognition of TBM by months or years. Most of these patients have an acquired form of TBM in which the etiology in unknown. Diagnosis of TBM is made by airway computed tomography scan and flexible bronchoscopy with forced expiration. The prevailing definition of TBM as a 50% reduction in cross-sectional area is nonspecific, with a high proportion of healthy volunteers meeting this threshold. The clinically significant threshold is complete or near-complete collapse of the airway. Airway stenting may treat TBM, although complications resulting from indwelling prostheses often limit the durability of stents. Surgical stabilization of the airway by posterior splinting (tracheobronchoplasty) effectively and permanently corrects malacic airways. Proper surgical selection is facilitated by a short-term stent trial.
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Affiliation(s)
- Sidhu P Gangadharan
- Division of Thoracic Surgery and Interventional Pulmonology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts 02215, USA.
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Gangadharan SP, Bakhos CT, Majid A, Kent MS, Michaud G, Ernst A, Ashiku SK, DeCamp MM. Technical aspects and outcomes of tracheobronchoplasty for severe tracheobronchomalacia. Ann Thorac Surg 2011; 91:1574-80; discussion 1580-1. [PMID: 21377650 DOI: 10.1016/j.athoracsur.2011.01.009] [Citation(s) in RCA: 49] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2010] [Revised: 12/31/2010] [Accepted: 01/04/2011] [Indexed: 10/18/2022]
Abstract
BACKGROUND Tracheobronchomalacia is an underrecognized cause of dyspnea, recurrent respiratory infections, and cough. Surgical stabilization with posterior membranous tracheobronchoplasty has been shown to be effective in selected patients with severe disease. This study examines the technical details and complications of this operation. METHODS A prospectively maintained database of tracheobronchomalacia patients was queried retrospectively to review all consecutive tracheobronchoplasties performed from October 2002 to June 2009. Posterior splinting was performed with polypropylene mesh. Patient demographics, surgical outcomes, and operative data were reviewed. RESULTS Sixty-three patients underwent surgical correction of tracheal and bilateral bronchial malacia. Twenty-three patients had chronic obstructive pulmonary disease, 18 had asthma, 5 had Mounier-Kuhn syndrome, and 4 had interstitial lung disease. Seven patients had a previous tracheotomy. Operative time was 373 ± 93 minutes. Median length of stay was 8 days (range, 4 to 92 days), of which 3 days (range, 0 to 91 days) were in intensive care. Seventy-five percent of patients were discharged home (28% with visiting nurse follow-up), and 25% went to a rehabilitation facility. Two patients (3.2%) died postoperatively-1 of worsening usual interstitial pneumonia, and the other of massive pulmonary embolism. Complications included a new respiratory infection in 14 patients, pulmonary embolism in 2, and atrial fibrillation in 6. Six patients required reintubation, and 9 received a postoperative tracheotomy; 47 patients required postoperative aspiration bronchoscopy. CONCLUSIONS In experienced hands, tracheobronchoplasty can be performed with a very low mortality rate and an acceptable perioperative complications rate in patients with significant pulmonary comorbidity. Intervention for postoperative respiratory morbidity is often necessary.
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Affiliation(s)
- Sidhu P Gangadharan
- Division of Thoracic Surgery and Interventional Pulmonology, Beth Israel Deaconess Medical Center, Department of Surgery, Harvard Medical School, Boston, Massachusetts 02215, USA.
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Interventional bronchoscopy from bench to bedside: new techniques for central and peripheral airway obstruction. Clin Chest Med 2010; 31:101-15, Table of Contents. [PMID: 20172436 DOI: 10.1016/j.ccm.2009.09.002] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
This article discusses how basic scientific concepts, based on a greater understanding of airway physiology, support the development and dissemination of multidimensional classification systems for tracheal stenosis, expiratory central airway collapse, and innovative interventional bronchoscopic procedures for patients with asthma and chronic obstructive pulmonary disease.
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One-Stage Repair of Ventricular Septal Defect and Severe Tracheomalacia by Aortopexy and Posterior Tracheal Wall Stabilization. Ann Thorac Surg 2010; 89:1677-8. [DOI: 10.1016/j.athoracsur.2009.06.065] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2009] [Revised: 05/25/2009] [Accepted: 06/09/2009] [Indexed: 11/23/2022]
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Ley S, Loukanov T, Ley-Zaporozhan J, Springer W, Sebening C, Sommerburg O, Hagl S, Gorenflo M. Long-Term Outcome After External Tracheal Stabilization Due to Congenital Tracheal Instability. Ann Thorac Surg 2010; 89:918-25. [DOI: 10.1016/j.athoracsur.2009.11.066] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2009] [Revised: 11/21/2009] [Accepted: 11/23/2009] [Indexed: 10/19/2022]
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Williamson JP, Phillips MJ, Hillman DR, Eastwood PR. Managing obstruction of the central airways. Intern Med J 2009; 40:399-410. [PMID: 19849741 DOI: 10.1111/j.1445-5994.2009.02113.x] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
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.
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Affiliation(s)
- J P Williamson
- Department of Pulmonary Physiology, Sir Charles Gairdner Hospital, Western Australia 6009, Australia.
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Murgu SD, Colt HG. Tracheobronchoplasty for severe tracheobronchomalacia. Chest 2009; 135:1403-1404. [PMID: 19420215 DOI: 10.1378/chest.08-2660] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Affiliation(s)
| | - Henri G Colt
- University of California School of Medicine, Irvine, CA
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Majid A, Guerrero J, Gangadharan S, Feller-Kopman D, Boiselle P, DeCamp M, Ashiku S, Michaud G, Herth F, Ernst A. Tracheobronchoplasty for severe tracheobronchomalacia: a prospective outcome analysis. Chest 2008; 134:801-807. [PMID: 18842912 DOI: 10.1378/chest.08-0728] [Citation(s) in RCA: 86] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
RATIONALE Central airway stabilization with silicone stents can improve respiratory symptoms in patients with severe symptomatic tracheobronchomalacia (TBM) but is associated with a relatively high rate of complications. Surgery with posterior tracheobronchial splinting using a polypropylene mesh has also been used for this condition but to date has not been evaluated prospectively and objectively for patient outcomes. OBJECTIVES To evaluate the effect of surgical tracheobronchoplasty on symptoms, functional status, quality of life, lung function, and exercise capacity in patients with severe and symptomatic TBM. METHODS A prospective observational study in which baseline measurements were compared to those obtained 3 months after surgical tracheobronchoplasty. MEASUREMENTS AND MAIN RESULTS Of 104 referred patients to our complex airway center for severe TBM, 77 had baseline measurements. Of this group, 57 patients had severe malacia and underwent stent placement for central airway stabilization. Of those, 37 patients reported improvement in respiratory symptoms and 35 were considered for surgical tracheobronchoplasty. Two patients were excluded from surgery for medical reasons. Median age was 61 years (range, 39 to 83 years), 20 patients were men, 11 patients (31%) had COPD, 9 patients (26%) had asthma, and 4 patients (11%) had Mounier-Kuhn syndrome. Thirty-three patients (94%) presented with severe dyspnea, 26 patients (74%) with uncontrollable cough, and 18 patients (51%) reported recurrent pulmonary infections. Two patients (3%) presented with respiratory failure requiring mechanical ventilation. After surgery, quality of life scores improved in 25 of 31 patients (p < 0.0001), dyspnea scores improved in 19 of 26 patients (p = 0.007), functional status scores improved in 20 of 31 patients (p = 0.003), and mean exercise capacity improved in 10 patients (p = 0.012). CONCLUSIONS In experienced hands, surgical central airway stabilization with posterior tracheobronchial splinting using a polypropylene mesh improves respiratory symptoms, health-related quality of life, and functional status in highly selected patients with severe symptomatic TBM.
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Affiliation(s)
- Adnan Majid
- Division of Cardiothoracic Surgery and Interventional Pulmonology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Jorge Guerrero
- Division of Cardiothoracic Surgery and Interventional Pulmonology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Sidhu Gangadharan
- Division of Cardiothoracic Surgery and Interventional Pulmonology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - David Feller-Kopman
- Division of Cardiothoracic Surgery and Interventional Pulmonology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Phillip Boiselle
- Center for Airway Imaging, Department of Radiology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Malcolm DeCamp
- Division of Cardiothoracic Surgery and Interventional Pulmonology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Simon Ashiku
- Division of Cardiothoracic Surgery and Interventional Pulmonology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Gaetane Michaud
- Division of Cardiothoracic Surgery and Interventional Pulmonology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Felix Herth
- Division of Pulmonary and Interdisciplinary Endoscopy, Thoraxklinik, Heidelberg, Germany
| | - Armin Ernst
- Division of Cardiothoracic Surgery and Interventional Pulmonology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA.
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Comparison of Expiratory CT Airway Abnormalities Before and After Tracheoplasty Surgery for Tracheobronchomalacia. J Thorac Imaging 2008; 23:121-6. [DOI: 10.1097/rti.0b013e3181653c41] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Murgu SD, Colt HG. Complications of Silicone Stent Insertion in Patients With Expiratory Central Airway Collapse. Ann Thorac Surg 2007; 84:1870-7. [DOI: 10.1016/j.athoracsur.2007.07.026] [Citation(s) in RCA: 49] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2007] [Revised: 07/10/2007] [Accepted: 07/11/2007] [Indexed: 10/22/2022]
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Tatekawa Y, Tojo T, Kanehiro H, Nakajima Y. Multistage Approach for Tracheobronchomalacia Caused by a Chest Deformity in the Setting of Severe Scoliosis. Surg Today 2007; 37:910-4. [PMID: 17879046 DOI: 10.1007/s00595-007-3532-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2007] [Accepted: 04/08/2007] [Indexed: 10/22/2022]
Abstract
We present a case of tracheobronchomalacia caused by thoracic morphologic changes associated with severe scoliosis. The patient underwent fundoplication for gastroesophageal reflux. After the operation, the patient developed clinically significant tracheobronchomalacia. Tracheobronchial reinforcement and splinting with autologous cartilage grafts was initially performed to externally stent the trachea. Next, tracheopexy of the intrathoracic trachea and sternal elevation was performed using a pectus bar to correct the tracheal compression between the sternum and the spine. Because the cervical trachea was compressed between the innominate artery and the cervical spine, external stenting and tracheopexy of the cervical trachea as well as anterior suspension of the innominate artery were performed. At present, the patient has a Tracheostoma Retainer in place and is being followed as an outpatient without the need for mechanical ventilation. Multistaged techniques for tracheobronchomalacia because of an abnormal chest configuration therefore offer the potential to achieve the long-term release of airway obstruction.
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Affiliation(s)
- Yukihiro Tatekawa
- Department of Surgery, Nara Medical University, 840 Shijyo-cho, Kashihara, Nara 634-8522, Japan
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Marolf A, Blaik M, Specht A. A RETROSPECTIVE STUDY OF THE RELATIONSHIP BETWEEN TRACHEAL COLLAPSE AND BRONCHIECTASIS IN DOGS. Vet Radiol Ultrasound 2007; 48:199-203. [PMID: 17508504 DOI: 10.1111/j.1740-8261.2007.00229.x] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
Abstract
Tracheal collapse is common in middle age toy and miniature breed dogs. Cartilaginous defects have been identified histologically and are considered a form of chondromalacia. In addition to tracheal cartilaginous changes, concurrent lower airway histologic changes indicative of inflammation have been noted in dogs with tracheal collapse and these changes may lead t o concurrent bronchiectasis. The purpose of this study was to investigate the prevalence of bronchiectasis in dogs with a previous radiographic diagnosis of tracheal collapse. The thoracic radiographs of 60 dogs with tracheal collapse were evaluated for evidence of concurrent bronchiectasis. Eighteen of 60 (30%) dogs had evidence of bronchiectasis, and all were cylindrical in morphology. The signalment of affected dogs was similar to that previously reported. The occurrence of bronchiectasis in this group of dogs with tracheal collapse (18 dogs) was six times higher (P < 0.05) than the expected prevalence within a random sample population (three dogs). The results of this study provide evidence of a link between tracheal collapse and bronchiectasis. A finding of bronchiectasis with tracheal collapse should encourage further evaluation for chronic lower airway disease in these patients.
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Affiliation(s)
- Angela Marolf
- Department of Small Animal Clinical Sciences, Veterinary Medical Center, University of Florida, 2015 SW 16th Avenue, PO Box 100102, Gainesville, USA
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Murgu SD, Colt HG. Expiratory Collapse of the Central Airways. Ann Thorac Surg 2006; 82:768; author reply 768-9. [PMID: 16863821 DOI: 10.1016/j.athoracsur.2005.10.031] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2005] [Revised: 09/28/2005] [Accepted: 10/19/2005] [Indexed: 11/30/2022]
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