[Endoscopic treatment of central airway stenosis: five years' experience]

Endobronchial Tumor With Ball Valve Mechanism: A Real Airway Emergency

Central airway obstruction due to the tumor can present as near-complete tracheal obstruction. The results can be life-threatening requiring emergent intervention. Rigid bronchoscopy has been preferred for the management of central airway obstruction. However, there are relatively few studies comparing rigid bronchoscopy and flexible bronchoscopy in treating these cases. We describe a 61-year-old woman with a lower trachea tumor with ball valve occlusion of the left mainstem bronchus and complete occlusion of the right mainstem bronchus successfully managed with flexible bronchoscopy and iCAST^® stent. We herein highlight the role of therapeutic flexible bronchoscopy with airway stenting as an efficacious treatment modality for the management of malignant central airway obstruction. 

Main tract stenosis complicated by granulomatous with polyangiitis: A case report

Granulomatosis with polyangiitis (GPA) is a rheumatic auto-immune disease involved in vasculitis. It is rarely reported that anti-neutrophil cytoplasmic antibodies (ANCAs) associated with GPA would cause main tract stenosis. The current report documents a 54-year-old woman, with a history of severe cough, presented with wheezing and shortness of breath. Although she was treated with cephalosporin antibiotics for half a month, the symptoms were not alleviated. Accordingly, laboratory testing, radiology and pathology was performed at the Department of Respiratory and Critical Care Medicine, Huashan Hospital. Blood samples were tested negative for ANCAs. Chest CT revealed stenosis of the main trachea and uneven thickening of the tracheal wall. Nasal sinuses CT scanning indicated thickening of the nasal mucosa. Pathological analysis demonstrated chronic granulomatous inflammation with focal lesions. According to the classification criteria of ACR/EULAR provisional 2017, the patient was diagnosed with the ANCAs-negative GPA. Following treatment with oral prednisone only for 6 months, obstruction of main tract was significantly improved. This case study is of interest for the promotion a potentially novel therapeutic intervention for GPA associated with the absence ANCA of in clinic.

Laryngotracheal Stenosis: A Retrospective Analysis of Their Aetiology, Diagnose and Treatment

BACKGROUND:

Laryngotracheal stenosis created as a result of a long-term consequence of prolonged endotracheal intubation is a state of narrowing of the airway, which, depending on the degree of narrowing, can be from an asymptomatic to a potentially life-threatening condition.

AIM:

To understand the severity of postintubation laryngeal stenoses, their diagnosis, endoscopic evaluation, endoscopic and surgical treatment and their success in a multi-year period realised in the University Clinic for Ear, Nose and Throat in Skopje, Macedonia.

MATERIAL AND METHODS:

Through a proper history, physical examination, endoscopic and imaging evaluation of the ear, nose and throat in the Clinic, in the period of 8 years, that is, from 2010 to 2017, laryngotracheal stenosis was diagnosed in a total of 36 patients. During this period, 24 male or 66.7% were diagnosed, as were 12 female subjects or 33.3% of diagnosed patients. Of the analysed total of 36 patients, by Mayers cotton classification, 14 or 38% are patients with grade 1 stenosis, 5 or 13% are grade 2, and 10 or 27% are grade 3, while 7 or 19% are grade 4 stenosis

RESULTS:

It is essential for all laryngotracheal stenoses to exist or to provide a breathing path that depends on the degree of stenosis. Further course of treatment also depends on the characteristics of the stenotic zone that is visualised endoscopically. At the Clinic for ear nose and throat in Skopje, endoscopic treatment was performed through a series of dilatations within 21 patients, or 58 % of the examinee, as well as the administration of mitomycin and corticoderates in 21 patients or 52% of the examinee. The applied actions and procedures had shown 100% outcome on stenoses not longer than 2 cm, who have a fibro-inflammatory scar and by Myer cotton classification 1 and second stadium. Patients that have failed endoscopic treatment, surgical treatment are a method of choice. Surgical treatments have been performed in 4 patients with realised end of the anastomosis, and 3 crycotracheal reconstructions, which is decannulated. After an extensive follow-up of these patients, depending on their condition, multiple endoscopic evaluations have been decannulated to 21 patients or 58%, and after a series of multiple unsuccessful endoscopic treatments, a condition with tracheal stoma occurs in 8 patients or 22% of the examinee.

CONCLUSION:

The observations indicate that the methods used, which are explained previously, have good effects in terms of the achieved outcomes. Due to limited resources, it is necessary to improve new methods and approaches in the treatment of stenoses, depending on their type and severity, thereby improving patient outcomes. Also, to reduce laryngotracheal stenoses, appropriate tubes and low pressure of the caffeine in the endotracheal tubules should be used.

Erythromycin combined with corticosteroid reduced inflammation and modified trauma-induced tracheal stenosis in a rabbit model

Background:

Patients with endotracheal intubation or tracheostomy are subject to benign tracheal stenosis (TS), for which current therapies are unsatisfactory. We conducted a preliminary investigation of drugs and drug combinations for the prevention and treatment of TS in a rabbit model.

Methods:

Fifty-four rabbits were apportioned into nine groups according to treatment: sham-operated control; untreated TS model; amikacin; budesonide; erythromycin; penicillin; amikacin + budesonide; erythromycin + budesonide; and penicillin + budesonide. TS was induced by abrasion during surgery. The drugs were applied for 7 days before and 10 days after the surgery. Rabbits were killed on the eleventh day. Tracheal specimens were processed for determining alterations in the thicknesses of tracheal epithelium and lamina propria via hematoxylin and eosin. The tracheal mRNA (assessed by real-time quantitative polymerase chain reaction) expressions of the following fibrotic-related factors were determined: transforming growth factor-β1 (TGF- β1), collagen type I (COL1A1), collagen type III (COL3A1), and interleukin-17 (IL-17). The protein levels of TGF-β1, COL1A1, and COL3A1 were determined through immunohistochemistry and integrated optical densities.

Results:

Compared with all other groups, the untreated TS model had significantly thicker tracheal epithelium and lamina propria, and higher mRNA and protein levels of all targeted fibrotic factors. The mRNA and protein levels of the targeted fibrotic factors in all the drug-treated groups were lower than those of the untreated TS model, and differences were most significant in the erythromycin + budesonide group.

Conclusions:

Erythromycin combined with budesonide may reduce inflammation and modify fibrosis progression in TS after tracheal injury.

The clinical feasibility of flexible bronchoscopy interventional therapy in patients with central airway stenosis and respiratory failure caused by malignancy

Objective

The aim of this study was to investigate the clinical effects and feasibility of using flexible bronchoscopy intervention in cases of malignancy that causes central airway stenosis and respiratory failure.

Methods

The clinical data of patients who were admitted to the Department of Respiratory Medicine at the First Affiliated Hospital of Nanjing Medical University and underwent treatment of a malignant tumor with central airway stenosis and respiratory failure by flexible bronchos-copy from February 2010 to May 2013 were analyzed using a retrospective method. The age, gender, location, extent of airway stenosis, interventional therapy, efficacy, and complications for 12 patients were collected and analyzed using the SPSS 13.0 software.

Results

After interventional therapy, the dyspnea index for all the patients improved signifi-cantly, and compared with before treatment, the difference was statistically significant (t=13.40, P<0.01). Eleven patients with respiratory failure were corrected, and only one patient was treated via tracheal intubation with mechanical ventilation. There were no severe complications, such as massive hemorrhaging or cardiac arrest in any case.

Conclusion

Flexible bronchoscopy interventional treatment for central airway stenosis and respiratory failure caused by malignant tumors is an effective and safe method. It should be applied in clinical work.

Difficulty in tracheal extubation followed by tracheal collapse after balloon dilatation for tracheal stenosis therapy: A case report

RATIONALE

Tracheobronchomalacia (TBM) refers to the weakening trachea or the trachea loss of structural integrity of airway cartilaginous structures. It causes tracheal stenosis, resulting in significantly high rates of mortality. Bronchoplasty by high-pressure balloon dilation under general anesthesia is a simple but effective and safe method to treat tracheobronchial stenosis. However, recurrent postoperative dyspnea after extubation due to tracheal collapse is still a challenge for anesthetists.

PATIENT CONCERNS

A 52-year-old man weighing 72 kg was scheduled for balloon dilatation surgery under general anesthesia because of breathing difficulties caused by tracheal stenosis. His previous medical history included rheumatoid arthritis, obstructive sleep apnea syndrome (OSAS), chronic bronchitis and a history of tracheal intubation. Laryngeal computerized tomography confirmed the stenosis at the level of thyroid gland.

DIAGNOSIS

The tracheal collapse after balloon dilatation for tracheal stenosis therapy.

INTERVENTIONS

Postoperatively, the patient presented with more serious and repetitive symptoms of dyspnea after extubation when compared to that before treatment. So, we had to re-insert the laryngeal mask airway (LMA), and exclude some anesthesia-associated factors, such as laryngospasm, bronchospasm and so on. After a series of treatments, we ultimately found the cause in time (the airway collapsed), and succeeded in tracheal extubation after the stent was inserted.

OUTCOMES

The patient recovered well and reported high satisfaction with anesthesia management.

LESSONS

In such an emergency even, the anesthesiologist should take valuable treatments to ensure the patient's effective ventilation. If the anesthesia-related factors can be eliminated, tracheomalacia or airway collapse should be considered whenever dyspnea occurs in the patients who unexpectedly fail to be extubated.

Outcome of advanced lung cancer with central airway obstruction versus without central airway obstruction

Patients with central airway obstruction (CAO) from advanced lung cancer present with significant morbidity and are assumed to have lower survival. Hence, they are offered only palliative support. We asked if patients who have advanced lung cancer with CAO (recanalised and treated) will behave similarly to those with advanced lung cancer without CAO. This study was a retrospective review of the medical records of the patients managed for advanced lung cancer during 2010 and 2015 at our institution. 85 patients were studied. Median survival and 1-, 2- and 5-year survival were 5.8 months, 30.3%, 11.7% and 2.3% versus 9.3 months, 35.7%, 9.6% and 4.7%, respectively, in the CAO and no CAO groups (p=0.30). More patients presented with respiratory failure (15 (35%) versus none; p=0.0001) and required assisted mechanical ventilation (10 (23.3%) versus none; p=0.001) in the CAO group compared with the no CAO group. Fewer patients received chemotherapy in the CAO group (11 (25.5%)) compared with the no CAO group (23 (54.7%); p=0.008). There was no difference in survival among patients with advanced lung cancer whether they presented with CAO or without CAO. Survival was similar to those without CAO in patients with recanalised CAO despite greater morbidity and lesser use of chemotherapy, strongly advocating bronchoscopic recanalisation of CAO. These findings dispel the nihilism associated with such cases.

Airway stent complications: the role of follow-up bronchoscopy as a surveillance method

Background

Airway stenting has become an integral part of the therapeutic endoscopic management of obstructive benign and malignant central airway diseases. Despite increased use of airway stents and frequent stent-associated complications, no clear guidelines for surveillance and maintenance exist. This study aim is to elucidate predictive factors associated with development of stent complications, as well as an optimal surveillance period for follow-up bronchoscopy for early detection and possible prevention of stent-associated complications.

Methods

Retrospective cohort study of all patients who underwent airway stent placements at our institution from April 2010 to December 2013 for benign and malignant airway diseases. Metallic, silicone (straight, Y stent, T-tube) and hybrid stents were included in the study. Stent complications were analyzed at the time of follow-up bronchoscopy performed four to six weeks after initial stent placement or earlier if patients became symptomatic.

Results

The study included 134 patients of which 147 stents were placed. Follow-up bronchoscopy was performed in 94 patients. Symptomatic status at the time of follow-up bronchoscopy was not associated with stent complications [odds ratio (OR) =1.88; 95% CI: 0.79-4.45; P=0.15]. Patient age, sex, indication for stent placement, and stent location, were not associated with development of complications (all P>0.05). Compared to all other stents, hybrid stents were more likely to migrate (OR =6.60; 95% CI: 2.16-20.2; P=0.001) or obstruct by secretions (OR =2.53; 95% CI: 1.10-5.84; P=0.03). There were no complications associated with surveillance bronchoscopy.

Conclusions

Surveillance bronchoscopy within 4 to 6 weeks of stent placement may be useful for early detection of complications and their subsequent management, regardless of symptomatic status and indication for stent placement. Prospective multicenter studies are needed to compare optimal surveillance methods and the impact on patient mortality, morbidity and healthcare costs.

A bronchoscopic approach to benign subglottic stenosis

Objectives:

Subglottic stenosis is an abnormal narrowing of the tracheal lumen at the level of subglottis (the area in between the vocal cords and the cricoid cartilage). It can cause significant symptoms due to severe attenuation of airflow. We describe our experience in alleviating symptoms by addressing the stenosis using fibreoptic bronchoscopic methods.

Methods:

We report all concurrent cases performed between September 2015 and July 2016. We use a combination of balloon dilation, electro-surgery knife to dilate and incise stenotic segments followed by steroid injection to modulate healing.

Results:

We treated 10 patients in the study period, 8 of which were women. A total of 39 procedures were performed on these patients during this period. Gastro-esophageal reflux was the most common comorbidity associated with stenosis. The majority of the patients required more than 2 therapeutic procedures, but none required more than 4 procedures. There were no complications.

Conclusion:

Tracheal stenosis and in particular subglottic stenosis is a recurrent process and its management requires extensive collaboration amongst treating specialties. Our technique of steroid injection after dilation of the stenosis was effective in symptom control and decreased the number of repeat procedures.