Tracheobronchomalacia in adults

Ultralow-Dose Dynamic Expiratory CT and Repeated Imaging Enhance Evaluation for Tracheomalacia

OBJECTIVE

This study aims to determine if a novel imaging protocol (ultralow-dose dynamic expiratory computed tomography [CT] with repeated imaging) identifies tracheomalacia (TM) more reliably than traditional dynamic tracheal CT.

METHODS

We performed a retrospective evaluation of 184 consecutive ultralow-dose dynamic CTs for TM during 2017. The protocol obtains images during 1 inspiration and 2 forced expirations. Tracheal narrowing during both expirations (airway narrowing [percentage] during first dynamic expiration CT [DE1], airway narrowing [percentage] during second dynamic expiration CT [DE2]) was reported as a percentage of inspiratory area. We identified maximum narrowing of each patient's sequence (maximum narrowing [percentage] on either dynamic expiration CT [DEmax] = greatest narrowing of DE1 or DE2) and compared DE1, DE2, and DEmax in individual studies and between patients. Outcomes included frequency of TM, tracheal narrowing, and severity. Reliability was assessed by comparing tracheal area narrowing and TM grade.

RESULTS

There was significantly more airway narrowing using 2 expiratory image acquisitions. Average DEmax tracheal area was 12% narrower than DE1 alone and 21% worse than DE2 alone (both P < 0.001). Using DEmax, TM was diagnosed 35% more often than DE1 alone and 31% more often than DE2 alone ( P < 0.001). DEmax identified more severe distribution of TM compared with DE1 or DE2 alone ( P < 0.001). Reliability between DE1 and DE2 was good for tracheal narrowing and moderate for TM grade. The mean effective radiation dose was 2.41 millisievert (mSv) for routine inspiration CT and 0.07 mSv for each dynamic expiration CT (total effective radiation, 2.55 mSv).

CONCLUSIONS

Dynamic expiration CT with 2 expiratory image acquisitions enhanced evaluation of TM, minimally increased radiation dose, and should be considered as a noninvasive screening option.

Unexpected Airway Collapse: A Rare Case of Spontaneous Postoperative Tracheobronchomalacia in the Absence of Identifiable Risk Factors

We report the case of a 53-year-old female who developed tracheobronchomalacia immediately following an uncomplicated robotic hysterectomy with bilateral salpingo-oophorectomy to treat postmenopausal bleeding. Induction of anesthesia was notable for moderately difficult intubation, managed with applied cricothyroid pressure and a small 6.5 endotracheal tube placement via GlideScope. The surgical course was uneventful. The patient remained intubated in the post-anesthesia care unit but was not providing end-tidal volumes. Attempts to replace the endotracheal tube with a larger tube were unsuccessful and the patient was temporarily unable to ventilate. Rapid troubleshooting discovered that a laryngeal mask airway (LMA) could sufficiently ventilate the patient. An otolaryngologist was able to perform direct bronchoscopy, which revealed more than 50% dynamic anterior-posterior collapse of the trachea and bronchi. The patient was subsequently awakened from anesthesia and monitored in the intensive care unit, ventilating with an LMA. After a couple of hours, it was determined that the patient's airway was protected, and the LMA was removed.

Preoperative Workup of Patients With Excessive Central Airway Collapse: Does Stent Evaluation Serve a Role?

BACKGROUND

Tracheobronchoplasty (TBP) is a definitive anatomic intervention for patients with severe symptomatic expiratory central airway collapse. Although stent evaluations have been described for surgical workup, current literature does not address if improvement during stent evaluation is sustained after TBP. We compared health-related quality of life (HRQOL) and functional status responses after airway stenting to those post-TBP.

METHODS

A retrospective review was performed in patients with severe expiratory central airway collapse who underwent stent evaluation followed by TBP from January 2004 to December 2019. Baseline, poststent, 3- and 12-month postoperative HRQOL scores, and functional status were analyzed with statistical tests as appropriate.

RESULTS

One hundred twenty patients underwent a stent evaluation and TBP. Baseline and stent evaluation measurements were compared with statistically and clinically significant differences in the Cough Quality-of-life Questionnaire (CQLQ) (55 vs. 68, P <0.01), Modified Medical Research Council (mMRC) 0 to 2 (90% vs. 47%, P <0.01), 6-minute walk test (6MWT) (1301 ft vs. 1138 ft, P <0.01). Improvements in the HRQOL and functional status were maintained from stent evaluation to 3 months postoperatively [CQLQ 55 vs. 54, P =0.63; mMRC 0 to 2 (87% vs. 84%), P =0.39; 6MWT 1350 ft vs. 1314 ft, P =0.33], and 12 months postoperatively [CQLQ 54 vs. 54, P =0.91; mMRC 0 to 2 (95% vs. 86%), P =0.74; 6MWT 1409 ft vs. 1328 ft, P =0.13]. The magnitude of change between the data was not significantly different between the stent evaluation, 3-, and 12 months postoperative. Predicted forced expiratory volume in 1-second measurements at baseline, after stent placement, 3 months, and 12 months post-TBP were 74%, 79%, 73%, and 73%, respectively, and not clinically significant.

CONCLUSIONS

Improvement after stent evaluation and the magnitude of improvement may be predictive of postoperative outcomes up to 1 year after surgery.

Bronchoscopy for refractory/unexplained cough with mucus

INTRODUCTION

Refractory/unexplained cough (RUCC) is typically associated with throat symptoms and a dry cough. Some patients attending specialist cough clinics however, report sputum production (>1 tablespoon daily) and atypical sensations (urge-to-cough in chest). Bronchoscopy findings in this specific cohort have rarely been described.

AIMS

We aimed to evaluate bronchoscopy, bronchoalveolar lavage (BAL) cell differential and microbiology findings in RUCC with mucus production.

METHODS

We retrospectively reviewed case notes, procedure results and treatment of patients undergoing bronchoscopy for RUCC with more than a tablespoon of sputum daily.

RESULTS

Data were included from 54 patients with RUCC, normal or trivial findings on CT (Computerised Tomography) imaging and no response to guideline-directed treatment of their cough. Most (84%) patients had BAL neutrophilia and excessive dynamic airway collapse (EDAC) was seen in 31%. Treatment strategies in these patients differed to those adopted in typical RUCC associated with a dry cough. Management was influenced or changed in 48/54 (89%) of the patients undergoing bronchoscopy.

CONCLUSIONS

Bronchoscopy provides high diagnostic value in RUCC with mucus production (>1 tbsp daily), identifying specific treatable traits including neutrophilic airway inflammation and EDAC.

Thermoablative Techniques to Treat Excessive Central Airway Collapse

Excessive central airway collapse (ECAC) is a condition characterized by the excessive narrowing of the trachea and mainstem bronchi during expiration, which can be caused by Tracheobronchomalacia (TBM) or Excessive Dynamic Airway Collapse (EDAC). The initial standard of care for central airway collapse is to address any underlying conditions such as asthma, COPD, and gastro-esophageal reflux. In severe cases, when medical treatment fails, a stent-trial is offered to determine if surgical correction is a viable option, and tracheobronchoplasty is suggested as a definitive treatment approach. Thermoablative bronchoscopic treatments, such as Argon plasma coagulation (APC) and laser techniques (potassium-titanyl-phosphate [KTP], holmium and yttrium aluminum pevroskyte [YAP]) are a promising alternative to traditional surgery. However, further research is needed to assess their safety and effectiveness in humans before being widely used.

Tracheobronchoplasty: Indications and Best Approaches

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.

Improvement in postoperative lung function in patients with moderate to severe airway obstruction after robotic-assisted thoracoscopic tracheobronchoplasty

OBJECTIVE

The study objective was to examine pulmonary function and quality of life improvement after robotic-assisted thoracoscopic tracheobronchoplasty for patients with different degrees of obstructive airway disease.

METHODS

We performed a retrospective review of a prospective database of patients who underwent robotic-assisted thoracoscopic tracheobronchoplasty between 2013 and 2020.

RESULTS

A total of 118 patients underwent robotic-assisted thoracoscopic tracheobronchoplasty. Preoperative and postoperative pulmonary function tests were available for 108 patients. Postoperative pulmonary function tests at a median of 16 months demonstrated a significant increase in percent predicted forced expiratory volume in 1 second (preoperative median: 76.76% predicted, postoperative: 83% predicted, P = .002). Preoperative and postoperative St George Respiratory Questionnaires were available for 64 patients with a significant decrease in postoperative score at a median of 7 months (preoperative median: 61, postoperative: 41.60, P < .001). When stratified by preoperative degree of obstruction, robotic-assisted thoracoscopic tracheobronchoplasty improved forced expiratory volume in 1 second in moderate to very severe obstruction with a statistically significant improvement in moderate (preoperative median: 63.91% predicted, postoperative median: 73% predicted, P = .001) and severe (preoperative median: 44% predicted, postoperative median: 57% predicted, P = .007) obstruction. St George Respiratory Questionnaire scores improved for all patients. Improvement for mild (preoperative median: 61.27, postoperative median: 36.71, P < .001) and moderate (preoperative median: 57.15, postoperative median: 47.52, P = .03) obstruction was statistically significant.

CONCLUSIONS

Robotic-assisted thoracoscopic tracheobronchoplasty improves obstruction and symptoms. With limited follow-up, subgroup analysis showed forced expiratory volume in 1 second improved in severe preoperative obstruction and quality of life improved in moderate obstruction. Future follow-up is required to determine robotic-assisted thoracoscopic tracheobronchoplasty effects on the most severe group, but we cannot conclude that increased degree of preoperative obstruction precludes surgery.

Stent Evaluation for Expiratory Central Airway Collapse: Does the Type of Stent Really Matter?

BACKGROUND

Careful selection of patients with expiratory central airway collapse (ECAC) that may benefit from tracheobronchoplasty (TBP) can be aided by a short-term airway stent evaluation. This can be performed with either silicone Y-stents (SYSs) or uncovered self-expanding metallic airway-stents (USEMAS). No direct comparison has been made between these 2 stent types.

METHODS

This was a small retrospective review of consecutive patients that underwent a stent evaluation. A propensity score was used to match patients in the USEMAS and SYS groups. Outcomes included complications, changes in the health-related quality-of-life (HR-QoL), and changes in exercise capacity. Baseline measurements were compared with those obtained during stent evaluation and after TBP.

RESULTS

Forty-two patients with severe ECAC underwent USEMAS placement, while 18 patients had an SYS placed. Propensity score matching resulted in 13 matched SYS and USEMAS pairs. The SYS group had an increased rate of mucus plugging (38.5% vs. 0%, P <0.047). Although not statically significant, a clinical improvement was observed in HR-QoL and exercise capacity in the USEMAS group during stent placement. In patients who underwent TBP, both USEMAS and SYS groups had a statistically significant change in the Modified Medical Research Council Dyspnea Scale during stent evaluation and after TBP.

CONCLUSION

In patients with severe ECAC, short-term evaluation with airway stents appears to be safe and improves respiratory symptoms, HR-QoL, and exercise capacity. The use of USEMAS led to a lower complication rate, a greater improvement in HR-QoL and exercise capacity, and appeared to better predict how the patients would respond to TBP.

Bronchoscopy-Guided Intervention Therapy With Extracorporeal Membrane Oxygenation Support for Relapsing Polychondritis With Severe Tracheobronchomalacia: A Case Report and Literature Review

Relapsing polychondritis is an immune disorder of unknown etiology involving multiple systems that is characterized by persistent inflammation and destruction of cartilage, including the ears, nose, costal, joint, and airways. Airway involvement caused by relapsing polychondritis is common, and tracheobronchomalacia is the most serious complication, which is life-threatening. Currently, the exact mechanism of relapsing polychondritis with tracheobronchomalacia is unknown. Although glucocorticoids and immunosuppressive agents are administered, failures often occur. Currently, bronchoscopy-guided intervention therapy used in tracheobronchomalacia caused by chronic obstructive pulmonary disease or other etiology has gradually increased, but bronchoscopy-guided intervention therapy with extracorporeal membrane oxygenation assist used in tracheobronchomalacia caused by relapsing polychondritis has not been reported. Here, we report a case of relapsing polychondritis with severe tracheobronchomalacia. Although drug therapy was provided and airway stent implantation was performed, the tracheal stenosis was further aggravated. Because conventional anesthesia and mechanical ventilation cannot meet the needs of bronchoscopy-guided intervention therapy or guarantee sufficient safety. The intervention treatment was performed with the support of extracorporeal membrane oxygenation, which was successfully completed without obvious complications. The symptoms were significantly improved, and the patient was discharged uneventfully.

A Pilot Gene Expression and Histopathologic Analysis of Tracheal Resections in Tracheobronchomalacia

BACKGROUND

The airway structures and mRNA expression of genes that regulate airway inflammation and remodeling may be altered in the trachea of patients with tracheobronchomalacia (TBM).

METHODS

Fourteen tracheal specimens from 2005-to-2018 were used in this study. Surgical resection specimens from patients with TBM and tracheal stenosis (TS) were compared to control tracheal specimens obtained from autopsy cases. We investigated the mRNA expression of genes encoding fibroblast growth factor (FGF), binding protein 2 (FGFBP2), FGF receptor R3 (FGFR3), interleukin-1 beta (IL1β), tumor growth factor-beta 1 (TGFβ1), tissue inhibitor of metalloproteinases 1 (TIMP1), and intercellular adhesion molecule 1 (ICAM1), as well as established markers of airway inflammation including interferon-gamma (IFNγ) and tumor necrosis factor (TNF). The relative expression of target transcripts was assessed by qRT-PCR. A histological examination of the same resected airway specimens was performed on formalin-fixed paraffin embedded tissue sections.

RESULTS

FGFBP2 and FGFR3 showed higher expression in TBM compared to TS and control groups (p<0.05, p<0.01, respectively). Furthermore, both TGFβ1 and TIMP1 were elevated in TBM compared to controls (p<0.05). Conversely, ICAM1 was downregulated in TBM versus TS and controls (p<0.05). IL1β, IFNγ, and TNF were increased in TBM although did not achieve statistical significance. Histologically, compared to control airways, both TBM and TS demonstrated submucosal fibrotic changes, with TBM additionally demonstrating alterations in elastin fiber quality and density in the posterior membrane.

CONCLUSIONS

Significant changes in gene expression are observed in the tracheal walls of patients with TBM and TS compared to controls.

Unexplained recurrent shock in peripheral T-cell lymphoma: A case report

Malignant lymphoma sometimes manifests with septic-like shock symptoms. We report a case of peripheral T-cell lymphoma presenting with unexplained recurrent shock in absence of apparent lymphadenopathy. The patient also experienced varied symptoms, including severe chest and back pain, respiratory distress due to tracheobronchomalacia, skin rash, and fever.

Robotic-assisted tracheobronchoplasty: Quality of life and pulmonary function assessment on intermediate follow-up

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.

A successful surgical tracheobronchoplasty in a case of expiratory collapse of central airways associated with tracheobronchomalacia in a severely deformed single lung patient

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.

Robotic-assisted tracheobronchial surgery

Robotic technology is positioned to transform the approach to tracheobronchial surgery. With its magnified 3D view, intuitive controls, wristed-instruments, high-fidelity simulation platforms, and the steady implementation of new technical improvement, the robot is well-suited to manage the careful dissection and delicate handling of the airway in tracheobronchial surgery. This innovative technology has the potential to promote the widespread adoption of minimally invasive techniques for this complex thoracic surgery.

Longitudinal Follow-up of Patients With Tracheobronchomalacia After Undergoing Tracheobronchoplasty: Computed Tomography Findings and Clinical Correlation

PURPOSE

The purpose of this study was to evaluate intermediate and long-term changes in expiratory tracheal collapsibility by computed tomography (CT) in patients with tracheobronchomalacia following surgical treatment with tracheobronchoplasty and to correlate CT findings with clinical findings.

MATERIALS AND METHODS

Between 2003 and 2016, 18 patients with tracheobronchomalacia underwent tracheobronchoplasty and were imaged preoperatively and postoperatively at both intermediate and long-term intervals. Imaging included end-inspiratory and dynamic expiratory phase scans. The cross-sectional area of the airway lumen was measured at 2 standard levels (1 cm above the aortic arch and carina). These measurements were used to calculate % collapsibility. Clinical findings recorded included a questionnaire on symptomatology and a 6-minute walk test.

RESULTS

Before surgery, expiratory collapsibility of the upper trachea was 72%±25% (mean±SD) and that of the lower trachea was 68%±22%. On intermediate follow-up (mean, 1.5 y), collapsibility significantly decreased to 37%±21% at the upper trachea and 35%±19% at the lower trachea (P<0.001). On long-term follow-up (mean, 6 y), collapsibility increased to 51%±20% at the upper trachea and 47%±17% at the lower trachea and was significantly worse than on intermediate follow-up (P=0.002). However, collapsibility on long-term follow-up remained significantly lower than preoperative collapsibility (P=0.015). Clinical findings showed a similar trend as quantitative CT measurements.

CONCLUSION

Expiratory tracheal collapsibility substantially decreases after tracheobronchoplasty on intermediate follow-up. At long-term follow-up, tracheal collapsibility shows a modest increase, but remains significantly lower than the preoperative baseline. Quantitative measurements from dynamic CT have the potential to play an important role as imaging biomarkers for assessing response to tracheobronchoplasty.

Tracheobronchoplasty after a trial with a silicone Y-stent in a patient with Mounier-Kuhn syndrome

Tracheobronchomegaly or Mounier-Kuhn syndrome is a rare disorder characterized by the widening of the trachea and the main bronchi. It is a form of tracheomalacia called 'cartilaginous malacic' and is characterized by deformation of the tracheal cartilages and intrusion of the redundant membranous wall into the lumen of the airway. We present a patient with Mounier-Kuhn syndrome managed like patients with tracheomalacia of other aetiologies-a tracheobronchoplasty with a reconstructed D-shaped trachea and stabilization of the posterior membranous wall by attaching a polypropylene mesh to the posterior membranous wall of the trachea and the main bronchi after a trial period with a tracheobronchial Y-shaped silicone stent.

First series of minimally invasive, robot-assisted tracheobronchoplasty with mesh for severe tracheobronchomalacia

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.

Frailty Characteristics Predict Respiratory Failure in Patients Undergoing Tracheobronchoplasty

BACKGROUND

Respiratory complications are the leading cause of morbidity in patients undergoing tracheobronchoplasty, yet risk stratification systems on this population are insufficient. We investigated the association between frailty and risk of major respiratory complications after tracheobronchoplasty.

METHODS

A retrospective review was made of 161 consecutive tracheobronchoplasties (October 2002 to September 2016). A frailty index was developed by the deficit-accumulation approach comprising 26 multidomain preoperative variables. The main outcome was a composite endpoint of major respiratory complications within 30 days of surgery. Odds ratio (OR) and 95% confidence interval (CI) were estimated using logistic regression.

RESULTS

The cohort consisted of 103 women (64%), median age of 58 years (interquartile range, 51 to 66) and median FI of 0.25 (interquartile range, 0.1 to 0.3). Forty-eight patients (30%) had respiratory complications, the most common being respiratory failure (n = 27, 16.8%) and pneumonia (n = 25, 15.5%). Severe frailty (frailty index ≥0.33) was strongly associated with major respiratory complications (73.8% versus 2.5%; OR 58.8, 95% CI: 9.6 to 358.3). The association with severe frailty appeared stronger for respiratory failure (47.6% versus 2.5%; OR 30, 95% CI: 4.7 to 189.9) than for pneumonia (40.5% versus 0%; OR 35.2. 95% CI: 2.0 to 599.8). Further adjustment for intraoperative crystalloid volume or forced expiratory volume in 1 second moderately attenuated the association between frailty with major respiratory complications (OR 17.4. 95% CI: 2.0 to 150.8), respiratory failure (OR 13.1, 95% CI: 1.7 to 95.8), and pneumonia (OR 20.1, 95% CI: 1.1 to 341.8).

CONCLUSIONS

Frailty, as indicated by frailty index, was associated with major respiratory complications, particularly respiratory failure after tracheobronchoplasty. Preoperative identification of frailty may help guide decision making for patients considering this effective, although arduous procedure.

Airway stenting in excessive central airway collapse

In tracheobronchomalacia (TBM) and other disorders, weakened airway walls lead to expiratory central airway collapse (ECAC) and can cause symptoms of cough, dyspnea, retained secretions, and recurrent pulmonary infections. Diagnosis of severe ECAC is based on the presence of >90% expiratory airway collapse on dynamic computed tomography (CT) and/or bronchoscopy. We offer patients with severe ECAC a trial of airway stenting to determine whether splinting of the central airways leads to improvements in symptoms, quality of life, exercise capacity, or respiratory function. Patients who respond positively to airway stenting are considered for tracheobronchoplasty.

Tracheobronchomalacia

The term tracheobronchomalacia refers to excessively compliant and collapsible central airways leading to symptoms. Although seen as a coexisting condition with various other pulmonary condition, it may cause symptoms by itself. The condition is often misdiagnosed as asthma, bronchitis or just chronic cough due to a lack of specific pathognomonic history and clinical findings. The investigation revolves around different modes of imaging, lung function testing and usually confirmed by flexible bronchoscopy. The treatment widely varies based on the cause, with most cases treated conservatively with non-invasive ventilation. Some may require surgery or stent placement. In this article, we aim to discuss the pathophysiology behind this condition and recognize the common symptoms and causes of tracheobronchomalacia. The article will highlight the diagnostic steps as well as therapeutic interventions based on the specific cause.

Current concepts in severe adult tracheobronchomalacia: evaluation and treatment

There is increasing recognition of tracheobronchomalacia (TBM) in patients with respiratory complaints, though its true incidence in the adult population remains unknown. Most of these patients have an acquired form of severe diffuse TBM of unclear etiology. The mainstays of diagnosis are dynamic (inspiratory and expiratory) airway computed tomography (CT) scan and dynamic flexible bronchoscopy with forced expiratory maneuvers. While the prevailing definition of TBM is 50% reduction in cross-sectional area, a high proportion of healthy volunteers meet this threshold, thus this threshold fails to identify patients that might benefit from intervention. Therefore, we consider complete or near-complete collapse (>90% reduction in cross-sectional area) of the airway to be severe enough to warrant potential intervention. Surgical central airway stabilization by posterior mesh splinting (tracheobronchoplasty) effectively corrects malacic airways and has been shown to lead to significant improvement in symptoms, health-related quality of life, as well as functional and exercise capacity in carefully selected adults with severe diffuse TBM. A short-term stent trial clarifies a patient's candidacy for surgical intervention. Coordination of care between experienced interventional pulmonologists, radiologists, and thoracic surgeons is essential for optimal outcomes.

Transtracheal single-point stent fixation in posttracheotomy tracheomalacia under cone-beam computer tomography guidance by transmural suturing with the Berci needle - a perspective on a new tool to avoid stent migration of Dumon stents

Tracheomalacia or tracheobronchomalacia (TM or TBM) is a common problem especially for elderly patients often unfit for surgical techniques. Several surgical or minimally invasive techniques have already been described. Stenting is one option but in general long-time stenting is accompanied by a high complication rate. Stent removal is more difficult in case of self-expandable nitinol stents or metallic stents in general in comparison to silicone stents. The main disadvantage of silicone stents in comparison to uncovered metallic stents is migration and plugging. We compared the operation time and in particular the duration of a sufficient Dumon stent fixation with different techniques in a patient with severe posttracheotomy TM and strongly reduced mobility of the vocal cords due to Parkinson’s disease. The combined approach with simultaneous Dumon stenting and endoluminal transtracheal externalized suture under cone-beam computer tomography guidance with the Berci needle was by far the fastest approach compared to a (not performed) surgical intervention, or even purely endoluminal suturing through the rigid bronchoscope. The duration of the endoluminal transtracheal externalized suture was between 5 minutes and 9 minutes with the Berci needle; the pure endoluminal approach needed 51 minutes. The alternative of tracheobronchoplasty was refused by the patient. In general, 180 minutes for this surgical approach is calculated. The costs of the different approaches are supposed to vary widely due to the fact that in Germany 1 minute in an operation room costs on average approximately 50–60€ inclusive of taxes. In our own hospital (tertiary level), it is nearly 30€ per minute in an operation room for a surgical approach. Calculating an additional 15 minutes for patient preparation and transfer to wake-up room, therefore a total duration inside the investigation room of 30 minutes, the cost per flexible bronchoscopy is per minute on average less than 6€. Although the Dumon stenting requires a set-up with more expensive anesthesiology accompaniment, which takes longer than a flexible investigation estimated at 1 hour in an operation room, still without calculation of the costs of the materials and specialized staff that the surgical approach would consume at least 3,000€ more than a minimally invasive approach performed with the Berci needle. This difference is due to the longer time of the surgical intervention which is calculated at approximately 180 minutes in comparison to the achieved non-surgical approach of 60 minutes in the operation suite.

Respiratory support with venovenous extracorporeal membrane oxygenation during stenting of tracheobronchomalacia

A subset of patients with severe airway disease cannot be adequately supported with conventional mechanical ventilation during complex airway procedures. We report the successful respiratory support of a patient with severe tracheobronchomalacia with venovenous extracorporeal membrane oxygenation during rigid bronchoscopy with stent removal and stent placement.

Technical aspects and outcomes of tracheobronchoplasty for severe tracheobronchomalacia

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.