Factors predicting outcome following airway stenting for post-tuberculosis tracheobronchial stenosis

Long term management of people with post-tuberculosis lung disease

Post-tuberculosis lung disease (PTLD) is emerging as a significant area of global interest. As the number of patients surviving tuberculosis (TB) increases, the subsequent long-term repercussions have drawn increased attention due to their profound clinical and socioeconomic impacts. A primary obstacle to its comprehensive study has been its marked heterogeneity. The disease presents a spectrum of clinical manifestations which encompass tracheobronchial stenosis, bronchiectasis, granulomas with fibrosis, cavitation with associated aspergillosis, chronic pleural diseases, and small airway diseases-all persistent consequences of PTLD. The spectrum of symptoms a patient may experience varies based on the severity of the initial infection and the efficacy of the treatment received. As a result, the long-term management of PTLD necessitates a detailed and specific approach, addressing each manifestation individually-a tailored strategy. In the immediate aftermath (0-12 months after anti-TB chemotherapy), there should be an emphasis on monitoring for relapse, tracheobronchial stenosis, and smoking cessation. Subsequent management should focus on addressing hemoptysis, managing infection including aspergillosis, and TB-associated chronic obstructive pulmonary disease or restrictive lung function. There remains a vast expanse of knowledge to be discovered in PTLD. This review emphasizes the pressing need for comprehensive, consolidated guidelines for management of patients with PTLD.

Clinical Factors for Successful Removal of Airway Silicone Stents in Patients With Post-Tuberculosis Tracheobronchial Stenosis

BACKGROUND

After relieving stenosis with an airway silicone stent in post-tuberculosis bronchial stenosis (PTTS), stent removal is attempted if it is determined that airway patency can be maintained even after stent removal. However, the factors affecting airway stent removal are not well known. We investigate the factors that enable the successful removal of airway silicone stents in patients with PTTS.

METHODS

We retrospectively analyzed PTTS patients who underwent bronchoscopic intervention from January 2004 to December 2019. Successful stent removal is defined as airway patency maintained when the stent is removed, so that reinsertion of the stent is not required. A multivariate logistic regression analysis was used to identify independent factors associated with successful stent removal at the first attempt.

RESULTS

Total 344 patients were analyzed. Patients were followed up for a median of 47.9 (26.9-85.2) months after airway stent insertion. Approximately 69% of PTTS patients finally maintained airway patency after the stent was removed. Factors related to successful stent removal at the first attempt were older age and male sex. Absence of parenchymal calcification, segmental consolidation & bronchiolitis, and no trachea involved lesion were relevant to the successful stent removal. Stent dwelling for 12-24 months was associated with successful stent removal compared to a duration of less than 12 months.

CONCLUSION

For patients whose airway patency is determined to be maintained even without a stent, it is necessary to attempt stent removal in consideration of factors related to successful stent removal.

Rigid Bronchoscopy for Post-tuberculosis Tracheobronchial Stenosis

The healing process of tracheobronchial tuberculosis (TB) results in tracheobronchial fibrosis causing airway stenosis in 11% to 42% of patients. In Korea, where pulmonary TB is still prevalent, post-TB tracheobronchial stenosis (PTTS) is one of the main causes of benign airway stenosis causing progressive dyspnea, hypoxemia, and often life-threatening respiratory insufficiency. The development of rigid bronchoscopy replaced surgical management 30 years ago, and nowadays PTTS is mainly managed by bronchoscopic intervention in Korea. Similar to pulmonary TB, tracheobronchial TB is treated with combination of anti-TB medications. The indication of rigid bronchoscopy is more than American Thoracic Society (ATS) grade 3 dyspnea in PTTS patients. First, the narrowed airway is dilated by multiple techniques including ballooning, laser resection, and bougienation under general anesthesia. Then, most of the patients need silicone stenting to maintain the patency of dilated airway; 1.5 to 2 years after indwelling, the stent could be removed, this has shown a 70% success rate. Acute complications without mortality develop in less than 10% of patients. Subgroup analysis showed successful removal of the stent was significantly associated with male sex, young age, good baseline lung function and absence of complete one lobe collapse. In conclusion, rigid bronchoscopy could be applied to PTTS patients with acceptable efficacy and tolerable safety.

Trends and an Online Survey on the Use of Rigid Bronchoscopy in Korea

BACKGROUND

Although almost all interventional pulmonologists agree that rigid bronchoscopy is irreplaceable in the field of interventional pulmonology, less is known about the types of diseases that the procedure is used for and what difficulties the operators face during the procedure. The purpose of this study is to evaluate what diseases rigid bronchoscopy is used for, whether it is widely used, and what challenges the operators face in Korea.

METHODS

We enrolled 14 hospitals in this retrospective cohort of patients who underwent rigid bronchoscopy between 2003 and 2020. An online survey was conducted with 14 operators to investigate the difficulties associated with the procedure.

RESULTS

While the number of new patients at Samsung Medical Center (SMC) increased from 189 in 2003-2005 to 468 in 2018-2020, that of other institutions increased from 0 to 238. The proportion of SMC patients in the total started at 100% and steadily decreased to 59.2%. The proportion of malignancy as the indication for the procedure steadily increased from 29.1% to 43.0%, whereas post-tuberculous stenosis (25.4% to 12.9%) and post-intubation stenosis (19.0% to 10.9%) steadily decreased (all P for trends < 0.001). In the online survey, half of the respondents stated that over the past year they performed less than one procedure per month. The fewer the procedures performed within the last year, the more likely collaboration with other departments was viewed as a recent obstacle (Spearman correlation coefficient, r_s = -0.740, P = 0.003) and recent administrative difficulties were encountered (r_s = -0.616, P = 0.019).

CONCLUSION

This study demonstrated that the number of patients undergoing rigid bronchoscopy has been increasing, especially among cancer patients. For this procedure to be used more widely, it will be important for beginners to systematically learn about the procedure itself as well as to achieve multidisciplinary consultation.

Prognostic Factors for Tracheal Restenosis after Stent Removal in Patients with Post-Intubation and Post-Tracheostomy Tracheal Stenosis

PURPOSE

Long-term tracheal stent placement can increase the risk of stent-related complications; hence, removal of the stent after stabilization is attempted. However, little evidence has been established regarding the risk factors for tracheal restenosis. We aimed to identify the risk factors for tracheal restenosis in patients with post-intubation tracheal stenosis (PITS) and post-tracheostomy tracheal stenosis (PTTS).

MATERIALS AND METHODS

We retrospectively analyzed patients with PITS and PTTS between January 2004 and December 2019. Patients were classified into a success or failure group according to treatment outcomes. Patients with successful stent removal were defined as patients who did not require additional intervention after stent removal during the follow-up period. Multiple logistic regression analysis was performed to identify the factors associated with tracheal restenosis.

RESULTS

Among 269 stented patients, 130 patients who had removed the stent were enrolled in this study. During the follow-up period, 73 (56.2%) patients had a stable clinical course; however, 57 (43.8%) patients had restenosis. The proportion of trauma-induced intubation was higher in the success group than in the failure group (p=0.026), and the median stent length was shorter in the success group (45 mm) than in the failure group (50 mm, p=0.001). On multivariate analysis, trauma-induced intubation [adjusted odds ratio (aOR), 0.329; 95% confidence interval (CI), 0.117-0.927; p=0.036], and stent length <50 mm (aOR, 0.274; 95% CI, 0.130-0.578; p=0.001) were associated with a decreased risk of restenosis.

CONCLUSION

Trauma-induced intubation and stent length were associated with successful stent removal.

Multi-disciplinary management of patients with benign airway strictures: A review

Histologically benign airway strictures are frequently misdiagnosed as asthma or COPD and may present with severe symptoms including respiratory failure. A clear understanding of pathophysiology and existing classification systems is needed to determine the appropriate treatment options and predict clinical course. Clinically significant airway strictures can involve the upper and central airways extending from the subglottis to the lobar airways. Optimal evaluation includes a proper history and physical examination, neck and chest computed tomography, pulmonary function testing, endoscopy and serology. Available treatments include medical therapy, endoscopic procedures and open surgery which are based on the stricture's extent, location, etiology, morphology, severity of airway narrowing and patient's functional status. The acuity of the process, patient's co-morbidities and operability at the time of evaluation determine the need for open surgical or endoscopic interventions. The optimal management of patients with benign airway strictures requires the availability, expertise and collaboration of otolaryngologists, thoracic surgeons and interventional pulmonologists. Multidisciplinary airway teams can facilitate accurate diagnosis, guide management and avoid unnecessary procedures that could potentially worsen the extent of the disease or clinical course. Implementation of a complex airway program including multidisciplinary clinics and conferences ensures that such collaboration leads to timely, patient-centered and evidence-based interventions. In this article we outline algorithms of care and illustrate therapeutic techniques based on published evidence.

Self-expanding covered metallic stents as a transition to silicone stent implantation in management of severe post-tuberculosis bronchial stenosis

BACKGROUND AND AIMS

Post-tuberculosis bronchial stenosis (PTBS) is one of the most common complications of tracheobronchial tuberculosis. Silicone stent serves as a major treatment for maintaining airway patency. However, silicone stent placement remains a large challenge in patients with severe cicatricial PTBS. Our objective was to evaluate the efficacy and safety of covered, self-expanding, metallic stents (SEMSs) as a transition to silicone stent implantation for treating severe PTBS.

METHODS

We retrospectively reviewed the data of patients with severe PTBS who received airway stenting in the First Affiliated Hospital of Guangdong Medical University between September 2015 and May 2019. The types of the stent, intervention procedures, bronchoscopic findings, clinical outcomes and related complications were collected and analyzed.

RESULTS

Fifty-eight cases with severe PTBS were included in this study. Thirteen (22.4%) of the patients received bronchial silicone stent implantation immediately after dilations. For the remaining 45 (77.6%) patients, silicone stents could not be deployed after dilations and SEMSs implantation was implemented as a bridge to silicone stenting. The SEMSs were placed for an interval of 28.4 ± 11.1 days. All of the silicone stents were inserted successfully following the removal of SEMSs. No SEMS-related complication occurred. The subgroup analysis showed that patients who received transitional SEMSs had less luminal caliber but fewer transbronchial dilations before silicone stent implantation (p < 0.05).

CONCLUSION

Covered SEMS placement as a transition to silicone stenting could serve as a feasible procedure to reduce complications and improve the success rate of silicone stent implantation in patients with severe PTBS.The reviews of this paper are available via the supplemental material section.

Clinical Outcomes of Complications Following Self-Expandable Metallic Stent Insertion for Benign Tracheobronchial Stenosis

Background and Objectives: The use of metallic stents in benign TBS is controversial. Here, we report the clinical outcomes of patients who developed complications due to self-expandable metallic stent (SEMS) insertion for benign TBS. Materials and Methods: Our institution, which is the largest and most active referral hospital for airway stenosis in South Korea, only uses silicone stents. We conducted a retrospective review of 20 patients referred after the insertion of SEMS for benign TBS from 2006 to 2015. Results: All 20 patients underwent rigid bronchoscopy for SEMS removal due to airway obstruction from granulation tissue overgrowth. All but one (95%) experienced successful removal of the SEMS. During a median follow-up period of 40 months, a median of seven rigid bronchoscopies per patient was needed to maintain airway patency. Three (15%) patients suffered acute complications during SEMS removal (bleeding (10%) and fistula (5%)). All patients suffered chronic complications (granulation tissue (80%), stent migration (58%), mucostasis (55%), and restenosis (43%)). Eventually, 15 patients (75%) needed airway prostheses (silicone stent (75%) and tracheostomy (25%)). Conclusion: Our findings indicate that SEMS should be avoided until positive results are consistently reported by high-quality studies in patients with benign TBS.

Long-term outcomes of tracheobronchial stenosis due to tuberculosis (TSTB) in symptomatic patients: airway intervention vs. conservative management

Background

Patients with tracheobronchial stenosis due to tuberculosis (TSTB) have a variable clinical course and response to treatment including airway intervention. There are no clear guidelines on the best approach to manage such patients. This study examines long-term outcomes of patients with TSTB and factors associated with recurrent symptoms or need for repeat airway intervention following initial bronchoscopic intervention.

Methods

This is a retrospective analysis of patients with TSTB over an 18-year period. Symptoms, radiological, bronchoscopic findings, airway interventions and complications were obtained. Multivariate logistic regression analysis was performed to identify factors predictive of recurrence of symptoms or need for repeat airway intervention.

Results

A total of 131 patients with mean age 50±18 years and median follow-up 5 (interquartile range, 2–10) years were included. Nineteen (29.7%) patients underwent balloon dilatation alone, 22 (34.4%) had additional resection or stenting, and 19 (29.7%) underwent all 3 procedures. Among patients conservatively managed, a larger proportion (55.6%) of patients with no recurrence of symptoms had active TB. Patients who developed recurrent symptoms had longer symptom duration (12 vs. 3 months, P=0.025), and more had recurrent lower respiratory tract infections (50% vs. 5.6%, P=0.003), lung collapse (90.0% vs. 41.7%, P=0.011) or linear fibrosis (70.0% vs. 30.6%, P=0.033) compared to those without recurrent symptoms. Bronchomalacia (OR =17.18; 95% CI, 3.43–86.18) and prior bronchoscopic airway resection (OR =4.97; 95% CI, 1.20–20.60) were strongly associated with the recurrence of symptoms or need for repeat airway intervention on multivariate logistic regression analysis.

Conclusions

Bronchomalacia and prior bronchoscopic airway resection are associated with the recurrence of symptoms despite airway intervention. Patients who are diagnosed with TSTB early in the course of active TB may be conservatively managed.

Long-term follow-up of self-expandable metallic stents in benign tracheobronchial stenosis: a retrospective study

BACKGROUND

Self-expandable metallic stents (SEMSs) have enabled a approving management of malignant airway stenosis. However, the long-term efficacy and safety of this treatment in patients with benign airway stricture are unclear. We conducted this study to retrospectively determine the efficacy and long-term outcomes in patients who have undergone SEMS placement for benign tracheobronchial stenosis.

METHODS

All patients treated with SEMSs from July 2003 to June 2016 were reviewed for symptomatic response, complications, and long-term outcomes.

RESULTS

Total 131 stents were successfully deployed in 116 patients. Ninety-eight patients demonstrated clinical improvement after stent insertion (84.48%; 95% confidence interval [CI]: 77.89-91.07). Compared with uncovered stents, covered stents were associated with more sore throats complaints or chest pain (13.89% versus 28.81%, P = 0.036) and with higher incidences of major and minor granulation tissue formation and with recurrent stenosis (4.17% versus 15.25%, P = 0.029; 11.11% versus 37.29%, P < 0.0001 and 9.72% versus 28.81%, P = 0.005, respectively). Each covered and uncovered stent developing tissue hyperplasia required a median of 2 (range: 1-15) and 1(range: 1-7) fibrobronchoscope with electrocautery therapy, respectively. At follow-up (median: 1276 days; range: 2-4263), 68 patients had complete resolution, 15 remained under interventional treatment, 8 had bronchial occlusions, 7 underwent surgery, 14 were lost to follow-up, and 4 died of stent unrelated causes.

CONCLUSION

SEMS placement achieved most clinical improvement among patients in our study, if adequate endotracheal measures were used to address stent-related complications. The use of permanent SEMSs for benign tracheobronchial stenosis was effective and safe for the majority of patients in a long-term follow-up.

TRIAL REGISTRATION

The study has been retrospectively registered in the China Clinical Trial Registry on October 21, 2018 (Registry ID: ChiCTR1800019024 ).

Bronchoscopic techniques in the management of patients with tuberculosis

Tuberculosis (TB) is one of the leading causes of morbidity and mortality worldwide. Early diagnosis and treatment are key to prevent Mycobacterium tuberculosis transmission. Bronchoscopy can play a primary role in pulmonary TB diagnosis, particularly for suspected patients with scarce sputum or sputum smear negativity, and with endobronchial disease. Bronchoscopic needle aspiration techniques are accurate and safe means adopted to investigate hilar and mediastinal lymph nodes in cases of suspected TB lymphadenopathy. Tracheobronchial stenosis represents the worst complication of endobronchial tuberculosis. Bronchoscopic procedures are less invasive therapeutic strategies than conventional surgery to be adopted in the management of TB-related stenosis. We conducted a non-systematic review aimed at describing the scientific literature on the role of bronchoscopic techniques in the diagnosis and therapy of patients with TB. We focused on three main areas of interventions: bronchoscopic diagnosis of smear negative/sputum scarce TB patients, endobronchial TB diagnosis and treatment and needle aspiration techniques for intrathoracic TB lymphadenopathy. We described experiences on bronchoalveolar lavage, bronchial washing, and biopsy techniques for the diagnosis of patients with tracheobronchial and pulmonary TB; furthermore, we described the role played by conventional and ultrasound-guided transbronchial needle aspiration in the diagnosis of suspected hilar and mediastinal TB adenopathy. Finally, we assessed the role of the bronchoscopic therapy in the treatment of endobronchial TB and its complications, focusing on dilation techniques (such as balloon dilation and airway stenting) and ablative procedures (both heat and cold therapies).

Surgical reconstruction for tuberculous airway stenosis: management for patients with concomitant tracheal malacia

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.

Timing of silicone stent removal in patients with post-tuberculosis bronchial stenosis

CONTEXT:

In patients with post-tuberculosis bronchial stenosis (PTBS), the severity of bronchial stenosis affects the restenosis rate after the silicone stent is removed. In PTBS patients with incomplete bronchial obstruction, who had a favorable prognosis, the timing of stent removal to ensure airway patency is not clear.

AIMS:

We evaluated the time for silicone stent removal in patients with incomplete PTBS.

SETTINGS AND DESIGN:

A retrospective study examined PTBS patients who underwent stenting and removal of a silicone stent.

METHODS:

Incomplete bronchial stenosis was defined as PTBS other than total bronchial obstruction, which had a luminal opening at the stenotic segment on bronchoscopic intervention. The duration of stenting was defined as the interval from stent insertion to removal. The study included 44 PTBS patients and the patients were grouped at intervals of 6 months according to the duration of stenting.

RESULTS:

Patients stented for more than 12 months had a significantly lower restenosis rate than those stented for less than 12 months (4% vs. 35%, P = 0.009). Multiple logistic regression revealed an association between stenting for more than 12 months and a low restenosis rate (odds ratio 12.095; 95% confidence interval 1.097-133.377). Moreover, no restenosis was observed in PTBS patients when the stent was placed more than 14 months previously.

CONCLUSIONS:

In patients with incomplete PTBS, stent placement for longer than 12 months reduced restenosis after stent removal.

Tracheobronchial stenosis: causes and advances in management

Tracheobronchial stenosis, narrowing of the airways by neoplastic or nonneoplastic processes, may be focal, as occurs with postintubation tracheal stenosis or a focal narrowing from a tumor, or more diffuse, such as those caused by inflammatory diseases. Symptoms develop when the narrowing impedes flow and increases resistance within the airways. Computed tomography defines the extent and severity of disease; endoscopy facilitates understanding of the cause so that an algorithm for treatment can be devised. Bronchoscopic interventions include balloons, ablative treatment, and stenting to provide symptomatic relief. Surgical resection may be curative and a multidisciplinary approach to tracheobronchial stenosis is required.

Posttuberculosis tracheobronchial stenosis: use of CT to optimize the time of silicone stent removal

PURPOSE

To evaluate whether air pockets (tracheobronchial air columns in the space between the outer surface of the stent and the adjacent airway wall) discernible at computed tomography (CT) can help optimize the time of stent removal in patients with posttuberculosis tracheobronchial stenosis (PTTS).

MATERIALS AND METHODS

The study was approved by the institutional review board, and informed consent was obtained from all patients. Data from 41 patients (five men, 36 women) with a median age of 39 years (range, 21-64 years) who underwent silicone stent placement owing to PTTS, followed by CT and stent removal 6-12 months after clinical stabilization, were investigated retrospectively. Two radiologists determined whether the extent of air pockets on CT scans was associated with clinical success, which was defined as maintenance of a prosthesis-free airway for more than 2 years after stent removal. Radiologic features were compared for outcome by using a Wilcoxon two-sample test or Fisher exact test.

RESULTS

Stents were removed successfully in 31 patients (76%). Air pockets longer than 1 cm or longer than 2 cm were associated with successful stent removal (P = .04 and P = .006, respectively). The sensitivity and specificity of air pocket length in the prediction of successful stent removal were 84% and 50%, respectively, for air pockets longer than 1 cm and 68% and 70% for air pockets longer than 2 cm.

CONCLUSION

The extent of air pockets at chest CT shows correlation with the success of stent removal, indicates regression of stenosis, and may help guide the optimal time for stent removal.