Laser treatment for tracheobronchial tumours: local or general anaesthesia?

Clinical Approach to Central Airway Obstruction in Adult Patients: Perioperative Focus on Causes and Management Including Tracheobronchial Stenting

Central airway obstruction (CAO) is a life-threatening condition associated with poor prognosis. Therapeutic bronchoscopy along with systemic therapies significantly improve survival and quality of life in patients with symptomatic benign and malignant CAO. Endoluminal therapies and tracheobronchial stenting may be used, and a multidisciplinary approach is essential for holistic management of CAO. Perioperative planning and evaluation, as well as attention to intraoperative and postoperative management are key to optimal outcomes. This review provides an overview of the etiology and clinical approach to CAO, perioperative considerations for endoluminal therapies and tracheobronchial stenting, perioperative evaluation and preparation for therapeutic bronchoscopy, and management of operative and postoperative challenges in CAO.

Management of Central Airway Obstruction: An American College of Chest Physicians Clinical Practice Guideline

BACKGROUND

Central airway obstruction (CAO), seen in a variety of malignant and nonmalignant airway disorders, is associated with a poor prognosis. The management of CAO is dependent on provider training and local resources, which may make the clinical approach and outcomes highly variable. We reviewed the current literature and provided evidence-based recommendations for the management of CAO.

METHODS

A multidisciplinary expert panel developed key questions using the Patient, Intervention, Comparator, and Outcomes format and conducted a systematic literature search using MEDLINE (PubMed) and the Cochrane Library. The panel screened references for inclusion and used vetted evaluation tools to assess the quality of included studies and extract data, and graded the level of evidence supporting each recommendation. A modified Delphi technique was used to reach consensus on recommendations.

RESULTS

A total of 9,688 abstracts were reviewed, 150 full-text articles were assessed, and 31 studies were included in the analysis. One good practice statement and 10 graded recommendations were developed. The overall certainty of evidence was very low.

CONCLUSIONS

Therapeutic bronchoscopy can improve the symptoms, quality of life, and survival of patients with malignant and nonmalignant CAO. Multi-modality therapeutic options, including rigid bronchoscopy with general anesthesia, tumor/tissue debridement, ablation, dilation, and stent placement, should be utilized when appropriate. Therapeutic options and outcomes are dependent on the underlying etiology of CAO. A multidisciplinary approach and shared decision-making with the patient are strongly encouraged.

Malignant Airway Obstruction and the Use of Nd:YAG Laser: A Systematic Review on Its Efficacy and Safety

Endobronchial malignancies with significant airway obstruction can lead to multiple complications including pneumonia, and atelectasis over a period of time. Various intraluminal treatments have proven their value in palliative treatment for advanced malignancies. Nd:YAG (neodymium-doped yttrium aluminum garnet; Nd:Y3Al5O12) laser has established its role as a major palliative intervention due to its minimal side effects and improvement in quality of life by relieving local symptoms. The systematic review was conducted with the goal of elucidating the patient characteristics, pre-treatment parameters, clinical outcomes, and possible complications resulting from the use of the Nd:YAG laser. A thorough literature search for relevant studies was conducted on PubMed, Embase, and Cochrane Library from the inception of the idea to November 24, 2022. Our study included all original studies including retrospective studies and prospective trials, but excluded case reports, case series with less than 10 patients, and studies with incomplete or irrelevant data. A total of 11 studies were included in the analysis. The primary outcomes focused on the evaluation of pulmonary functional tests, postprocedural stenosis, blood gas parameters after the procedure, and survival outcomes. Improvement in clinical status, improvement in objective scale for dyspnea, and complications were the secondary outcomes. Our study shows that Nd:YAG laser treatment is an effective form of palliative treatment to provide subjective and objective improvement in patients with advanced and inoperable endobronchial malignancies. Due to the heterogeneous study populations in the studies reviewed and the presence of many limitations, more studies are still warranted to reach a definitive conclusion.

Interventional bronchoscopy in the management of thoracic malignancy

Educational Aims

Interventional bronchoscopy is a rapidly expanding field in respiratory medicine offering minimally invasive therapeutic and palliative procedures for all types of lung neoplasms. This field has progressed over the last couple of decades with the application of new technology. The HERMES European curriculum recommendations include interventional bronchoscopy skills in the modules of thoracic tumours and bronchoscopy [1]. However, interventional bronchoscopy is not available in all training centres and consequently, not all trainees will obtain experience unless they rotate to centres specifically offering such training.

In this review, we give an overview of interventional bronchoscopic procedures used for the treatment and palliation of thoracic malignancy. These can be applied either with flexible or rigid bronchoscopy or a combination of both depending on the anatomical location of the tumour, the complexity of the case, bleeding risk, the operator’s expertise and preference as well as local availability. Specialised anaesthetic support and appropriately trained endoscopy staff are essential, allowing a multimodality approach to meet the high complexity of these cases.

Interventional bronchoscopy is integral to the treatment and palliation of lung cancerhttp://ow.ly/R25w0

Subcarinal ventilation-assisted Y-shaped stent insertion under local anesthesia for patients with complex tracheobronchial stenosis: initial clinical experience

PURPOSE

We aimed to report our preliminary results of subcarinal ventilation-assisted Y-shaped stent insertion under local anesthesia for patients with complex lower tracheal-carinal-main bronchial complex stenosis.

MATERIALS AND METHODS

Seven consecutive patients with lower tracheal-carinal-main bronchial complex stenosis underwent Y-shaped stent insertion under local anesthesia. During the procedure, subcarinal ventilation was performed using a 4 F angiographic catheter, and stent insertion was performed under the protection of ventilation. Data on technical success, clinical outcome, and follow-up were collected and analyzed.

RESULTS

Subcarinal ventilation-assisted Y-shaped stent insertion under local anesthesia was technically successful in all patients without any major procedure-related complications. Seven stents were inserted in seven patients. Respiratory function improved in all patients, with the Hugh-Jones classification of respiratory status improving from grade IV-V before stenting to grade I-II after stenting. During the follow-up, one patient experienced re-stenosis of the stent. Average survival time was 185.7 days (range, 96-285 days) after the stenting procedure.

CONCLUSION

Subcarinal ventilation-assisted Y-shaped stent insertion under local anesthesia can be an effective, simple, and safe method for lower tracheal-carinal-main bronchial complex stenosis.

Central airway obstruction caused by a peripheral hamartoma

We report the first case of a hamartoma, arising from peripheral lung tissue, which extended proximally over several decades to occlude the large airways. The patient's symptoms were originally attributed to asthma and the correct diagnosis was only made when she developed life-threatening airway obstruction. The endobronchial component of the hamartoma was debulked with urgent laser therapy, while the peripheral base of the tumour was resected by elective right middle lobectomy.

Bronchoscopic NdYAG laser treatment in lung cancer, 30 years on: an institutional review

We review our 21-year experience in bronchoscopic NdYAG laser for lung cancer and the relevant literature. Patients totaling 1,159 received 2,235 bronchoscopic treatments. The pre-requisite for laser therapy was the presence of >50% obstruction of the bronchial lumen. We use the rigid bronchoscope, with the patient under general anaesthetic and application of laser in its non-contact mode. Two patients (0.17%) died following the procedure, and 4.8% had non-fatal complications. Four to 6 weeks after treatment there was a 48% increase in bronchial calibre and an increase of 27% (mean) in forced vital capacity and 15% (mean) in forced expiratory volume in one second, respectively. These paralleled symptomatic relief and chest X-ray improvement. Literature review indicated results similar to ours in those centres with high volume activity. Thirty years on, bronchoscopic YAG laser therapy of lung cancer still has an important role in palliation of patients with inoperable lung cancer, particularly those requiring immediate relief of bronchial obstruction.

Diagnóstico e estadiamento do câncer de pulmão

O câncer do pulmão pode apresentar-se sob diversas formas e vários são os meios de diagnosticá-lo. A escolha do melhor método para o seu diagnóstico depende de diferentes aspectos relacionados ao tumor, ao paciente e à habilidade da equipe médica. Dentre os métodos mais comumente utilizados para o diagnóstico do câncer do pulmão, podemos contar, além dos exames radiológicos, que não serão abordados neste artigo, a citologia do escarro, a broncofibroscopia, a punção aspirativa transtorácica e a toracoscopia, entre outros. O estadiamento reflete a extensão anatômica do câncer. As regras de estadiamento propostas por Denoix foram adaptadas de maneira satisfatória para o câncer do pulmão e, embora tenham sofrido diversas modificações, devidas ao avanço tecnológico dos métodos de diagnóstico, são importantes para orientar o tratamento e estimar o prognóstico. Com o advento de novas modalidades de tratamento, principalmente as combinadas, o estadiamento tende a assumir importância cada vez maior, tanto na escolha da modalidade terapêutica mais adequada quanto na comparação dos resultados.

Therapeutic bronchoscopy in lung cancer. Laser therapy, electrocautery, brachytherapy, stents, and photodynamic therapy

Therapeutic bronchoscopic techniques such as LPR, EC, brachytherapy, stents, and PDT are effective tools in the palliation and local control of lung cancer. Palliation of malignant tracheobronchial obstruction by LPR, stents, brachytherapy, PDT, or a combination thereof results in relief of dyspnea, hemoptysis, and postobstructive pneumonia. Importantly, it avoids intubation in patients with respiratory distress and facilitates the weaning of patients from MV. In the exciting field of lung cancer screening and treatment of early lung cancer, PDT, brachytherapy, EC, and LPR may represent treatment alternatives to surgical resection, especially in a select group of patients with high surgical risk or favorable endobronchial lesions. Clinicians await the results of future studies, which will (1) better define the impact of each treatment modality on patient care in terms of cost, survival, and improvement in quality of life, and (2) determine the optimal combination therapy relative to bronchoscopic and conventional treatment for effective palliation and cure of lung cancer.

Treatment of endotracheal or endobronchial obstruction by non-small cell lung cancer: lack of patients in an MRC randomized trial leaves key questions unanswered. Medical Research Council Lung Cancer Working Party

Symptoms of endotracheal or endobronchial obstruction caused by non-small cell lung cancer (NSCLC) may be relieved with external beam radiotherapy (XRT) or endobronchial treatment. The comparative roles of these two methods need to be established. Patients with predominantly intraluminal obstruction of the trachea, a main bronchus or a lobar bronchus by unresectable NSCLC were randomized to XRT versus the clinician's choice of endobronchial treatment with brachytherapy, laser resection or cryotherapy, according to local availability and practice. Clinicians' assessments included symptoms of obstruction, WHO performance status, lung function tests and adverse effects of treatment. Patients completed a Rotterdam Symptom Checklist at all assessments and a daily diary card to record the severity of major symptoms during the first 4 weeks. To show a difference of 15% in the relief of breathlessness rates at 4 months (from 65% to 80%), 400 patients were required. In spite of our many previously successful lung cancer trials, and initial interest from clinicians in 24 UK centres, who estimated they could randomize 200 patients per year into the present trial, only 75 patients were randomized from seven centres over 3.5 years. Intake to the trial was therefore abandoned in November 1996 although an independent Data Monitoring and Ethics Committee had concluded in April 1996 that the scientific case for the trial was still strong; there were no competing trials; there were no design problems; and much had been done to promote the trial. The main reasons given by centres for the slow intake were: lack of referrals of untreated patients; patients being referred specifically for endobronchial treatment; patients having already received XRT; emergency endobronchial relief of obstruction being necessary; and XRT and endobronchial treatment being considered complementary and not as alternatives. The relative advantages and disadvantages of XRT versus endobronchial treatment remain to be determined. The lack of recruitment to this trial raises the issue of innovative techniques not being given the chance of proving their worth compared with traditional treatments.

Anesthetic management of laser surgery for central airway obstruction: a 12-year case series

The retrospective 12-year experience of anesthetizing patients with central airway obstructions for laser treatment with a CO2 and two types of Nd:YAG laser has been reviewed and evaluated. More than 300 patients have been treated, many on several occasions. The beneficial effects of treatment to the majority of patients have been significant. There has been a small associated mortality because the majority are in the high-risk categories of fitness for anesthesia, but no clinical evidence that it is directly attributable to the techniques of anesthesia or ventilation. Therefore, although laser technology has evolved into systems suitable to be applied with fiberoptic bronchoscopes and local and sedation anesthesia, the use of a rigid bronchoscope and the evolved techniques of anesthesia and ventilation remain appropriate to the clinical needs and offer advantages.

Defining the roles of high dose rate endobronchial brachytherapy and laser resection for recurrent bronchial malignancy

Endobronchial therapy is commonly used in the palliative management of malignant disease, but the optimal combinations of treatment modalities (laser, brachytherapy, external beam radiotherapy) have not been defined. We have undertaken a prospective analysis of symptom response, duration of response, and prognostic factors for 117 patients treated with brachytherapy at a single centre, to identify hypotheses suitable for prospective randomised studies. All but one patient had received previous treatment. The percentage of patients with scores of 0 or 1 (none or mild) for each symptom pre-treatment and at 3 months were as follows: cough 62% to 77% (43% improving by at least one grade, N.S.); dyspnoea 32% to 56% (50% improvement by at least one grade, P = 0.0063); haemoptysis 78% to 97%; performance status 65% to 84% (54% by at least one grade, P = 0.0417). An actuarial risk of fatal haemoptysis at 2 years of 20% was associated with prior laser resection (P = 0.048). Death before 2 months was associated with dyspnoea scores of 3 or 4. Suggestions for randomised studies are made to address some of the uncertainties revealed by the analysis.

Bronchoscopic treatment of lung tumors

Several bronchoscopic techniques for the treatment of patients with tracheobronchial pathology have become available during the last decade. Technical development and additional instruments have provided the bronchoscopist with several alternatives for bronchoscopic therapeutic interventions. The majority of patients with malignant tracheobronchial neoplasm have a dismal prognosis. Palliation is the main aim of the treatment. However, in patients with an early-stage tumor, bronchoscopic treatment may have a curative potential. Resectability, after tumor reduction by a bronchoscopic treatment, may be improved. This article discusses various bronchoscopic techniques, the advantages and disadvantages of each method and the possible benefit which can be derived from such a treatment.

Laser therapy for endobronchial tumours

Endobronchial laser therapy has been performed at Knightswood Hospital, Glasgow since 1983. During the period 1983 to 1990, 62 patients underwent a total of 149 laser treatments. The principal indications for therapy were tracheo-carinal stridor (24%), dyspnoea due to bronchial occlusion (60%) and haemoptysis (13%). Squamous carcinoma accounted for 80% of the lesions. Over 75% of patients had already received some form of prior therapy (radiotherapy 71%, chemotherapy 8%, surgical resection 11%). Laser therapy reduced stridor in 67% of patients with tracheal and carinal tumours and produced symptomatic improvement in 72% of patients with bronchial obstruction but without evidence of lobar collapse. Haemoptysis was controlled in all but one of patients treated. Two patients (3.2%) died during laser treatment following severe haemorrhage.

Endoscopic palliation of tracheobronchial malignancies

The prognosis for tracheobronchial tumours remains poor. Most patients can be offered only palliation. When the main symptom is breathlessness or refractory haemoptysis from a large airway tumour endoscopic treatment may be very effective. Over the last decade most attention has focused on the neodymium YAG laser. This often produces dramatic effects but has some important limitations. In the last few years better techniques for stenting and intrabronchial radiotherapy (brachytherapy) have also been developed. This article discusses the range of techniques now available and aims to help clinicians decide which patients may benefit from referral to centres providing these techniques.

Complications of general anesthesia for Nd:YAG laser resection of endobronchial tumors

We studied the incidence and mechanisms of cardiovascular complications and postoperative respiratory insufficiency associated with GA and Nd:YAG laser endobronchial tumor resection. The records of 73 patients undergoing 87 procedures were reviewed. Preoperative status, anesthetic methods and perioperative complications were analyzed by multiple regression to determine predictors of outcome. Twenty-three percent of patients had greater than 90 percent mainstem bronchus obstruction. Longer serum elimination half-life of relaxant drug was significantly correlated with longer duration of mechanical ventilation after neuromuscular blockade reversal. Cardiovascular complications were noted in 24 procedures and often required therapeutic intervention. Variables predicting cardiovascular complications included longer duration of GA and increasing age. Perioperative respiratory and cardiovascular complications are common after GA for Nd: YAG laser resection. Short-acting neuromuscular relaxants, careful assessment prior to postoperative extubation, limiting duration of GA and cardiovascular monitoring are recommended when implementing GA for Nd: YAG laser resection of endobronchial tumors.

Indication and results of endobronchial laser therapy

Endobronchial laser therapy will be carried out predominantly at obstructing bronchial carcinomas of the major airways. Concerning tumors distal of the bifurcation, corresponding pre-examinations (angiography, bronchography, fluoroscopy) should make it sufficiently probable that, after the recanalization of a bronchus, the patient will have a functional benefit. At non-completely obstructing tumors an occlusion of the bronchus may be prevented by an endobronchial laser resection. Only then is scarred stenosis suitable, if it concerns membranous changes; longer stenosis bring poor long-term results only. At a larger endobronchial bleeding the laser is not suitable for controlling the hemorrhage. The long-term results of the therapy for benign endobronchial lesions are good. The results of malignant changes depend basically on the localization and on the growth rate of the tumor. With a careful selection of patients very good immediate results may be obtained at nearly all endobronchial lesions.

Bronchography in the assessment of patients with lung collapse for endoscopic laser therapy

In an attempt to improve selection of patients and the efficacy of endoscopic laser treatment, a bronchographic technique has been developed for patients with tumours causing complete endobronchial obstruction. This technique has shown patent distal airways in 16 out of 17 patients with a collapsed lung or lobe. These airways were abnormally dilated in each case, suggesting bronchiectasis. In one patient the appearances of bronchiectasis were sufficiently severe to decide against attempting treatment. Treatment was not attempted in another patient as a large cavity was seen within the collapsed lung and this was thought to carry a risk of postoperative infection and haemorrhage. Treatment with a neodymium YAG laser under general anaesthesia successfully recanalised the airway in 12 of the 15 remaining patients and was associated with a substantial reduction in breathlessness. The procedure was abandoned prematurely in one patient because of life threatening haemorrhage. In the remaining two patients in whom treatment was unsuccessful bronchography had suggested very extensive endobronchial obstruction. Spirometry and radionuclide lung scans were performed before and after treatment in eight patients treated successfully and showed significant improvements. Four patients were investigated within two weeks of lung re-expansion by repeat bronchography (three patients) or computed tomography (one patient); in each case the calibre of the airways had returned almost to normal. Thus the radiological demonstration of bronchial dilation in a collapsed lung does not necessarily imply a diagnosis of irreversible bronchiectasis and should not be regarded as a contraindication to treatment. It is concluded that preoperative bronchography provides reliable data on the extent of tumour, the patency of the distal airways, and presence of extensive cavitation. This information should facilitate successful laser treatment.

High frequency jet ventilation via a tracheoscope for endobronchial laser surgery

Palliative surgery of malignant endobronchial tumours is associated with various anaesthetic risks. A technique is described using a neodymium:yttrium-aluminium-garnet (Nd:YAG) laser in combination with a special tracheoscope and high frequency jet ventilation (HFJV). The purpose of this technique is to provide separation of anaesthetic and surgical manipulations, good conditions of ventilation and easy access to the lungs for the surgeon. We present our experience with 14 adult patients in whom large endobronchial neoplasms were resected using this technique under intravenous anaesthesia and muscle relaxation. Careful perioperative monitoring and a good outcome allowed us to conclude that this set-up may contribute to improving efficiency and safety of endoscopic resections of endobronchial and/or endotracheal tumours.

Changes in regional ventilation and perfusion of the lung after endoscopic laser treatment

To determine whether endoscopic laser treatment improves both ventilation and perfusion in patients with advanced lung cancer, krypton-81m ventilation and technetium-99m labelled macro-aggregate perfusion scanning was performed immediately before and two or four days after treatment in a consecutive series of 28 patients. Twelve patients had not received any other treatment before laser therapy and 16 had undergone previous treatments that included radiotherapy. Ventilation and perfusion were quantified by expressing the number of counts in the affected lung as a percentage of the total counts. Ventilation and perfusion improved after laser treatment in 23 patients (82%). The mean ventilation score in the affected lung rose by 50% (p less than 0.001) and the mean perfusion score rose by 24% (p less than 0.001). Incremental changes in ventilation and perfusion scores were positively correlated (r = 0.80). Mean spirometric values, six minute walking distance, the Karnofsky performance index, and breathlessness and wellbeing scores also improved significantly. Patients with main bronchial obstruction who had had no radiotherapy showed the most striking improvements. It is concluded that the removal of intraluminal tumour from the bronchial tree leads to matched improvements in ventilation and perfusion in most patients and that this is associated with valuable improvement in symptoms.

Anaesthesia for resection of lesions of the trachea and main bronchi using the neodymium yttrium aluminium garnet (Nd YAG) laser. A report of 75 treatments in 52 patients

The management of anaesthesia and outcome of 75 treatments in 52 patients are discussed. Total intravenous anaesthetic techniques were used with venturi ventilation via a rigid bronchoscope. A number of complications occurred, but there was no death or major surgical complication. All complications except one were apparent intraoperatively or in the recovery room. As the considerable risk of intraoperative hypoxia was considered to outweigh the minimal risk of intratracheal fire or explosion, no attempt was made to limit inspired oxygen concentration (FIO2) during the application of the laser. The results of ventilation/perfusion studies and a recent diagnostic bronchoscopy were very helpful in patient selection.

Diathermy resection and radioactive gold grains for palliation of obstruction due to recurrence of bronchial carcinoma after external irradiation

During 1985-7 15 patients previously treated by external radiotherapy for inoperable carcinoma of the lower trachea and major bronchi underwent endobronchial insertion of radioactive gold grains as a palliative procedure for relief of symptoms. Four patients had undergone three or more endobronchial laser treatments before being referred. Under general anaesthesia diathermy was used to resect obstructing tumour before the insertion of the gold grains into the tumour and the compressed endobronchial wall. Four patients died within one month. The remaining 11 patients were symptomatically and objectively improved when assessed at one month. Both collapsed lungs and three out of six collapsed lobes had re-expanded. Fourteen of the 15 patients died within 13 months (median survival 2.5 months); one patient with recurrent symptoms after 10 months underwent a further implantation and is alive after two years.