Tuberculous Tracheobronchial Strictures Treated with Balloon Dilation: A Single-Center Experience in 113 Patients during a 17-year Period

An effective case of bronchoscopic balloon dilatation for tuberculous bronchial stenosis

Endobronchial tuberculosis often causes bronchial stenosis. Balloon dilation is a minimally invasive and effective bronchoscopic intervention for bronchial stenosis; however, reports on balloon dilation in older individuals are limited. We present a case of a 77-year-old woman with endobronchial tuberculosis and clarify the efficacy and safety of balloon dilation. She presented with dyspnea, right lung atelectasis, and respiratory failure 55 days after initiation of antituberculosis therapy. We performed bronchoscopic balloon dilatation for the right main bronchial stenosis. Consequently, respiratory failure rapidly improved. Chest computed tomography (CT) showed improved lung atelectasis; however, severe bronchial stenosis and rhonchi persisted. Therefore, we performed a second balloon dilatation. CT 3 months after the first balloon dilation showed right upper bronchial stenosis and right lung middle lobe atelectasis. Restenosis was absent 21 months after third balloon dilatation. Bronchoscopic balloon dilation is effective for restenosis with repeated treatment and can be safely performed in older individuals.

Balloon Bronchoplasty for the Treatment of Bronchial Stenosis After Lung Transplantation: A Single-Center 10-Year Experience

OBJECTIVE

To assess the safety and efficacy of balloon dilatation under dual guidance using fluoroscopy and bronchoscopy for treating bronchial stenosis following lung transplantation (LT), and to elucidate the factors associated with patency after the procedure.

MATERIALS AND METHODS

From September, 2012, to April, 2021, 50 patients (mean age ± standard deviation, 54.4 ± 12.2 years) with bronchial stenosis among 361 recipients of LT were retrospectively analyzed. The safety of balloon dilatation was assessed by evaluating procedure-related complications. Efficacy was assessed by evaluating the technical success, primary patency, and secondary patency. Primary and secondary cumulative patency rates were calculated using the Kaplan-Meier method. The factors associated with patency after the procedure were evaluated using multivariable Cox hazard proportional regression analysis.

RESULTS

In total, 65 bronchi were treated with balloon dilatation in 50 patients. The total number of treatment sessions was 277 and the technical success rate was 99.3% (275/277 sessions). No major procedure-related complications were noted. During the mean follow-up period of 34.6 ± 30.8 months, primary patency was achieved in 12 of 65 bronchi (18.5%). However, the patency rate improved to 76.9% (50 of 65 bronchi) after repeated balloon dilatation (secondary patency). The 6-month, 1-year, 3-year, and 5-year secondary patency rates were 95.4%, 90.8%, 83.1%, and 78.5%, respectively. The presence of clinical symptoms was a significant prognostic factor associated with reduced primary patency (adjusted hazard ratio [HR], 0.465; 95% confidence interval [CI], 0.220-0.987). Early-stage treatment ≤ 6 months (adjusted HR, 3.588; 95% CI, 1.093-11.780) and prolonged balloon dilatation > 5 min (adjusted HR, 3.285; 95% CI, 1.018-10.598) were associated with significantly higher secondary patency.

CONCLUSION

Repeated balloon dilatation was determined to be safe and effective for treating bronchial stenosis following LT. Early-stage treatment and prolonged balloon dilatation could significantly promote long-term patency.

Therapeutic bronchoscopy for central airway diseases

Over the past century rigid bronchoscopy has been established as the main therapeutic means for central airway diseases of both benign and malignant aetiology. Its use requires general anaesthesia and mechanical ventilation usually in the form of manual or high-frequency jet ventilation. Techniques applied to regain patency of the central airways include mechanical debulking, thermal ablation (laser, electrocautery and argon plasma coagulation) and cryo-surgery. Each of these techniques have their advantages and limitations and best results can be attained by combining different modalities according to the type, location and extent of the airway blockage. If needed, deployment of airway endoprostheses (stents), as either fixed-diameter silicone or self-expandable metal stents, may preserve the airways patency often at the cost of several complications. Newer generation of customised stents either three-dimensional printed or drug-eluting stents constitute a promise for improved safety and efficacy results in the near future. Treating central disease of benign or malignant aetiology, foreign body aspiration or massive bleeding in the airways requires a structured approach with combined techniques, a dedicated team of professionals and experience to treat eventual complications. Specific training and fellowships in interventional pulmonology should therefore be offered to those who wish to specialise in this field.

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).

Comparison between traditional and small-diameter tube-assisted bronchoscopic balloon dilatation in the treatment of benign tracheal stenosis

OBJECTIVE

To compare the safety and efficacy between using a small-diameter tube-assisted bronchoscopic balloon dilatation (BBD) and the traditional BBD in the treatment of benign tracheal stenosis.

METHODS

A retrospective study included 58 patients with benign tracheal stenosis from August 2009 to December 2014 was made. The patients who underwent traditional BBD were divided into group A, and who underwent a small-diameter tube-assisted BBD were divided into group B. The tracheal diameter, dyspnea index and blood gas analysis results were detected before and after BBD. Efficacy and complications were evaluated after BBD.

RESULTS

There were significant differences in oxygen saturation (PaO₂ ) during the operations comparing with before and after operations in group A (P = .005), while there was no significant difference in group B (P = .079). The tracheal diameter obviously increased (in group A, from 4.16 ± 1.43 mm to 12.47 ± 1.41 mm, P = .000; in group B: from 4.94 ± 1.59 mm to 12.61 ± 1.41 mm, P = .000). Dyspnea index obviously decreased (group A: from 3.21 ± 0.93 to 0.50 ± 0.59, P = .000; group B: from 3.24 ± 0.89 to 0.65 ± 0.69, P = .000). The immediately cure rate in both groups was 100%. Long-term effect was significantly better in group B than that in group A (85.3% vs 59.1%, P = .021), at the end of the follow-up period.

CONCLUSIONS

Small-diameter tube-assisted BBD obtains better safety and long-term efficacy than the traditional BBD in the treatment of benign tracheal stenosis. However, close attention should be given to the risk of the adverse effects caused by carbon dioxide retention.

Tracheobronchial tuberculosis: a clinical review

Endobronchial tuberculosis (EBTB) is defined as tuberculous infection of the tracheobronchial tree. The exact pathogenesis is unclear, and it has a heterogenous clinical course. Its diagnosis requires the clinician to have a high index of suspicion based on clinical symptoms and radiological features. Computed tomography and bronchoscopy are useful tools in its evaluation. The goal of treatment is in the eradication of tuberculous bacilli with appropriate anti-tuberculous therapy. Use of corticosteroids is controversial for the prevention of tracheobronchial stenosis. Interventional bronchoscopy or surgical intervention is employed to restore airway patency once significant stenosis occurs.

Influence of Contrast Agent Dilution on Ballon Deflation Time and Visibility During Tracheal Balloon Dilation: A 3D Printed Phantom Study

PURPOSE

To determine the effect of contrast medium dilution during tracheal balloon dilation on balloon deflation time and visibility using a 3-dimensional (3D) printed airway phantom.

MATERIALS AND METHODS

A comparison study to investigate balloon deflation times and image quality was performed using two contrast agents with different viscosities, i.e., iohexol and ioxithalamate, and six contrast dilutions with a 3D printed airway phantom.

RESULTS

Compared to 1:0 concentration, 3:1, 2:1, 1:1, 1:2, and 1:3, contrast/saline ratios resulted in a 46% (56.2 s), 59.8% (73.1 s), 74.9% (91.6 s), 81.7% (99.8 s), and 83.5% (102 s) reduction for iohexol, respectively, and a 51.8% (54.7 s), 63.8% (67.6 s), 74.7% (79.2 s), 80.5% (85.3 s), and 82.4% (87.4 s) reduction for ioxithalamate, respectively, in the mean balloon deflation time, although at the expense of decreased balloon opacity (3.5, 6.9, 11.1, 12.4, and 13.9%, for iohexol, respectively, and 3.2, 6, 9.6, 10.8, and 12.4%, for ioxithalamate, respectively).

CONCLUSIONS

Use of a lower viscosity contrast agent and higher contrast dilution is considered to be able to reduce balloon deflation times and then simultaneously decrease visualization of balloons. The rapid balloon deflation time is likely to improve the safe performance of interventional procedures.

From electrocautery, balloon dilatation, neodymium-doped:yttrium-aluminum-garnet (Nd:YAG) laser to argon plasma coagulation and cryotherapy

Over the past decade, there has been significant advancement in the development/application of therapeutics in thoracic diseases. Ablation methods using heat or cold energy in the airway is safe and effective for treating complex airway disorders including malignant and non-malignant central airway obstruction (CAO) without limiting the impact of future definitive therapy. Timely and efficient use of endobronchial ablative therapies combined with mechanical debridement or stent placement results in immediate relief of dyspnea for CAO. Therapeutic modalities reviewed in this article including electrocautery, balloon dilation (BD), neodymium-doped:yttrium-aluminum-garnet (Nd:YAG) laser, argon plasma coagulation (APC), and cryotherapy are often combined to achieve the desired results. This review aims to provide a clinically oriented review of these technologies in the modern era of interventional pulmonology (IP).