Benign noninflammatory bronchial stenosis: treatment with balloon dilation

Balloon tracheoplasty for tracheal stenosis after prolonged intubation: a simple procedure, but is it effective?

Background

Tracheal stenosis following prolonged intubation is a relatively rare but serious problem. This condition is usually managed by surgical or endoscopic interventions. Bronchoscopic balloon dilatation for tracheal stenosis is considered a valuable tool used for the management of tracheal stenosis. In this article, we try to evaluate the role of balloon tracheoplasty in the management of tracheal stenosis and to assess the number of dilatation sessions usually needed as well as the short to midterm outcome.

Results

This study involved 40 patients with tracheal stenosis diagnosed by computed tomography (neck and chest) and bronchoscopy at the Security Force Hospital in Riyadh, KSA, between January 2013 and August 2018. Patients’ data were retrospectively reviewed and analyzed. Patients’ age ranged between 18 and 60 years. Thirty patients were males (75%); those patients underwent balloon tracheoplasty via dilatation of areas of narrowing using catheter balloon insufflation guided by fiber-optic bronchoscope. Ninety-five percent of the patients had initial success with acceptable dilatation of the stenotic area and improvement of the symptoms. There were no technical or major problems which resulted from the procedure, and no patient complained of severe pain or severe discomfort after the procedure. From the total of 81 BBD sessions, no in-hospital mortality is related to the procedure itself, and ICU stay ranged between 1 and 5 days post-procedure. Among those 40 patients, 16 patients (40%) needed one session, 10 patients (25%) needed two sessions, 8 patients (20%) needed three sessions, and 6 patients (15%) needed more than three sessions of balloon dilatation.

Conclusion

Balloon tracheoplasty is a simple, safe method and could be a promising and effective approach that offers immediate symptomatic relief for tracheal stenosis in cases with a history of prolonged intubation. It is worth mentioning that BBD is considered as a temporary measure, and most of the cases will need definitive or additional treatment either resection or stent placement.

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).

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.

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

PURPOSE

To evaluate the safety and effectiveness of balloon dilation in the treatment of tuberculous tracheobronchial strictures (TTBSs) in a series of 113 patients at a single institution.

MATERIALS AND METHODS

The institutional review board approved the study and waived the requirement to obtain informed consent. Between 1997 and 2014, under bronchoscopic and fluoroscopic guidance, a total of 167 balloon dilation sessions were performed in 113 consecutive patients (14 male and 99 female patients; mean age, 37 years [age range, 17-73 years]), with a range of one to eight sessions per patient (mean, 1.5 sessions). Outcomes were number and/or frequency of balloon dilations, technical success, primary and secondary clinical success, improvement in respiratory status, airway patency rate, and alternative treatment after balloon dilation. A two-tailed paired t test and the Kaplan-Meier method were used to evaluate the improvement in respiratory status and airway patency rate after balloon dilation, respectively.

RESULTS

Dilation was successful in 82 patients (73%) after single (n = 67) or multiple (n = 15) balloon dilations, with a mean follow-up of 30.3 months. Clinical failure occurred in 31 patients (27%). In these 31 patients, symptoms recurred 1 day to 113 months (mean, 13 months) after repeat balloon dilations. These 31 patients required alternative treatment, including temporary stent placement (n = 12), cutting balloon dilation (n = 12), radiation-eluting balloon dilation (n = 3), and surgery (n = 4). Before, immediately after, and 1 month after the procedure, pulmonary function test results showed significant improvements in mean forced vital capacity (P < .001), forced expiratory volume in 1 second (P = .001), forced expiratory flow in the midexpiratory phase (P = .020), and peak expiratory flow (P = .005).

CONCLUSION

Balloon dilation of TTBSs is a safe, minimally invasive primary treatment that relieved symptoms in a large percentage of patients (73%). In patients with TTBSs refractory to balloon dilation, temporary stent placement, cutting balloon dilation, or radiation-eluting balloon dilation can be an alternative treatment.

Fluoroscopically guided balloon dilation for benign bronchial stricture occurring after radiotherapy in patients with lung cancer

PURPOSE

To evaluate the safety and clinical effectiveness of fluoroscopically guided balloon dilation in patients with benign bronchial stricture occurring after radiotherapy (RT).

METHODS

From March 2002 to January 2013, ten patients with benign bronchial stricture occurring after RT underwent fluoroscopically guided balloon dilation as their initial treatment. Technical success, primary and secondary clinical success, improvement in respiratory status, and complications were evaluated. The symptomatic improvement period was calculated.

RESULTS

A total of 15 balloon dilation sessions were performed in ten patients, with a range of 1-4 sessions per patient (mean 1.5 sessions). Technical success was achieved in 100 %. Six of the ten patients exhibited no symptom recurrence and required no further treatment until the end of follow-up (range 4-105 months). Four patients (40 %) experienced recurrent symptom, and two of four patients underwent repeat balloon dilations. The remaining two patients underwent cutting balloon dilation and temporary stent placement, respectively, and they exhibited symptom improvement after adjuvant treatment until the end of our study. Finally, primary clinical success was achieved in six of ten patients (60 %) and secondary clinical success was achieved in eight of ten patients (80 %). The mean symptom improvement period was 61.9 ± 16 months (95 % confidence interval 30.6-93.3).

CONCLUSION

Fluoroscopically guided balloon dilation seems to be safe and clinically effective for the treatment of RT-induced benign bronchial stricture. Temporary stent placement or cutting balloon dilation could be considered in patients with benign bronchial strictures resistant to fluoroscopically guided balloon dilation.

Management of benign tracheal strictures caused by tracheostomy

PURPOSE

To evaluate the clinical efficacy and safety of radiologic management for the treatment of benign tracheal strictures caused by tracheostomy.

MATERIALS AND METHODS

We retrospectively reviewed of 13 patients with benign tracheal stricture caused by tracheostomy that was treated with balloon dilation or stent placement. Balloon dilation had initially been performed. Stent placement was indicated in patients who showed a poor response to balloon dilation. Outcomes were assessed according to the following variables: technical and clinical success, Hugh-Jones classification scale before and after the procedures, and complications.

RESULTS

Balloon dilation and stent placement were technically successful in all patients. Nine of the 13 patients (69 %) showed no response to balloon dilation, and the remaining the four patients showed a positive response to initial balloon dilation. Six of the nine (67 %) patients showed a good response to temporary stent placement and required no further treatment. Mean Hugh-Jones grades improved from 3.6 ± 0.8 to 1.8 ± 1.1 (P < 0.001). During a follow-up period of 2.6-40.8 months (mean 16.5), overall clinical success was achieved in 10 patients (77 %) after a single balloon dilation (n = 4) and temporary stent placement (n = 6). The remaining three patients with clinical failure underwent tracheal resection (n = 3).

CONCLUSION

Radiologic management can be a safe and effective therapeutic option for treating benign tracheal stricture caused by tracheostomy. Temporary stent placement can be effective in patients with symptoms recurring soon after balloon dilation.

Successfully treated postbronchoplasty bronchial stenosis using short-interval repeated endobronchial balloon dilation

A 63-year-old man with a history of lung cancer underwent lobectomy of the right upper lobe and bronchoplasty. At the 2-month follow-up, bronchial stenosis due to a granuloma was observed. Endoscopic débridement and balloon dilation were performed. At 1 month after the dilation, atelectasis occurred owing to cicatricial stenosis. We repeated balloon dilation, but the patient suffered from cicatricial restenosis. After a failed stent placement, balloon dilation was then performed every 2 weeks under local anesthesia; the stenosis was resolved after performing dilation 7 times. Short-term repeated balloon dilation was effective in this case.

Interventional management of tracheobronchial strictures

Tracheobronchial balloon dilation and stent placement have been well used in the treatment of patients with benign and/or malignant diseases. Balloon dilation is the first option in the treatment of benign airway stenosis. Although balloon dilation is simple and fast, recurrence rate is high. Stent placement promptly relieves acute airway distress from malignant extraluminal and intraluminal airway obstruction. Temporary stent placement may be an alternative for benign airway strictures refractory to balloon dilation. This article reviews the indications, pre-procedure evaluation, technique, outcomes and complications of balloon dilation and stent placement with regard to benign and malignant tracheobronchial stenoses.

Update on lung transplantation for emphysema

Lung transplantation in the modern era remains an evolving field and a viable option for patients suffering from end-stage emphysema. Recent modifications for recipient prioritization has resulted in a modest decrease in the number of patients with emphysema receiving transplants. More time will be required to determine what impact, if any, these modifications will have on the overall survival of patients with end-stage emphysema. Ongoing research will address persistent issues with lung transplantation, most notably, primary graft dysfunction and chronic BOS.

Liquid (188)Re-filled balloon dilation for the treatment of refractory benign airway strictures: preliminary experience

PURPOSE

To present the preliminary results of beta irradiation with use of liquid rhenium 188 ((188)Re)-filled balloon dilation in the treatment of refractory benign airway strictures.

MATERIALS AND METHODS

Ten sessions of beta irradiation by using liquid (188)Re-filled balloon dilation were prospectively performed in nine patients with refractory bronchial strictures between 2003 and 2006. Indications for treatment were dyspnea caused by repeat stricture or no response to previous treatment (ie, balloon dilation and/or temporary stent placement or laser therapy) in seven patients and dyspnea caused by exuberant granulation tissue formation at the distal end of the placed stent in two. To assess the treatment efficacy, the authors calculated and compared the mean intervals of interventional treatments before and after dilation with (188)Re and mercaptoacetyltriglycine (MAG(3))-filled balloons.

RESULTS

Liquid (188)Re-filled balloon dilation was successfully performed in all nine patients, with no procedure-related complications. Immediately after the procedure, all patients showed resolution of their dyspnea. Five patients remained asymptomatic at 5-25-month follow-up. Four patients experienced dyspnea caused by recurrent stricture 1-10 months after dilation. The mean intervals between interventional treatments increased significantly from 3.1 months +/- 2.1 before (188)Re-MAG(3)-filled balloon dilation to 10.8 months +/- 8.8 after (188)Re-MAG(3)-filled balloon dilation in all nine patients (Wilcoxon signed rank test, P = .025).

CONCLUSIONS

beta irradiation with liquid (188)Re-filled balloon dilation can be safely used for refractory benign airway strictures. A large study with longer follow-up is needed to draw a definite conclusion.

[Segmental tracheal resection for the treatment of tracheal stenoses]

BACKGROUND

Segmental tracheal resection is considered to be the standard treatment of tracheal stenoses.

MATERIALS/METHODS

During the time period 1985-2002, segmental tracheal resection with a primary end-to-end anastomosis was performed in 117 patients with a cervical or upper thoracal stenosis of the trachea. The age distribution of the patients was between 7 and 77 years. Of the patients with a benign tracheal stenosis, sufficient data for a retrospective analysis were available in 101 patients. The length of the resected tracheal segments varied between 2 and 6 cm which required mobilisation of the trachea and the larynx and, if necessary, incision of the pulmonary ligament.

RESULTS

In 5 patients a permanent damage of the recurrent laryngeal nerve was seen, of which 4 had undergone revision surgery and 10 months after surgery 93% presented with a large and stable tracheal lumen without any relevant restenosis. Due to a restenosis of 70-80% causing dyspnea at rest, 3% of the 101 patients had to undergo revision surgery. In 4% a mild and asymptomatic restenosis of 30-40% was seen which did not require any further treatment.

CONCLUSION

These results demonstrate that segmental tracheal resection can safely and effectively remove stenotic tracheal segments of up to 6 cm and is therefore the treatment of choice.

Tracheobronchial Laceration After Balloon Dilation for Benign Strictures

BACKGROUND

Although balloon dilation is a safe procedure, it can lead to laceration of the airway, causing bleeding, pneumothorax, pneumomediastinum, or mediastinitis. We therefore determined the incidence and clinical significance of tracheobronchial lacerations after balloon dilation for treatment of benign tracheobronchial strictures.

METHODS

We evaluated 97 patients who had undergone balloon dilation in 124 sessions for the treatment of benign tracheobronchial strictures. The degree of airway laceration was evaluated bronchoscopically. The cumulative airway patency rate after balloon dilation was compared in patients with and without lacerations using Kaplan-Meier survival curves and log-rank testing.

RESULTS

There were 64 tracheobronchial lacerations (51.6%) during the 124 sessions of balloon dilation. Of these, 60 were superficial and 4 were deep, but there were no incidents of transmural laceration. In patients with lacerations, mild chest pain (n = 5), blood-tinged sputum (n = 21), and pneumomediastinum (n = 2) occurred, but all resolved completely within 24 h. All superficial lacerations healed spontaneously within 1 month, and all deep lacerations healed 2 to 9 months after conservative treatment. During the follow-up period, the median cumulative airway patency period in patients with and without lacerations was 24 and 4 months (p < 0.05), respectively.

CONCLUSION

Laceration secondary to balloon dilation in the tracheobronchial tree is relatively common but rarely progresses to transmural laceration and may improve patency outcomes.

Bronchoscopic balloon dilatation in the management of bronchial stenosis following lung transplantation

BACKGROUND

Bronchial stenosis (BS) is currently found in 7-15% of lung transplantation (LT) recipients. Current treatment strategies have included Nd:Yag laser, cryotherapy, bougie dilatation and stent placement. Bronchoscopic balloon dilatation has been used as alternative treatment in a few cases with controversial results. This is a study to prospectively assess the efficacy of bronchoscopic balloon dilatation as a first step in the management of post-LT BS.

METHODS

From January 1995 to December 2002, bronchoscopic balloon dilatation was evaluated as first therapeutic option in all consecutive LT patients with BS. Symptoms, pulmonary function tests, airway diameter and use of other therapeutic techniques were evaluated.

RESULTS

A total of 10 out of 284 anastomed airways (3.5%) in 9 out of 152 LT patients were included in the study and follow-up lasted from 6 to 81 months. Dilatation of all but one BS met with initial success: increase of both luminal dimensions and forced vital capacity (P=0.01), and relief of symptoms. Bronchoscopic balloon dilatation long-term follow-up showed effective results in 5 out of 10 (50%) bronchial stenoses, after an average of 4 bronchoscopic balloon dilatation procedures (range 1-8). No severe complications were observed. Stent placement was required in the other 5 bronchial stenoses.

CONCLUSIONS

Bronchoscopic balloon dilatation is a safe method that should be considered as first therapeutic treatment of post-LT BS. Its use avoids the need for stent placement in up to 50% of cases.

Deep tracheal laceration after balloon dilation for benign tracheobronchial stenosis: case reports of two patients

We report two cases of deep tracheal laceration in female patients after balloon dilation for benign tracheobronchial stenosis. Immediate post-procedure bronchoscopy and CT including 3D reconstructions showed deep lacerations in the posterior tracheal wall. Clinically, the patients' dyspnoea subsided and there has been no recurrence during follow-up after balloon dilation. On the follow-up 3D-reconstructed CT scans obtained 2 months and 8 months following balloon dilation, respectively, the lacerations had healed completely and there was considerable improvement in lumen size.

Use of 3-Dimensional Computed Tomography Reconstruction Studies in the Preoperative Assessment of Patients Undergoing Balloon Dilatation for Tracheobronchial Stenosis

BACKGROUND

Balloon dilatation (BD) is a useful method of treating tracheobronchial stenosis (TBS); however, accurate preoperative identification of the lesion is difficult. Three-dimensional computed tomography (3D-CT) is an imaging method that may allow more accurate definition of the lesion(s) preoperatively.

STUDY OBJECTIVE

It is the aim of this study to present our finding using 3D-CT as a part of the preoperative evaluation of patients with TBS undergoing BD.

METHODS

We studied a prospective case series of 17 consecutive patients who underwent 29 BDs for TBS from a variety of benign and malignant causes at a tertiary care hospital. All patients had a preoperative spiral CT; these data were processed by a software program, VIDA, which was developed at this institution, and 3D-CT reconstruction images of the TBS were created. This enabled accurate preoperative anatomic definition of the lesion. The patients subsequently underwent BD.

RESULTS

All 17 patients had lesions identified with 3D-CT. Six patients had tracheal lesions and 12 patients had main stem lesions. One patient had combined tracheal and main stem lesions and 2 other patients had bilateral main stem lesions. Nine out of 17 patients required only one BD. One patient had a failed BD. The remaining 6 patients required more than one BD for optimal results (up to a maximum of 4). The follow-up period ranged from 1 to 34 months.

CONCLUSIONS

3D-CT offers accurate definition of TBS, including anatomic location, number of lesions present and status of airway distal to lesion. In this study, all preoperative lesions were correctly identified prior to BD.

Interventional Bronchoscopy in the Management of Airway Stenosis Due to Tracheobronchial Tuberculosis

STUDY OBJECTIVES

To assess the efficacy and complications of interventional bronchoscopic techniques in treating airway stenosis due to tracheobronchial tuberculosis.

DESIGN

Case series.

SETTING

Respiratory care centers at two tertiary care referral teaching hospitals in Japan, Hiroshima City Hospital and Okayama Red Cross Hospital.

PATIENTS AND INTERVENTIONS

A total of 30 patients were admitted to the hospital with a diagnosis of tracheobronchial tuberculosis between January 1991 and January 2002. Of those 11 patients received interventional bronchoscopy, including stent placement, laser photoresection, argon plasma coagulation (APC), balloon dilatation, cryotherapy, and endobronchial ultrasonography (EBUS). One patient with complete bronchial obstruction underwent a left pneumonectomy.

RESULTS

Six patients underwent stent placement after balloon dilatation, while the remaining five patients underwent only balloon dilatation. In six patients, Dumon stents were successfully placed to reestablish the patency of the central airways. Two patients first had Ultraflex stents implanted but had problems with granulation tissue formation and stent deterioration caused by metal fatigue due to chronic coughing. Dumon stents then were placed within the Ultraflex stents after the patient had received treatment with APC and mechanical reaming using the bevel of a rigid bronchoscope. In four patients, EBUS images demonstrated the destruction of bronchial cartilage or the thickening of the bronchial wall. The main complications of Dumon stents are migration and granulation tissue formation, necessitating stent removal, or replacement, and the application of cryotherapy to the granuloma at the edge of the stent.

CONCLUSION

Interventional bronchoscopy should be considered feasible for management of tuberculous tracheobronchial stenosis. Dumon stents seem to be appropriate, since removal or replacement is always possible. Ultraflex stents should not be used in these circumstances because removal is difficult and their long-term safety is uncertain. EBUS could provide useful information in evaluating the condition of the airway wall in cases of tracheobronchial tuberculosis with potential for bronchoscopic intervention.

Benign tracheobronchial stenoses: long-term clinical experience with balloon dilation

PURPOSE

To assess the safety and long-term efficacy of balloon dilation in the treatment of benign tracheobronchial stenosis.

MATERIALS AND METHODS

Balloon dilation was performed under fluoroscopic guidance in 59 consecutive patients with benign tracheobronchial stenosis. Most patients had tuberculosis (48 of 59, 81%). Two to three serial balloon insufflations were performed for 5-180 seconds (mean, 85 sec) with inflation pressures as high as 16 atm with use of 6-20-mm-diameter balloon catheters. Patients with clinical evidence of restenosis underwent repeat balloon dilation. Patients were followed for 12-42 months (mean, 32 mo).

RESULTS

A total of 101 balloon dilation sessions were performed in 59 patients, with a range of one to four sessions per patient (mean, 1.7 sessions). Initial symptomatic improvement was achieved in 49 (83%) of the 59 patients; however, during the follow-up period, 39 (80%) of the 49 patients experienced recurrence of their symptoms. The primary patency rates at 3, 6, 9, 12, 18, 24, and 32 months were 92%, 60%, 45%, 24%, 20%, 20%, and 20%, respectively. The secondary patency rates at 3, 6, 9, 12, 18, 24, and 32 months were 92%, 87%, 75%, 43%, 43%, 43%, and 43%, respectively. Procedure-related major complications of deep mucosal laceration (n = 2) and bronchospasm (n = 1) occurred in three patients, but they experienced no subsequent problems.

CONCLUSION

Although the recurrence rate is high during the long-term follow-up period, balloon dilation seems to be a safe primary treatment modality for benign tracheobronchial stenoses and has an acceptable secondary patency rate.

Fiberoptic bronchoscopic balloon dilatation in malignant tracheobronchial disease: indications and results

STUDY OBJECTIVES

Bronchoscopic balloon dilatation (BBD) has become a valuable tool in the treatment of benign tracheobronchial stenoses. The objective of this study was to assess indications for and results of fiberoptic BBD in treating malignant lesions.

DESIGN

One hundred twenty-six balloon dilatation procedures were performed in 78 patients with predominantly bronchial carcinoma. BBD was only performed when alternative modes of local treatment (eg, laser therapy or stent implantation) were not indicated or were inappropriate. Indications were symptomatic stenoses of the tracheobronchial tree: dyspnea or stridor (52%), retention pneumonia (15%), atelectasis (10%), retention of secretions (21%), or lung abscess (2%).

RESULTS

Fifty-five percent of all procedures consisted of dilatations of tracheal or bronchial lesions (group 1). In 22% of procedures, a stent was dilated (group 2). In 13%, BBD was used to facilitate stent placement (group 3), and in 10% to enable the correct positioning of irradiation probes for brachytherapy (group 4). In group 1 and group 2, 2 of 2 lung abscesses resolved, 5 of 8 atelectases resolved, and 11 of 12 retention pneumonias resolved. Dyspnea improved in only 12 of 32 patients. No abscess recurred. Two pneumonias and two atelectases reappeared due to restenosis. Stent implantation and brachytherapy procedures were facilitated in 90% of cases. In 52% of cases, BBD was supported by high-frequency jet ventilation. Complications consisted of one fatal hemoptysis caused by a lacerated pulmonary artery, and minor bleeding not necessitating specific therapy.

CONCLUSIONS

Fiberoptic BBD is useful in the management of airway stents prior to and postimplantation, as well as in the placement of brachytherapy catheters. BBD is also successful in the resolution of poststenotic lung abscesses, retention pneumonias, and atelectases.

The emerging role of flexible bronchoscopy in pediatrics

Great advances had been made in rigid instrumentation, with the introduction of the glass rod telescope. With relatively few exceptions, however, bronchoscopy was still performed primarily for therapeutic indications, such as the removal of foreign bodies from the airway. It would remain for the introduction of the flexible bronchoscope to stimulate the widespread development of diagnostic bronchoscopy in pediatric practice.

Anaesthesia for patients with a transplanted organ

Increasing numbers of individuals leading normal lives have transplanted organs. They may appear in any hospital for treatment of trauma or general diseases. Common anaesthesia methods can be used for these patients, but safe conduct of anaesthesia requires knowledge of the immunosuppression, risk factors, and altered physiology or drug actions. This article reviews the anaesthesia-related literature on patients with transplanted organs.

Spiral CT optimization for measurement of bronchial lumen diameter using an experimental model

The aim of the study was to determine optimal parameters for demonstrating sublobar bronchi on spiral CT. Measurements were obtained from five parallel polyethylene tubes embedded in foam matrix with similar radiographic characteristics to segmental and subsegmental bronchi and to lung parenchyma, respectively. Collimation widths of 1.5, 2, 3 and 4 mm were used, with a pitch of 1 or 1.5 and a reconstruction interval of 1 mm or 2 mm. Various slice planes were used. Images acquired orthogonally were viewed normally. Images acquired in planes oblique or parallel to the long axes of the tubes were reformatted into a plane orthogonal to the long axes of the tubes to be comparable with the directly acquired orthogonal images. Tube diameters were measured at lung window settings (L, -400; W, 1300) and compared with known true inner and outer tube diameters. Measurements from images acquired orthogonal to the tube long axes were accurate regardless of slice thickness. Images acquired obliquely or parallel only produced accurate measurements at the lowest slice thickness (1.5 mm). Pitch and reconstruction interval had no effect on measurement error in any scan plane. It is concluded that a slice thickness of 1.5 mm or less, with a pitch of 1.5, should be used when acquiring images at angles other than orthogonal to the long axes of experimental tubes equivalent to the segmental and subsegmental bronchi. It is suggested that similar parameters should be used in vivo and that the examination should be targeted to the area of the bronchial tree in question to reduce patient dose and length of breath-hold.

Advances in pediatric airway radiology

Radiologic evaluation of the airway has been used as a screening tool and an adjunct to endoscopy for many years. It provides noninvasive data on the structure of the airway while avoiding the risk of general anesthesia. In the past, standard radiographs provided only a shadow of the intricate anatomy of the pediatric airway. Not only have there been advances in static imaging but there now exists technology that enable noninvasive dynamic imaging and new techniques for image-guided intervention within the airway. This article focuses on four specific areas: airway fluoroscopy, functional swallow studies, controlled ventilation computed tomography, and interventional airway techniques.

Tuberculous stenosis of the left main bronchus: results of treatment with balloons and metallic stents

PURPOSE

To assess the results of treatment with balloon dilation and metallic Z stents in patients with tuberculous stenosis of the left main bronchus.

MATERIALS AND METHODS

Nineteen patients with tuberculous stenosis of the left main bronchus were treated with balloon (n = 15) and self-expanding metallic Z stents (n = 4). Respiratory status and pulmonary function tests were followed up for 2-90 months.

RESULTS

In the balloon group, improvements in dyspnea occurred in 73% (11 of 15 patients) immediately, 73% after 1 month, 73% after 6 months, 64% after 1 year, 64% after 3 years, and 42% after 6 years (Kaplan-Meier method). Improvement of pulmonary function (FEV1 or FVC) was achieved in 62% (eight of 13) after 1 year. In the stent group, immediate improvements of dyspnea or pulmonary function occurred in all patients. However, fracture of the stents occurred in two patients, at 4 and 18 months, respectively. Occlusion of the lumen of the stent by granulation tissue occurred in another at 18 months.

CONCLUSION

Balloon dilation can be an effective method for the treatment of tuberculous stenosis of the main bronchus. Metallic Z stents should be used cautiously because of their problems of mechanical durability and overgrowth of granulation tissue.

Long-term results of fiberoptic bronchoscopic balloon dilation in the management of benign tracheobronchial stenosis

STUDY OBJECTIVES

To assess the short- and long-term effects of balloon dilatation using a fiberoptic bronchoscope in the management of benign tracheobronchial stenosis (TBS). Treatment strategies have included open surgical resection or endoscopic techniques. The endoscopic techniques have included Nd:Yag laser, cryotherapy, stent placement, rigid bronchoscopy, and balloon dilation (BD).

DESIGN

Prospective sequentiality study.

SETTING

Tertiary care academic hospital.

PATIENTS

This study consisted of 14 patients, ages ranging from 35 to 72 years, whose symptoms of dyspnea, cough, or wheeze were attributable to a TBS.

INTERVENTION

This study describes the use of flexible fiberoptic bronchoscopy (FFB) with a balloon catheter for airway dilation. Each patient underwent FFB, in which a balloon catheter was threaded over the guidewire and positioned across the stenosis. Under direct visualization, the balloon was inflated for 30 to 120 s. Repeat inflation-deflation cycles were done if airway narrowing remained after the initial attempt.

RESULTS

Seven patients had TBS following lung transplantation, three after sleeve resection, two following irradiation therapy, and two due to fibrosing mediastinitis. All patients had initial success: increased airway dimensions and symptom relief. Ten patients had successful airway dilation after one session. Of the four patients who required multiple sessions, one had cryotherapy and in each of the others an airway stent was placed.

CONCLUSIONS

BD offers immediate symptom relief and can be used in conjunction with Nd:Yag laser, cryotherapy, stent placement, or mechanical dilation with a rigid bronchoscope. The advantages of FFB with BD include operator familiarity, patient safety, and avoidance of general anesthesia.

Thin-section spiral volumetric CT for the assessment of lobar and segmental bronchial stenoses

Thin-section volumetric computed tomography (CT) was used to examine the lobar and segmental bronchi of five patients who had stenoses of these airways diagnosed by previous bronchography and/or bronchoscopy. Four of 23 lobar bronchi and 42 of 72 segmental bronchi were judged to be stenotic by CT. Our findings in this small group suggest that thin-section volumetric CT is a promising non-invasive technique that is likely to prove useful in the assessment of such stenoses in the future.