Bronchoscopic intervention obviates the need for continued mechanical ventilation in patients with airway obstruction and respiratory failure from inoperable non-small-cell lung cancer

Weaning-associated interventions for ventilated intensive care patients: A scoping review

BACKGROUND

Mechanical ventilation is a core intervention in critical care, but may also lead to negative consequences. Therefore, ventilator weaning is crucial for patient recovery. Numerous weaning interventions have been investigated, but an overview of interventions to evaluate different foci on weaning research is still missing.

AIM

To provide an overview of interventions associated with ventilator weaning.

STUDY DESIGN

We conducted a scoping review. A systematic search of the Medline, CINAHL and Cochrane Library databases was carried out in May 2023. Interventions from studies or reviews that aimed to extubate or decannulate mechanically ventilated patients in intensive care units were included. Studies concerning children, outpatients or non-invasive ventilation were excluded. Screening and data extraction were conducted independently by three reviewers. Identified interventions were thematically analysed and clustered.

RESULTS

Of the 7175 records identified, 193 studies were included. A total of six clusters were formed: entitled enteral nutrition (three studies), tracheostomy (17 studies), physical treatment (13 studies), ventilation modes and settings (47 studies), intervention bundles (42 studies), and pharmacological interventions including analgesic agents (8 studies), sedative agents (53 studies) and other agents (15 studies).

CONCLUSIONS

Ventilator weaning is widely researched with a special focus on ventilation modes and pharmacological agents. Some aspects remain poorly researched or unaddressed (e.g. nutrition, delirium treatment, sleep promotion).

RELEVANCE TO CLINICAL PRACTICE

This review compiles studies on ventilator weaning interventions in thematic clusters, highlighting the need for multidisciplinary care and consideration of various interventions. Future research should combine different interventions and investigate their interconnection.

World Association for Bronchology and Interventional Pulmonology (WABIP) guidelines on airway stenting for malignant central airway obstruction

Malignant Central Airway Obstruction (MCAO) encompasses significant and symptomatic narrowing of the central airways that can occur due to primary lung cancer or metastatic disease. Therapeutic bronchoscopy is associated with high technical success and symptomatic relief and includes a wide range of airway interventions including airway stents. Published literature suggests that stenting practices vary significantly across the world primarily due to lack of guidance. This document aims to address this knowledge gap by addressing relevant questions related to airway stenting in MCAO. An international group of 17 experts from 17 institutions across 11 countries with experience in using airway stenting for MCAO was convened as part of this guideline statement through the World Association for Bronchology and Interventional Pulmonology (WABIP). We performed a literature and internet search for reports addressing six clinically relevant questions. This guideline statement, consisting of recommendations addressing these six PICO questions, was formulated by a systematic and rigorous process involving the evaluation of published evidence, augmented with expert experience when necessary. Panel members participated in the development of the final recommendations using the modified Delphi technique.

Interventional bronchoscopy in lung cancer treatment

Interventional bronchoscopy has seen significant advancements in recent decades, particularly in the context of lung cancer. This method has expanded not only diagnostic capabilities but also therapeutic options. In this article, we will outline various therapeutic approaches employed through either a rigid or flexible bronchoscope in multimodal lung cancer treatment. A pivotal focus lies in addressing central airway obstruction resulting from cancer. We will delve into the treatment of initial malignant changes in central airways and explore the rapidly evolving domain of early peripheral malignant lesions, increasingly discovered incidentally or through lung cancer screening programmes. A successful interventional bronchoscopic procedure not only alleviates severe symptoms but also enhances the patient's functional status, paving the way for subsequent multimodal treatments and thereby extending the possibilities for survival. Interventional bronchoscopy proves effective in treating initial cancerous changes in patients unsuitable for surgical or other aggressive treatments due to accompanying diseases. The key advantage of interventional bronchoscopy lies in its minimal invasiveness, effectiveness and favourable safety profile.

Feasibility, Tolerability, and Effectiveness of Transbronchial Interventions in Elderly Patients With Malignant Central Airway Obstruction: A Retrospective Single-institution Study

BACKGROUND

In elderly patients with malignant central airway obstruction (MCAO), the treating physicians often hesitate to undertake transbronchial interventions (TBIs) as a palliative procedure in view of the advanced age of the patients.

METHODS

We conducted this retrospective study to evaluate the differences in the feasibility, tolerability, and effectiveness of TBIs between elderly (aged 75 years old or above; elderly group; n=27) and nonelderly (aged below 75 years old; nonelderly group; n=50) patients with MCAO. The primary endpoint was the incidence of complications during (within 24 hours) and after (>24 hours) TBIs.

RESULTS

The mean age of the patients was 81 years in the elderly group and 61 years in the nonelderly group. The complications encountered during/after TBI included endobronchial bleeding or hypoxemia requiring intubation occurring during the TBIs, and bacterial pneumonia, airway reocclusion, and stent migration occurring after the TBIs, although there was no difference in the frequency of complications during/after the TBIs between the elderly group and nonelderly group (26% vs. 30%, P =0.706). There was no difference in the percentage of patients in whom successful airway recanalization was achieved by TBI (93% vs. 80%, P =0.197), the percentage of patients who showed symptomatic improvement after the TBIs (67% vs. 76%, P =0.380) and the OS after the TBIs (6.1 vs. 7.3 months, P =0.704) between the 2 groups.

CONCLUSION

TBIs can be undertaken without hesitation as a palliative procedure in elderly patients with MCAO.

Airway stenting for liberation from positive pressure ventilation in patients with central airway obstruction presenting with acute respiratory failure

BACKGROUND

Central airway obstruction (CAO) can lead to acute respiratory failure (RF) necessitating positive pressure ventilation (PPV). The efficacy of airway stenting to aid liberation from PPV in patients with severe acute RF has been scarcely published. We present a systematic review and our recent experience.

METHODS

A systematic review of PubMed was performed, and a retrospective review of cases performed at our two institutions from 2018 to 2022 in adult patients who needed stent insertion for extrinsic or mixed CAO complicated by RF necessitating PPV.

RESULTS

Fifteen studies were identified with a total of 156 patients. The weighted mean of successful liberation from PPV post-stenting was 84.5% and the median survival was 127.9 days. Our retrospective series included a total of 24 patients. The most common etiology was malignant CAO (83%). The types of PPV used included high-flow nasal cannula (HFNC) (21%), non-invasive ventilation (NIV) (17%) and Invasive Mechanical Ventilation (62%). The overall rate of successful liberation from PPV was 79%, with 55% of HFNC and NIV cases being liberated immediately post-procedure. The median survival of the patients with MCAO that were successfully liberated from PPV was 74 days (n = 16, range 3-893 days), and for those with that failed to be liberated from PPV, it was 22 days (n = 4, range 9-26 days).

CONCLUSION

In patients presenting with acute RF from extrinsic or mixed morphology CAO requiring PPV, airway stenting can successfully liberate most from the PPV. This may allow patients to receive pathology-directed treatment and better end-of-life care.

Interventional Pulmonology: Extending the Breadth of Thoracic Care

Interventional pulmonary medicine has developed as a subspecialty focused on the management of patients with complex thoracic disease. Leveraging minimally invasive techniques, interventional pulmonologists diagnose and treat pathologies that previously required more invasive options such as surgery. By mitigating procedural risk, interventional pulmonologists have extended the reach of care to a wider pool of vulnerable patients who require therapy. Endoscopic innovations, including endobronchial ultrasound and robotic and electromagnetic bronchoscopy, have enhanced the ability to perform diagnostic procedures on an ambulatory basis. Therapeutic procedures for patients with symptomatic airway disease, pleural disease, and severe emphysema have provided the ability to palliate symptoms. The combination of medical and procedural expertise has made interventional pulmonologists an integral part of comprehensive care teams for patients with oncologic, airway, and pleural needs. This review surveys key areas in which interventional pulmonologists have impacted the care of thoracic disease through bronchoscopic intervention.

[Bronchoscopic management of malignant central airway obstructions]

Up to 30% of lung cancer patients suffer from central airway obstruction, resulting in major deterioration in prognosis and quality of life. Interventional bronchoscopy combines a number of invasive techniques used during rigid bronchoscopy. It is designed to rapidly improve symptoms, primarily dyspnea. Applied according to very precise indications, this technique requires careful patient selection and needs to be incorporated into the multimodal oncological management in combination with systemic treatments, radiation therapy and surgery.

Therapeutic bronchoscopy for malignant central airway obstruction: impact on quality of life and risk-benefit analysis

PURPOSE OF REVIEW

Malignant central airway obstruction (CAO) is a common complication in cancer and confers significant symptom burden and reduction in quality of life. Multiple bronchoscopic interventions exist for malignant CAO. In this review, we discuss the role of therapeutic bronchoscopy in the management of malignant CAO, emphasizing its impact on symptom control and quality of life while balancing the risks and benefits of intervention.

RECENT FINDINGS

Significant practice variations exist among practitioners of therapeutic bronchoscopy, and limited data exist to guide real-time clinical decision-making. Recent analyses demonstrate that therapeutic bronchoscopy is effective for symptoms associated with malignant CAO with infrequent complications. These studies also show that many of the improvements in symptoms and quality of life are sustained after intervention and are associated with improved overall survival in patients with malignant CAO. Recent data have also shown that the improvement in symptoms associated with therapeutic bronchoscopy may enable more definitive cancer treatment, further improving patient outcomes.

SUMMARY

Therapeutic bronchoscopy is safe and effective at improving patient-centered outcomes in malignant CAO. Research is ongoing to better understand its optimal role in this setting, refine decision-making regarding advanced bronchoscopic interventions, and further improve patient outcomes.

Beware of spurious tracheo-bronchial stents

OBJECTIVE

To present a case of accidental sheath removal of tracheo-bronchial self-expandable metallic airway stent in a patient with endotracheal tumour.

METHODS

Design: Case Report; Setting: Tertiary care hospital; Patient: One.

RESULTS

A 65 years male, follow up case of endotracheal tumor with tracheo-bronchial self-expandable metallic stenting done presented with dry cough and difficulty in breathing since 8-10 days and suddenly coughed out thin whitish paper-like material 2 days back (which later proved as sheath of metallic stent). Direct laryngoscopy with flexible videobronchoscopy was done which showed tracheal stent well placed and intact, coughed out sheath couldn't be replaced back. Procedure was uneventful and patient was discharged in satisfactory condition and is doing well on regular follow up.

CONCLUSION

Self-expandable metallic airway stents (SEMAS) represents a standard method of airways stenting especially when employed for the management of malignant central airway obstruction. Despite the obvious stenting advantages, it may be complicated with stent migration and accidental removal or coughing out of stent especially in high tracheal stenosis. In our case, as a peculiar complication there was accidental removal of the tracheal stent sheath which couldn't be replaced back whereas stent was well in place and intact. We need to be beware of such spurious tracheo-bronchial stents.

Clinical Value of Bronchoscopy in Acute Respiratory Failure

Bronchoscopy may be considered the “added value” in the diagnostic and therapeutic pathway of different clinical scenarios occurring in acute respiratory critically ill patients. Rigid bronchoscopy is mainly employed in emergent clinical situations due to central airways obstruction, haemoptysis, and inhaled foreign body. Flexible bronchoscopy (FBO) has larger fields of acute applications. In intensive care settings, FBO is useful to facilitate intubation in difficult airways, guide percutaneous dilatational tracheostomy, and mucous plugs causing lobar/lung atelectasis. FBO plays a central diagnostic role in acute respiratory failure caused by intra-thoracic tumors, interstitial lung diseases, and suspected severe pneumonia. “Bronchoscopic” sampling has to be considered when “non-invasive” techniques are not diagnostic in suspected ventilator-associated pneumonia and in non-ventilated immunosuppressed patients. The combined use of either noninvasive ventilation (NIV) or High-flow nasal cannula (HFNC) with bronchoscopy is useful in different scenarios; the largest body of proven successful evidence has been found for NIV-supported diagnostic FBO in non-ventilated high risk patients to prevent and avoid intubation. The expected diagnostic/therapeutic goals of acute bronchoscopy should be balanced against the potential severe risks (i.e., cardio-pulmonary complications, bleeding, and pneumothorax). Expertise of the team is fundamental to achieve the best rate of success with the lowest rate of complications of diagnostic and therapeutic bronchoscopic procedures in acute clinical circumstances.

Therapeutic bronchoscopy facilitates liberation from mechanical ventilation and improves quality of life for critically ill patients with central airway obstruction

Central airway obstruction (CAO) remains a challenging disease for both patients who are suffering from it and for physicians who are managing it. Patients will frequently present with acute symptoms of respiratory failure that require management in an intensive care unit (ICU). While the true prevalence and incidence of CAO in the ICU setting is unknown, recent estimates suggest that approximately 20-30% of patients with a cancer diagnosis may present with CAO or develop it after diagnosis. Therapeutic bronchoscopy focuses on performing minimally invasive procedures using multiple ablative modalities to recanalize the central airway and alleviate the obstruction. While procedures are usually technically successful, they appear to be underutilized. An individually tailored approach is often used based on patient characteristics, operator preference, and available equipment. After therapeutic bronchoscopy procedures are completed, many patients are successfully liberated from mechanical ventilation (MV) or immediately transferred out of the ICU. Data reviewing the effects of therapeutic bronchoscopy have also shown success in palliation of symptoms, with significant improvement in subjective measures such as patient quality of life and dyspnea and objective values like pulmonary function studies. Given the potential benefits with a low risk profile and high likelihood of technical success, treatment of CAOs with therapeutic bronchoscopy represents a reasonable consideration for patients with acute respiratory failure in the ICU.

Efficacy and safety of transbronchial microwave ablation therapy under moderate sedation in malignant central airway obstruction patients with respiratory failure: a single-institution retrospective study

BACKGROUND

The safety and efficacy of transbronchial microwave ablation (TMA) therapy in patients with malignant central airway obstruction (CAO) with respiratory failure remains unclear.

METHODS

A total of 38 patients with advanced non-small cell lung cancer (NSCLC) or lung metastases with malignant endoluminal obstruction received TMA therapy under moderate sedation and high fractions of inspired oxygen (FiO₂). The success rate of airway patency restoration, complication rate, and overall survival time (OS) from the initiation of TMA therapy were compared in the following two groups of patients with malignant CAO patients: the group with respiratory failure (PaO₂/FiO₂ ≤ 300) (RF group, n = 10) and the group without respiratory failure (PaO₂/FiO₂ > 300) (non-RF group, n = 28) at the time of the TMA therapy.

RESULTS

Both the RF group and non-RF group received a median of two sessions of TMA. There was no significant difference in the percentage of patients who showed restored airway patency after the first session of TMA (90% vs. 96%), in the complication rate of TMA therapy (10% vs. 11%), or in the OS (7.1 months vs. 9.1 months) between the RF group and the non-RF group. Multivariate analysis identified no significant association between TMA therapy and the risk of death in malignant CAO patients with respiratory failure (p = 0.196).

CONCLUSION

TMA therapy under moderate sedation was well tolerated and effective in patients with malignant CAO, including those with respiratory failure.

Bronchoscopic Treatment of Airway Obstructions With a Novel Electrosurgical Device

OBJECTIVES

Airway obstructions (AOs) in the central airway or lobar bronchi develop due to malignant or benign disease. Because of the morbidity and mortality associated with AO, it is important to develop additional therapeutic ablative techniques. CoreCath2.7S is a novel monopolar radiofrequency electrosurgical device approved to treat obstructions of the upper airway and tracheobronchial tree by both cutting soft tissue and providing electrosurgical hemostasis. We present a large case series describing its use.

METHODS

Retrospective chart review was performed of all patients with AO undergoing airway recanalization with CoreCath2.7S at 2 interventional pulmonology practices from October 2017 to May 2019. Demographic information, AO etiology, location, and degree, and therapeutic modalities used were recorded.

RESULTS

Fifty-three patients underwent 64 procedures for AO due to malignant (n=30, 57%) or benign (n=23, 43%) disease. AOs were treated in the trachea (n=28), mainstem bronchi (n=23), and lobar bronchi (n=17). All AO occluded the airway at least 50%. Adjunctive therapeutic modalities were commonly used (n=60, 94%), including flexible cryoprobe (n=33), balloon dilation (n=23), rigid bronchoscopy (n=19), spray cryotherapy (n=19), argon plasma coagulation (n=14), and stenting (n=5). Restoration of airway patency was achieved in all cases without any periprocedural or immediate postprocedural complications.

CONCLUSION

CoreCath2.7S was successfully used to treat patients with AO due to malignant or benign disease. Airway patency was restored with no periprocedural or immediate postprocedural complications. It should be considered as another therapeutic modality in the growing field of ablative techniques for the treatment of AO.

Bronchoscopic treatment of inoperable nonsmall cell lung cancer

Patients with unresectable lung cancer range from those with early-stage or pre-invasive disease with comorbidities that preclude surgery to those with advanced stage disease in whom surgery is contraindicated. In such cases, a multidisciplinary approach to treatment is warranted, and may involve medical specialties including medical oncology, radiation oncology and interventional pulmonology. In this article we review bronchoscopic approaches to surgically unresectable lung cancer, including photodynamic therapy, brachytherapy, endoscopic ablation techniques and airway stenting. Current and past literature is reviewed to provide an overview of the topic, including a highlight of potential emerging approaches.

Internal fixation of the proximal tracheal self-expandable metallic stent (SEMS): migration prevention in high risk patients

Airway stenting provides an important treatment option for patients with proximal tracheal stenosis. However, the risk of migration remains a major challenging problem. In our report we describe the internal fixation of SEMS in 3 patients with proximal tracheal stenosis due to variable causes. The fixation was performed in different situations including: prophylaxis to prevent the stent migration, fixation due to displacement of the stent during insertion and finally internal fixation of migrated tracheal stent.

Airway stenting: Technological advancements and its role in interventional pulmonology

AS offers rapid and sustained relief of symptoms in most patients treated for malignant or benign CAO and can also be curative in itself in cases of benign tracheobronchial stenosis. In the past 30 years, this field has seen significant progress, from the misuse of vascular non-covered metallic stents to the development of silicone airway stents with an increasingly large panel of shapes and of hybrid, partially or fully covered, SEMS customized to the airways. This study aims to offer an overview on: (i) the respective advantages and drawbacks of these two main categories of devices; (ii) the main indications for AS and the rationale behind the choice of stent in each situation; and (iii) the main promises borne from the progress made in the field in the past few years, including the development of drug-eluting, biodegradable or patient-specific customized AS.

Evaluation of Safety and Short-term Outcomes of Therapeutic Rigid Bronchoscopy Using Total Intravenous Anesthesia and Spontaneous Assisted Ventilation

BACKGROUND

There is a paucity of published data regarding the optimal type of anesthesia and ventilation strategies during rigid bronchoscopy.

OBJECTIVE

The aim of our study is to report the procedural and anesthesia-related complications with rigid bronchoscopy using total intravenous anesthesia and spontaneous assisted ventilation.

METHODS

A retrospective review of patients undergoing therapeutic rigid bronchoscopy at the University of Chicago between October 2012 and December 2014 was performed. Data were recorded relating to patients' demographics, comorbidities, type of anesthesia, need for neuromuscular blockade (NMB), intraoperative hypoxemia, hypotension, perioperative adverse events, and mortality.

RESULTS

Fifty-five patients underwent 79 rigid bronchoscopy procedures; 90% were performed for malignant disease and 90% of patients had an American Society of Anesthesiologists (ASA) class III or IV. The majority (76%) did not require use of NMB. The most common adverse events were intraoperative hypoxemia (67%) and hypotension (77%). Major bleeding and postoperative respiratory failure occurred in 3.8 and 5.1% of procedures, respectively. There was no intraoperative mortality or cardiac dysrhythmias. The 30-day mortality was 7.6% and was associated with older age, inpatient status, congestive heart failure, home oxygen use, and procedural duration. Intraoperative hypoxemia, hypotension, and ASA class were not associated with 30-day mortality. The majority (94%) of patients were discharged home. The use of NMB did not impact outcomes.

CONCLUSIONS

This study suggests that therapeutic rigid bronchoscopy can be safely performed with total intravenous anesthesia and spontaneous assisted ventilation in patients with central airway obstruction, significant comorbidities, and a high ASA class. The only significant modifiable variable predicting the 30-day mortality was the duration of the procedure.

Effect of Palliative Bronchoscopic Interventions on Symptom Burden in Patients with Central Airway Narrowing: A Retrospective Review

INTRODUCTION

Early integration of palliative interventions in patients with central airway obstruction (CAO) has shown to reduce patients' distress due to breathlessness and achieve better outcomes at lower cost. This retrospective review was performed to determine whether rigid bronchoscopic interventions alleviated the symptom burden and the requirement for continued mechanical ventilation in patients with CAO in a tertiary care hospital.

MATERIALS AND METHODS

Detailed records of 105 patients with CAO were retrospectively studied. The Numerical Rating Scale (NRS) score for cough and dyspnea before and after the intervention was noted. A need for an escalation or reduction in level of care was also noted.

RESULTS

The mean NRS score for dyspnea (n = 84) reduced from 7.5 (4-9) (before procedure) to 2.5 (2-6) after intervention (P < 0.01). The mean NRS score for cough (n = 68) also reduced from 6.5 (4-8) (before procedure) to 4 (3-7) after intervention (P < 0.01). Of these patients, bronchoscopic intervention allowed transfer out of the ICU in 14 patients (42%) and immediate withdrawal of mechanical ventilation in 8 patients (42%).

CONCLUSION

There is an instantaneous valuable palliation of symptoms and improved health-care utilization with airway tumor debulking and stenting. Multidisciplinary interventions with emphasis delivery of palliative care provide better care of patients with CAO.

Outcome of advanced lung cancer with central airway obstruction versus without central airway obstruction

Patients with central airway obstruction (CAO) from advanced lung cancer present with significant morbidity and are assumed to have lower survival. Hence, they are offered only palliative support. We asked if patients who have advanced lung cancer with CAO (recanalised and treated) will behave similarly to those with advanced lung cancer without CAO. This study was a retrospective review of the medical records of the patients managed for advanced lung cancer during 2010 and 2015 at our institution. 85 patients were studied. Median survival and 1-, 2- and 5-year survival were 5.8 months, 30.3%, 11.7% and 2.3% versus 9.3 months, 35.7%, 9.6% and 4.7%, respectively, in the CAO and no CAO groups (p=0.30). More patients presented with respiratory failure (15 (35%) versus none; p=0.0001) and required assisted mechanical ventilation (10 (23.3%) versus none; p=0.001) in the CAO group compared with the no CAO group. Fewer patients received chemotherapy in the CAO group (11 (25.5%)) compared with the no CAO group (23 (54.7%); p=0.008). There was no difference in survival among patients with advanced lung cancer whether they presented with CAO or without CAO. Survival was similar to those without CAO in patients with recanalised CAO despite greater morbidity and lesser use of chemotherapy, strongly advocating bronchoscopic recanalisation of CAO. These findings dispel the nihilism associated with such cases.

Managing the oncologic patient with suspected pneumonia in the intensive care unit

INTRODUCTION

Solid cancer patients are frequently admitted in intensive care units for critical events. Improving survival rates in this setting is considered an achievable goal today. Respiratory failure is the main reason for admission, representing a primary target for research.

AREAS COVERED

This review presents a diagnostic and therapeutic algorithm for pneumonia and other severe respiratory events in the solid cancer population. It aims to increase awareness of the risk factors and the different etiologies in this changing scenario in which neutropenia no longer seems to be a decisive factor in poor outcome. Bacterial pneumonia is the leading cause, but opportunistic diseases and non-infectious etiologies, especially unexpected adverse effects of radiation, biological drugs and monoclonal antibodies, are becoming increasingly frequent. Options for respiratory support and diagnostics are discussed and indications for antibiotics in the management of pneumonia are detailed. Expert commentary: Prompt initiation of critical care to facilitate optimal decision-making in the management of respiratory failure, early etiological assessment and appropriate antibiotic therapy are cornerstones in management of severe pneumonia in oncologic patients.

Airway stenting in patients requiring intubation due to malignant airway stenosis: a 10-year experience

Background

Critically ill patients with severe acute respiratory failure due to malignant airway stenosis often require emergency intubation and mechanical ventilation. Urgent intervention is necessary for the survival of such patients. The aim of this study was to determine the efficacy and outcomes of airway stenting in patients with malignant airway stenosis requiring emergency intubation.

Methods

Patients with malignant airway stenosis who underwent emergency intubation prior to airway stent placement from September 2005 to September 2015 in a single center were retrospectively reviewed. All stenting procedures were performed using both rigid and flexible bronchoscopes under general anesthesia.

Results

Thirty patients with malignant airway stenosis (17 with lung cancer, 6 with esophageal cancer, and 7 with other types of malignancy) who required emergency intubation prior to stenting procedures (silicone stenting in 23 and metallic stenting in 7) were analyzed. Extubation within 48 hours after stenting could be performed in 28 of 30 patients (93%). Of the 21 chemoradiotherapy-naïve patients, 18 (86%) received chemotherapy and/or radiation therapy after stenting. No significant complications occurred during the stenting procedures. The median survival after stenting was 198 days (range, 13-3,009 days).

Conclusions

Airway stenting facilitates extubation in critically ill patients with malignant central airway stenosis. It plays an important role as a bridge to additional tumor-specific therapies, especially in chemoradiotherapy-naïve patients.

Role of Bronchoscopy in Prompt Discharge From the Intensive Care Unit

BACKGROUND

Intensive care unit (ICU) stays are 2.5 times more costly than other hospital stays, and 93.3% of ICU use is for respiratory disease with ventilator support. The aim of this study was to assess the role of bronchoscopy on discontinuation of mechanical ventilation, and prompt discharge from ICU in our institution.

METHODS

Retrospective review of medical records of patients referred for bronchoscopic intervention for acute respiratory failure from malignant or benign central airway diseases requiring ICU admission.

RESULTS

Twelve critically ill patients were studied. Median (range) age was 63 years (range, 35 to 85 y). Nine (75%) had endotracheal tube, and 3 (25%) had tracheostomy tube. Nine (75%) of 12 patients admitted to ICU could be transferred to general ward after median (range) interval of 2 days (range, 1 to 7 d) after the day of intervention. Median (range) prebronchoscopy and postbronchoscopy PaO2/FiO2 ratio was 102.8 (range, 99.2 to 328) and 180 (range, 129 to 380), respectively, with significant improvement postintervention (P=0.002). Radiologically, all 8 patients with lung atelectasis on presentation experienced complete reexpansion of the lung on the day after bronchoscopic intervention.

CONCLUSION

The majority of patients in our cohort (75%) of benign and malignant etiology could be promptly (within 2 d postbronchoscopy) transferred out from ICU to general ward after successful discontinuation of mechanical ventilation and extubation after bronchoscopic intervention. We advocate early recognition and bronchoscopic intervention in suitable patients.

Integration of interventional bronchoscopy in the management of lung cancer

Tracheal or bronchial proximal stenoses occur as complications in 20-30% of lung cancers, resulting in a dramatic alteration in quality of life and poor prognosis. Bronchoscopic management of these obstructions is based on what are known as "thermal" techniques for intraluminal stenosis and/or placement of tracheal or bronchial prostheses for extrinsic compressions, leading to rapid symptom palliation in the vast majority of patients. This invasive treatment should only be used in cases of symptomatic obstructions and in the presence of viable bronchial tree and downstream parenchyma. This review aims to clarify 1) the available methods for assessing the characteristics of stenoses before treatment, 2) the various techniques available including their preferred indications, outcomes and complications, and 3) the integration of interventional bronchoscopy in the multidisciplinary management of proximal bronchial cancers and its synergistic effects with the other specific treatments (surgery, radiotherapy or chemotherapy).

Fully covered self-expandable metal stent in tracheobronchial disorders: clinical experience

BACKGROUND

The third-generation fully covered self-expandable metallic stent (SEMS) has been developed to solve the problems of difficult removal and in-stent granuloma formation related to the uncovered or partially covered type. There are few written reports about the performance of this type of stents with early encouraging results.

OBJECTIVES

To report and analyse our experience with the Silmet® stent in the management of malignant and benign tracheobronchial disorders.

METHODS

We retrospectively reviewed medical records of patients who underwent fully covered SEMS Silmet placement at the Interventional Pulmonology Unit, La Maddalena Cancer Center, Palermo, Italy, between May 2010 and August 2013.

RESULTS

Stents were placed in 52 patients with malignant (n = 49) and benign airway obstruction (n = 2) and broncho-oesophageal fistula (n = 1). SEMSs were inserted into the trachea (n = 19), the main bronchi (n = 21) and the peripheral bronchi (n = 31). Besides 1 procedural dislocation, the deployment was successful in all patients with an immediate significant improvement of symptoms (Barthel Index p < 0.001; Medical Research Council score p < 0.001). A radiographic improvement was detected in 48% of patients. The mean follow-up duration was 119 ± 120 days (range 22-549 days). Complications observed were: migration (7.6%), tumour overgrowth (15%), infections (5.7%), granulation tissue formation (3.8%) and mucus plug (3.8%).

CONCLUSIONS

The Silmet stent is effective, safe and simple to implant and remove. We suggest its use in cases of tight stenoses, in the treatment of small- to medium-caliber airways or in cases of tortuous airways.