Airway stenting: Applications and practice management considerations

Determination of patient-specific airway stent fit using novel 3D reconstruction measurement techniques: a 4-year follow-up of a patient

Managing complex benign airway disease is a major challenge in interventional pulmonology. With the introduction of additive manufacturing in the medical field, patient-specific (PS) implants are an innovate prospect for airway management. Historically, stents were oversized to resist migration. However, the optimal degree and impact of stent oversizing remains unclear. The ability to design stents based on computed tomography (CT) invites opportunity to understand sizing. Here, we report a novel three-dimensional (3D) image reconstruction tool to quantify fit repeatedly over time. Analysis of CT imaging before and after successive stent implants in a single patient with different areas of stenosis and malacia was done. Nine PS airway stents over 4 years (five left mainstem and four right mainstem) were studied. The distance between the airway model and stent was calculated. The CT images were correlated to stent designs in CloudCompare software (v2.10-alpha) for novel analysis. Heat map was exported depicting the distances between the airway and the stent to the clinician's prescribed stent model. Corresponding histograms containing distances, mean, and standard deviation were reported. It is possible to measure stent fit based on heat map quantification on patient imaging. Observation of the airway over time and stent change suggests that the airway became more open over time requiring increased stent diameters. The ability to design and measure stent fit over time can help quantify the utility and impact of PS silicone airway stent. The airway appears to display plasticity such that there is notable change in stent prescription over time.

Association of the location and initial degree of malignant central airway stenosis with the risk of severe restenosis after interventional bronchoscopy

BACKGROUND

Therapeutic bronchoscopy is one of the effective methods in the treatment and management of malignant central airway stenosis (MCAS). However, restenosis after therapeutic bronchoscopy frequently occurs and severe restenosis (SR) can be life-threatening. Therefore, this study aimed at investigating the risk factors for SR after therapeutic bronchoscopy.

METHODS

The data of 233 consecutive cases with MCAS who were subjected to therapeutic bronchoscopy between 2015 and 2020 at a tertiary hospital were collected. Patients were divided into SR group and non-SR during 6 months after therapeutic bronchoscopy. Multiple logistic regression analysis was performed to determine the risk factors for SR.

RESULTS

SR during 6 months after therapeutic bronchoscopy occurred in 39.5% (92/233) of patients. The location and the initial degree of MCAS were associated with SR, as assessed by multiple logistic regression analysis (P < 0.05). The risk of SR after therapeutic bronchoscopy in the left main bronchus, right main bronchus, and right intermediate bronchus increased, compared to the risk when of MCAS was located in the trachea (OR (95% CI) of 8.821 (1.850-25.148), 6.583 (1.791-24.189), and 3.350 (0.831-13.511), respectively). In addition, the initial degree of MCAS was positively associated with an increased risk of SR (OR 1.020; 95% CI 1.006-1.035).

CONCLUSIONS

MCAS located in the left main bronchus, right main bronchus and right intermediate bronchus, as well as the higher initial degree of MCAS were independent risk factors for SR during 6 months after therapeutic bronchoscopy.

Advanced Diagnostic and Therapeutic Bronchoscopy: Technology and Reimbursement

Advanced interventional pulmonary procedures of the airways, pleural space, and mediastinum continue to evolve and be refined. Health care, finance, and clinical professionals are challenged by both the indications and related coding complexities. As the scope of interventional pulmonary procedures expands with advanced technique and medical innovation, program planning and ongoing collaboration among clinicians, finance executives, and reimbursement experts are key elements for success. We describe advanced bronchoscopic procedures, appropriate Current Procedural Terminology coding, valuations, and necessary modifiers to fill the knowledge gap between basic and advanced procedural coding. Our approach is to balance the description of procedures with the associated coding in a way that is of use to the proceduralist, the coding specialist, and other nonclinical professionals.

Clinical Efficacy of HiPorfin Photodynamic Therapy for Advanced Obstructive Esophageal Cancer

Objective:

To explore the clinical efficacy of HiPorfin photodynamic therapy for advanced esophageal cancer and evaluate its impact on survival.

Methods:

Retrospective analysis of 32 patients with advanced obstructive esophageal cancer at our institution from September 2013 to December 2016. HiPorfin was infused as the photosensitizer at a dose of 5 mg/kg, and after 48 hours, 630-nm laser irradiation was subsequently performed through an optical fiber that passed through the biopsy channel of a flexible endoscope.

Results:

The effectiveness rate was 78.1% (25/32), and the significant efficacy rate was 56.3% (18/32). The dysphagia score decreased from 3.43 ± 0.73 to 1.79 ± 0.53 (P < .05). There was no grade 3 or more toxicity. The median overall survival was estimated to be 16 months. Univariate analysis showed higher overall survival with a Karnofsky Performance Status score ≥80 compared with a Karnofsky Performance Status score <80 (hazard ratio: 2.626; 95% CI: 1.091-6.322; P = .024). Overall survival was higher in patients who had received radiation therapy than in patients who did not receive radiation therapy (hazard ratio: 3.574; 95% CI: 1.501-8.510; P = .002).

Conclusion:

Photodynamic therapy is an effective method for advanced esophageal cancer. The side effects are mild, and the short-term effect is good, especially in the relief of dysphagia. Photodynamic therapy can prolong the survival of patients with advanced esophageal cancer, and the Karnofsky Performance Status score and previous radiation therapy have a significant effect on the overall survival.

Interventional Bronchoscopy for the Treatment of Malignant Central Airway Stenosis: An Expert Recommendation for China

Malignant central airway stenosis refers to airway stenosis caused by primary or metastatic malignant tumors which may lead to different levels of dyspnea or asphyxia in patients. With the rapid development of interventional pulmonology, therapeutic bronchoscopy has become one of the main methods for the diagnosis and treatment of malignant central airway stenosis. However, the level of diagnosis and treatment of respiratory intervention techniques in China is uneven at present, the treatment methods are not uniform, the treatment effects vary greatly, and some treatments even lead to serious complications. The interventional treatment technology for malignant central airway stenosis in China needs to be standardized. Therefore, the relevant experts of the Beijing Health Promotion Association Respiratory and Oncology Intervention and Treatment Alliance have formulated this consensus after several rounds of full discussion.

Minimally invasive palliative interventions in advanced lung cancer

INTRODUCTION

Lung cancer is the leading cause of cancer-related deaths in the United States. Nearly 85% of all lung cancers are diagnosed at a late stage, with an associated five-year survival rate of 4%. Malignant central airway obstruction and malignant pleural effusions occur in upwards of 30% of these patients. Many of these patients are in need of palliative interventions for symptom control and to help improve their quality of life. Areas covered: This review covers the treatment modalities of malignant central airway obstruction and malignant pleural effusion. PubMed was used to search for the most up to date and clinically relevant articles that guide current treatment strategies. This review focuses on rigid bronchoscopy and the tools used for the relief of central airway obstruction, as well as intra-pleural catheter use and pleurodesis for the management of malignant pleural effusions. Expert commentary: There are multiple treatment modalities that may be used to help alleviate the symptoms of malignant central airway obstruction and pleural effusion. The modality used depends on the urgency of the situation, and specific patient's goals. An open dialog to understand the patient's end of life goals is an important factor when choosing the appropriate treatment strategy.

Double stenting with silicone and metallic stents for malignant airway stenosis

For severe malignant airway stenosis, there are several types of commercially available airway stents, and each has its own advantages and disadvantages. We herein describe the safety and efficacy of combination stenting with silicone and metallic stents for patients with extended malignant airway stenosis. Seven patients with malignant airway stenosis were treated via combination stenting with a silicone stent and a metallic stent for extended airway stenosis from the central to peripheral airways. Five patients were diagnosed with advanced esophageal cancer, two of whom had tracheoesophageal fistulas. One patient had adenoid cystic carcinoma, and another had mediastinal tumor. There were no specific complications related to the double stenting. Combination stenting with silicone and metallic stents proved to be a safe option for patients with severe, extended, and complicated malignant airway stenosis.

The management of near-fatal hemoptysis with left secondary carinal y stent

Massive hemoptysis can be a life threatening condition and needs urgent treatment in lung cancer. In the fiberoptic bronchoscopy of a fifty-two-year-old who was admitted with hemoptysis, left upper lobe upper division orifice was seen totally obstructed with a submucosal infiltration. One hour after the mucosal biopsies, massive hemoptysis occurred. Urgent rigid bronchoscopy was performed. The left main bronchus was occluded by sterile gauze. After cleaning of the coagulum patient was intubated and charged to intensive care unit. The next day, rigid bronchoscopy was repeated and the bleeding was observed to continue from the left upper lobe. Removing the gauze, 14 × 10 × 10 mm silicon Y stent was inserted in the left main bronchus after adjustments were made. Bleeding was stopped after insertion of the stent and patient could be extubated. In this case a successful control of hemoptysis was sustained after insertion of a customized silicon stent was presented.

Novel use of a percutaneous endoscopic gastrostomy tube fastener for securing silicone tracheal stents in patients with benign proximal airway obstruction

BACKGROUND

Benign tracheal obstruction occurs for a variety of reasons. Bronchoscopic intervention includes silicone stent placement, which effectively maintains airway patency. Stent migration is a common complication, particularly when placed in the proximal trachea. We used a novel technique of securing tracheal stents with a percutaneous endoscopic gastrostomy tube fastener (PEG-TF) to prevent stent migration. The purpose of this study was to determine the feasibility of securing silicone stents in the proximal trachea with PEG-TF.

METHODS

Silicone stents were placed under general anesthesia by rigid bronchoscopy in 7 consecutive patients with inoperable benign proximal tracheal obstruction. PEG-TFs were placed under sterile conditions with direct bronchoscopic visualization. A needle was inserted through the anterior neck and silicone stent wall allowing stylet introduction of a T-fastener into the interior of the stent. The T-fastener was secured externally by a metal clamp and cotton pledget at the surface of the neck. Patients had routine outpatient follow-up and covered the external portion of the PEG-TF with a waterproof dressing when showering.

RESULTS

All 7 PEG-TFs were placed without complications. The PEG-TFs were left in for 1 to 25 weeks. Complications of the PEG-TF included localized cellulitis and suture breakage. No stent migration occurred while the fastener was in place. Two stents were removed within 2 weeks due to patient's difficulty tolerating the stent.

CONCLUSIONS

Securing silicone stents in the proximal trachea is feasible and may prevent stent migration, but further study and possible modification of the PEG-TF device are needed.

Tracheal stenting for primary tracheal mucosa-associated lymphoid tissue lymphoma

Primary tracheal mucosa-associated lymphoid tissue (MALT) lymphoma is extremely rare. We report a 49-year-old female patient with the complaint of dyspnea. Fiberoptic bronchoscopy showed polypoid, variable-sized and irregular nodules causing narrowing of the tracheal lumen from the proximal trachea to the left main bronchus. Because of severe stenosis in the airway and the severity of symptoms, this case was unresectable. The patient was then treated successfully with placement of an endobronchial stent through bronchofibroscopy. After the placement of the stent, bronchoscopic biopsy was performed. Pathological analysis confirms a diagnosis of MALT-associated malignant lymphoma. We performed systemic chemotherapy on the patient. The temporary stent was removed after the reduction of the stenosis. This is the first case in which tracheal MALT lymphoma was treated successfully following tracheal stent insertion guided by bronchofibroscopy. Temporary tracheal stenting can be a favorable choice for a patient with tracheal stenosis caused by primary tracheal MALT lymphoma.

Usefulness of computed tomography virtual bronchoscopy in the evaluation of bronchi divisions

Background:

Since introduction of multislice CT scanners into clinical practice, virtual brochoscopy has gained a lot of quality and diagnostic potential. Nevertheless it does not have established place in diagnostics of tracheal and bronchi disorders and its potential has not been examined enough. Nowadays a majority of bronchial tree variants and lesions are revealed by bronchofiberoscopy, which is an objective and a relatively safe method, but has side effects, especially in higher-risk subjects. Therefore noninvasive techniques enabling evaluation of airways should be consistently developed and updated.

Material/Methods:

Material consisted of 100 adults (45 female, 55 male) aged between 18 and 65 years (mean 40 years, median 40.5 years, SD 14.02), who underwent chest CT examination by means of a 16-slice scanner. Every patient had normal appearance of chest organs, with the exception of minor abnormalities that did not alter airways route.

Divisions of bronchial tree to segmental level were evaluated and assigned to particular types by means of virtual bronchoscopy projection. In case of difficulties MPR or MinIP projection was used.

Results:

The frequency of lobar bronchi divisions other than the typical ones was in: right upper lobar bronchi 45%, left 55%; middle lobar bronchi 21%, lingula 26%; right lower lobar bronchi 28%, left 29%. Subsuperior bronchus or bronchi were found on the right side in 44% and on the left side in 37%. No dependency between types of bronchial divisions on different levels was found.

Covered bronchial stent insertion to manage airway obstruction with hemoptysis caused by lung cancer

Malignant airway obstruction and hemoptysis are common in lung cancer patients. Recently, airway stent is commonly used to preserve airway in malignant airway obstruction. Hemoptysis can be managed through various methods including conservative treatment, endobronchial tamponade, bronchoscopic intervention, embolization and surgery. In our case studies, we sought to investigate the effectiveness of airway stents for re-opening the airway as well as tamponade effects in four patients with malignant airway obstruction and bleeding caused by tumors or lymph node invasions.

Adenoid cystic carcinoma of the airway: a 30-year review at one institution

PURPOSE

The purpose of the study was to evaluate the treatment results of adenoid cystic carcinoma (ACC) of the airway at a single institution during a 30-year period.

MATERIALS AND METHODS

All cases of ACC of the airway over a 30-year period at one tertiary care institution were reviewed retrospectively. The demographics, treatment modalities, pathologic characteristics, and outcomes were evaluated.

RESULTS

Eleven patients were treated for ACC of the airway with an age range of 25 to 72 years (median, 48 years). Six patients presented with ACC in the larynx, and 5 patients had ACC of the trachea. All patients underwent surgical excision and radiation; 9 of 11 patients had postoperative external beam radiation, 1 patient had preoperative external beam radiation, and the remaining patient had postoperative neutron beam therapy. Four patients with tracheal ACC and none with laryngeal ACC had microscopic or grossly positive margins after surgery (P = .048). Eighty percent of patients had perineural invasion on pathology. Two patients with tracheal ACC had local recurrence of disease, which occurred at 1 and 10 months postoperatively. One patient with laryngeal ACC died of distant metastatic disease at 16 months. Follow-up varied from 4 to 168 months (median, 31 months).

CONCLUSIONS

We report high disease-free survival rates for ACC of the airway in patients who underwent definitive surgical resection followed by postoperative radiation. There is a higher risk for local recurrence and positive surgical margins with distal tracheal location. Distant disease ultimately determines survival.

Treatment outcomes of patients with adenoid cystic carcinoma of the airway

BACKGROUND

Adenoid cystic carcinoma (ACC) of the airway is a slowly growing tumor and airway narrowing is one of the main causes of death. The purposes of this study were to investigate treatment outcomes, prognostic factors, and the indications and outcomes of bronchoscopic interventions in patients with ACC of the airway.

METHODS

We retrospectively analyzed the clinical characteristics, treatment modalities, and clinical outcomes of patients with histologically-proven ACC of the airway treated between January 1995 and June 2009 at Samsung Medical Center.

RESULTS

A total of 30 patients were included in the study. Sixteen patients were male and the median age was 45 years. Multiple treatment modalities were required for the patients; 17 for surgery, 13 for definitive radiation therapy, 10 for adjuvant radiation therapy, and 1 for adjuvant chemotherapy. Bronchoscopic interventions were required to improve airway narrowing in 20 patients. After bronchoscopic intervention, 19 patients (95%) showed immediate improvement of airway narrowing and suffered no serious complications. The 5- and 10-year overall survival (OS) rates in these patients were 84% and 70%, respectively. The prognostic factors associated with OS were tumor size, tumor location, clinical T stage, surgery as an initial treatment, and bronchoscopic intervention.

CONCLUSIONS

ACC of the airway had a good long-term prognosis but bronchoscopic interventions were frequently required during the course of the disease due to the development of airway narrowing. Bronchoscopic interventions may be considered as a bridge therapy before surgery or radiation therapy and as a palliative therapy for airway narrowing.

Efficacy and tolerability of airway stents

The function of airway stents is to keep the tubular structures open and stable. Their insertion is essentially indicated for intrinsic obstruction or extrinsic compression of the airway, fistulae or tracheobronchomalacia. The aim of this study was to determine the tolera bility and efficacy of airway stents in situations in which their insertion was vital. A retrospective study of airway stent insertion with rigid bronchoscopy (23 patients) was carried out over a two year period (2006-2007) at the Diagnostic and Therapeutic Techniques Unit. We assessed indication, efficacy, tolerability, complications and exact insertion based on chest CT imaging. In all situations Dumon flexible silicon stents (Tracheobronxane were used, with the need for complementary techniques such as laser therapy and mechanical dilation having been previously evaluated by flexible bronchoscopy. The authors conclude that stent insertion has no complications and good tolerability in the majority of advanced stage oncological situations with indication for palliative management.

Advances in interventional pulmonology

PURPOSE OF REVIEW

Interventional pulmonology is a rapidly expanding field offering less invasive therapeutic procedures for significant pulmonary problems. Many of the therapies may be new for the anesthesiologist. Although less invasive than surgery, some of these procedures will carry significant risks and complications. The team approach by anesthesiologist and pulmonologist is key to the success of these procedures.

RECENT FINDINGS

Many modalities for central airway obstruction have emerged, including the expanding application of airway stenting procedures. Diagnostic bronchoscopy with ultrasound guidance promises great advances in lung cancer staging. New bronchoscopic treatments of asthma and emphysema are actively under investigation. Advances in anesthetic agents and techniques for interventional pulmonology procedures have also occurred.

SUMMARY

This review is intended to familiarize the anesthesiologist with current and rising therapeutic modalities for pulmonary disease. Knowledge of interventional pulmonology facilitates planning and preparation for well tolerated and effective procedures.