Therapeutic bronchoscopy for malignant central airway obstruction: success rates and impact on dyspnea and quality of life

Normal Saline Versus Hypertonic Saline for Airway STENT Maintenance: SALTY STENT Study

BACKGROUND

Mucus plugging is a common complication of airway stenting. There is no data or guidance on the best airway hygiene regimen and consequently wide practice variation exists.

METHODS

This single-center, nonblinded, randomized, pilot study aims to evaluate the effectiveness and safety of nebulized 3% saline (3%S) versus normal saline (NS) in reducing the incidence of mucus plugging in adult patients that undergo central airway stent placement. Patients were enrolled immediately after stent placement and randomized to nebulized 3%S or NS (3 mL) 3 times a day. Patients were scheduled for surveillance bronchoscopy in 4 to 6 weeks. Unscheduled bronchoscopies due to symptomatic mucus plugging were recorded.

RESULTS

From December 2022 to March 2024, 37 patients were screened, and 35 were enrolled. Four in the 3%S and 8 in the NS group did not undergo a surveillance bronchoscopy and were excluded from the final analysis. During surveillance bronchoscopy for the 3%S (n=13) and NS (n=10) groups, obstructive mucus plugging was noted in 7.7% versus 40%, granulation requiring intervention in 7.7% versus 10%, and >25% circumferential biofilm in 0% versus 30%, respectively. In the 3%S versus NS groups, 0% versus 20% of patients required an unscheduled bronchoscopy due to mucus plugging. There were no side effects reported with the daily use of 3%S or NS.

CONCLUSION

Nebulized 3%S is safe and may be equally or more effective than NS in preventing obstructive mucus plugging in patients who undergo airway stenting. A larger blinded randomized controlled trial is necessary to confirm this finding.

Therapeutic bronchoscopy for malignant central airway obstructions caused by non-bronchogenic cancers: Results from the EpiGETIF registry

BACKGROUND AND OBJECTIVE

Little is known about malignant central airway obstruction (MCAO) complicating the metastatic spread of non-bronchogenic solid cancers (NBC) and their bronchoscopic management. This study aimed to describe the epidemiology of this population and determine prognostic factors before therapeutic bronchoscopy (TB).

METHODS

In this multicenter study using the EpiGETIF registry, we analysed patients treated with TB for MCAO caused by NBC between January 2019 and December 2022.

RESULTS

From a database of 2389 patients, 436 patients (18%) with MCAO and NBC were identified. After excluding patients with direct local invasion, 214 patients (8.9%) were analysed. The main primaries involved were kidney (17.8%), colon (16.4%), sarcoma (15.4%), thyroid (8.9%) and head and neck (7.9%) cancers. Most patients (63.8%) had already received one or more lines of systemic treatment. Obstructions were purely intrinsic in 58.2%, extrinsic in 11.1% and mixed in 30.8%. Mechanical debulking was used in 73.4% of cases, combined with thermal techniques in 25.6% of cases. Airway stenting was required in 38.4% of patients. Median survival after TB was 11.2 months, influenced by histology (p = 0.002), performance status (p = 0.019), initial hypoxia (HR 1.45 [1.01-2.18]), prior oncologic treatment received (HR 1.82 [1.28-2.56], p < 0.001) and assessment of success at the end of the procedure (HR 0.66 [0.44-0.99], p < 0.001). Complications rate was 8.8%, mostly mild, with no procedure-related mortality.

CONCLUSION

TB for MCAO caused by a NBC metastasis provides rapid improvement of symptoms and prolonged survival. Patients should be promptly referred by medical oncologists for bronchoscopic management based on the prognostic factors identified.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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.

Tracheal Stent Ingestion: Unveiling Complications and Innovations in Management

Airway stenting has become integral to the therapeutic endoscopic management of benign and malignant obstructive airway diseases. Despite the increased use of stents, the absence of clear guidelines for surveillance and maintenance poses the potential for unique stent-associated complications. Our case reports a rare incident of tracheal stent dislodgement, leading to its ingestion and unexpected discovery within the stomach. This case serves the purpose of shedding light on a rare yet potentially life-threatening complication and discussing types of stent and characteristics to enhance gastroenterologists' understanding of stent-related challenges and equips them to anticipate and strategize the appropriate course of action.

Epidemiology and Survival of Malignant Central Airway Obstruction in Lung Cancer Identified on Cross-Sectional Imaging

BACKGROUND

The prevalence of malignant central airway obstruction at diagnosis and its 5-year incidence are largely unknown, as are basic epidemiological data pertaining to this serious condition. To address these data limitations, we retrospectively collected data from the cohort of patients diagnosed with lung cancer at our institution in 2015 and followed cohort patients 5 years forward, until 2020.

METHODS

We reviewed index PET/CT or CT scans at the time of lung cancer diagnosis to identify the presence, subtype, and severity of malignant central airway obstruction as well as progression/development over the next 5 years.

RESULTS

The prevalence of malignant central airway obstruction affecting the airway lumen by 25% or greater was 17%, and its 5-year incidence of development was 8.2%. Notable associations from the multivariate analysis included a younger age and a stepwise increase in obstruction with increasing stage of disease. Squamous cell carcinoma and small-cell lung cancer were the 2 histologic subtypes with the strongest association with obstruction. The presence of malignant central airway obstruction either at time of diagnosis or on follow-up imaging was associated with significantly shortened survival (multivariate Cox proportional HR for MCAO=1.702, P<0.001).

CONCLUSION

This study provides the first systematic characterization of fundamental epidemiological data on malignant central airway obstructions at a tertiary cancer center in the United States. This data is important to inform research directions and funding efforts of this serious complication. It also serves as a baseline value against which to compare for future studies.

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.

Therapeutic bronchoscopy for malignant central airway obstruction: Introduction to the EpiGETIF registry

BACKGROUND AND OBJECTIVE

EpiGETIF is a web-based, multicentre clinical database created in 2019 aiming for prospective collection of data regarding therapeutic rigid bronchoscopy (TB) for malignant central airway obstruction (MCAO).

METHODS

Patients were enrolled into the registry from January 2019 to November 2022. Data were prospectively entered through a web-interface, using standardized definitions for each item. The objective of this first extraction of data was to describe the population and the techniques used among the included centres to target, facilitate and encourage further studies in TB.

RESULTS

Overall, 2118 patients from 36 centres were included. Patients were on average 63.7 years old, mostly male and smokers. Most patients had a WHO score ≤2 (70.2%) and 39.6% required preoperative oxygen support, including mechanical ventilation in 6.7%. 62.4% had an already known histologic diagnosis but only 46.3% had received any oncologic treatment. Most tumours were bronchogenic (60.6%), causing mainly intrinsic or mixed obstruction (43.3% and 41.5%, respectively). Mechanical debulking was the most frequent technique (67.3%), while laser (9.8%) and cryo-recanalization (2.7%) use depended on local expertise. Stenting was required in 54.7%, silicone being the main type of stent used (55.3%). 96.3% of procedure results were considered at least partially successful, resulting in a mean 4.1 points decrease on the Borg scale of dyspnoea. Complications were noted in 10.9%.

CONCLUSION

This study exposes a high volume of TB that could represent a good source of future studies given the dismal amount of data about the effects of TB in certain populations and situations.

Airway stent intervention in a high-volume center: safe procedures and educational perspectives

Background

Airway intervention, including stenting, can rapidly improve a patient's respiratory condition, but the procedure requires highly specialized techniques and expertise. Therefore, educating young endoscopists and passing on the techniques are major issues. However, the best way to educate new doctors on these techniques remains unclear. This study analyzed our educational system for airway intervention and its outcomes.

Methods

Patients who underwent airway intervention regarding airway stents under general anesthesia in our department between January 2010 and September 2023 were included. The outcomes of interventions related to airway stents in our hospital were evaluated retrospectively, including from an educational perspective.

Results

A total of 96 patients (76 undergoing stenting for airway stenosis, 8 stenting for airway-esophageal fistula, and 12 stent removal) were analyzed. The median experience level of the main physician was 5 (range, 1-17) years, and that of the supervising physician was 18 (range, 5-23) years. The median number of physicians who participated in the interventions was four. A rigid bronchoscope was used in 86.5% of cases. The procedure success rate was 95.8%. Intraoperative complications occurred in 8.3% and postoperative complications in 10.5% of cases, and there was 1 procedure-related death (1.3%). In the analysis of factors related to the development of complications, the years of experience of the main physician had no influence.

Conclusions

These findings indicate that our method of airway intervention is safe. Young endoscopists were able to master the technique by gaining experience under the supervision of experts.

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.

Treatment of malignant airway obstruction with Y-shape sigma stent loaded with I125 seeds installed via rigid bronchoscopy

PURPOSE

To summarize and analyze the safety and efficacy of a Y-shape Sigma stent loaded with I125 in patients with inoperable malignant main airway obstruction.

METHODS

This study was approved by the Institutional Ethics Committee, and a written informed consent was obtained from each participant. A Y-shape Sigma stent loaded with I125 was placed under vision from rigid bronchoscopy. The primary endpoint was alleviation of symptoms and improvement of Karnofsky Performance Status (KPS) score, and the secondary endpoint was complications and technical success.

RESULTS

From November 2018 through June 2023, total 33 patients with malignant airway obstruction were palliatively treated by installing Y-shape Sigma stents loaded with I125. The airway lumen was immediately restored and the average airway opening significantly increased to 70 ± 9.4% after the procedure from baseline 30.2 ± 10.5% (p < 0.05). Average KPS score was improved from baseline 30.0 ± 10.0 to 70.0 ± 10.0 (p < 0.05) as well as PaO2 from baseline 50.1 ± 15.4 mmHg to 89.3 ± 8.6 mmHg (p < 0.05). The technical success rate of placing the stent in this study was 73%, and adverse events or complications including bleeding, I125 loss, and airway infection occurred during or after the procedure.

CONCLUSION

Placement of Y-shape Sigma stents under vision from rigid bronchoscopy in the patients with malignant airway obstruction is feasible and it immediately alleviates dyspnea and significantly improves quality of life.

Flexible CO2 Laser in Therapeutic Bronchoscopy: Initial Experiences in a Tertiary Center

BACKGROUND

CO2 Laser (CO2L) technology deployable through flexible endoscopes now allows for their use throughout the airway, although published data are limited.

METHODS

Retrospective analysis of CO2L bronchoscopic procedures, excluding glottic and subglottic interventions. Procedural success was defined as >50% visual reduction in airway obstruction in the area treated or resolution of the procedural indication.

RESULTS

Seventy-two procedures were performed on 36 patients. Nonmalignant indications comprised 66%: stent-associated granulation tissue (28%), granulomatosis with polyangiitis lesions (23%), and lung transplant-related granulation tissue (16%) were the most common. Bronchoscopic access was flexible only in 81% and primarily rigid (combined with flexible) in 18%. The site of intervention was the trachea at 19%, the mainstem at 56%, and lobar/segmental airways at 45%. Procedural success was 89%. CO2L was used exclusively in 19%; in 81%, additional techniques were required, most commonly balloon dilation (59%), cryo-debulking (23%), and rigid dilation (16%). Malignant indications had a nonsignificant trend toward requiring adjuvant techniques ( P =0.05). Seventy-six percent of the patients required more than 1 procedure. CO2L exclusive cases had no statistically different needs for subsequent therapeutic bronchoscopies ( P =0.10) or time to reintervention (109 vs. 41 days, P =0.07), and reintervention-free survival was similar ( P =0.10) and difficult to predict. The complication rate attributable to CO2L was 2.7%.

CONCLUSION

CO2L is a safe and useful tool when precise cutting and vaporization are desired. Its use in multi-modality approaches has high levels of success in adequately selected lesions, adding an ablative potential to dilation techniques. Vasculitis-associated scars/webs and granulation tissue (including stent-associated) appear to be ideal targets.

Correlation of Bronchoscopy and CT in Characterizing Malignant Central Airway Obstruction

BACKGROUND

Malignant Central Airway Obstruction (MCAO) presents a significant challenge in lung cancer management, with notable morbidity and mortality implications. While bronchoscopy is the established diagnostic standard for confirming MCAO and assessing obstruction subtype (intrinsic, extrinsic, mixed) and severity, Computed Tomography (CT) serves as an initial screening tool. However, the extent of agreement between CT and bronchoscopy findings for MCAO remains unclear.

METHODS

To assess the correlation between bronchoscopy and CT, we conducted a retrospective review of 108 patients at Roswell Park Comprehensive Cancer Center, analyzing CT and bronchoscopy results to document MCAO presence, severity, and subtype.

RESULTS

CT correctly identified MCAO in 99% of cases (107/108). Agreement regarding obstruction subtype (80.8%, Cohen's κ = 0.683, p < 0.001), and severity (65%, Quadratic κ = 0.657, p < 0.001) was moderate. CT tended to equally overestimate (7/19) and underestimate (7/19) the degree of obstruction. CT was also poor in identifying mucosal involvement in mixed MCAO.

CONCLUSIONS

CT demonstrates reasonable agreement with bronchoscopy in detecting obstruction. Nevertheless, when CT indicates a positive finding for MCAO, it is advisable to conduct bronchoscopy. This is because CT lacks reliability in determining the severity of obstruction and identifying the mucosal component of mixed disease.

A multicenter observational study assessing the safety, feasibility, and complications of Bonastent in central airway obstruction

BACKGROUND

Self-expandable metallic stents (SEMS) are increasingly used in the management of both malignant and nonmalignant airway stenosis. There are multiple stents available in the market; however, the current literature on the efficacy and safety of newly available 3rd generation SEMS (Bonastent) is extremely limited and only has data from single center studies.

OBJECTIVES

To report the efficacy and early (<7 days) and late (⩾7 days) complications in patients with central airway obstruction (CAO) treated with Bonastent placement at two institutions.

DESIGN

We performed a retrospective analysis of data of consecutive patients who underwent therapeutic bronchoscopy and Bonastent placement at two tertiary care university hospitals between January 2019 and November 2023.

METHODS

Bonastent deployment was performed in the operating room. Stents were deployed using rigid or flexible bronchoscopy under direct visualization with a flexible bronchoscope and in conjunction with fluoroscopic guidance. We then analyzed the effectiveness, short-term, and long-term complications of Bonastent placement.

RESULTS

A total of 107 Bonastents® were placed in 96 patients. The most common etiology of CAO was malignancy, 92.7% (n = 89), followed by excessive dynamic airway collapse (EDAC) and post-intubation tracheal stenosis. Seventy-three patients (76%) had improvement in symptoms or imaging within 7 days of stent placement, including successful liberation from mechanical ventilation in a patient with CAO. Early complications occurred in seven patients (two-airway bleeding, two-mucus plugging that improved with airway clearance, two-stent migrations, and one-cough).Late complications occurred in 23 patients (1-stent migration requiring revision bronchoscopy and replacement of airway stent, 11-mucus plugging, 6-granulation tissue, 2-pneumonia, 1-cough, 1-tumor ingrowth/stent fracture, 1-airway emergency due to excessive granulation tissue obstructing the distal end of the stent and had a failed cricothyroidotomy leading to death). Overall, the early complication rate was 7.3% (7/96) and late complication rate was 23.9% (23/96).

CONCLUSION

Our study is the first multicenter study that found a good safety profile with a low complication rate after tracheobronchial Bonastent placement with improvement in symptoms soon after stent placement.

Patient-specific airway stent using three-dimensional printing: a review

The primary function of an airway stent is to reestablish patency, impeding restenosis, supporting the tracheobronchial wall, or occluding fistulas. But stent-related complications are prevalent and can have devastating consequences. For this reason, stents are considered a last resort when there are no alternatives in treatment. Additionally, commercially available airway stents often poorly fit patients with complex airways, and they can cause various complications. At the end of the 20th century, three-dimensional (3D) printing technology was created. It has been transformative in healthcare and has been used in several applications. One of its first utilizations was the anatomical modeling of body structures that helps preoperative planning. In respiratory medicine, this technology has been essentially used in central airway diseases to produce 3D airway models and to create airway splints and prostheses. In the last decade, it has led to a transformation and allowed progress in personalized medicine, making patient-specific stents for individuals with complex airway problems. A patient-specific stent using 3D printing may minimize complications, improve quality of life, and reduce the need for repeated procedures. This review describes the recent advances in 3D printing technology, its use for developing airway prostheses to treat complex airway diseases, and the current evidence that supports its use.

Transarterial infusion chemotherapy for advanced esophageal cancer with airway stenosis

Purpose

This study aimed to investigate the safety and efficacy of transarterial infusion chemotherapy for the treatment of esophageal cancer with airway stenosis.

Methods

Data of patients with advanced esophageal cancer complicated with airway stenosis treated with transarterial infusion chemotherapy were retrospectively analyzed. Dyspnea, clinical efficacy and adverse reactions were evaluated.

Results

Of these patients, 27 had grade II preoperative dyspnea, and 31 had grade III preoperative dyspnea, 26 had grade I postoperative dyspnea, 25 had grade II postoperative dyspnea, and 7 had grade III postoperative dyspnea. Among 3 patients with left main bronchial stenosis and atelectasis, 2 had complete remission after transarterial infusion chemotherapy, and 1 demonstrated partial remission. After treatment, complete response, partial response, and stable disease were observed in 7, 34, and 17 cases, respectively. Total objective effective rate and disease control rate were 70.6% (41/58) and 100.0%, respectively. During follow up, 24 patients died of organ failure, and 17 patients died of tumor-related respiratory failure. Seven patients died of gastrointestinal bleeding, 1 patient died of myocardial infarction, and 9 patients survived.

Conclusions

Transarterial infusion chemotherapy is safe and effective for the treatment of advanced esophageal cancer with airway stenosis.

Tumor-Related Factors Affecting the Success of Interventional Bronchoscopy in Malignant Airway Obstructions

BACKGROUND

It is difficult to select patients who will benefit from endobronchial treatment (ET) in malignant central airway obstruction (MCAO). We aimed to determine the tumor-related factors that affect the success of MCAO treatment.

METHODS

ETs for MCAO between March 2019 and June 2021 were analyzed retrospectively. The relationships between the success of the procedure and the percentage of endoluminal obstruction, tumor size, and type of lesion were evaluated.

RESULTS

Totally, 220 ETs were administered to 205 patients. Treatment was significantly more successful for the patients with pure endobronchial lesions than those with mixed lesions. The success rate was significantly lower when the tumor size was greater than 54.5 mm and the degree of endoluminal stenosis exceeded 92%; the area under the curve was 0.734 (0.625-0.842; P=0.001) and 0.733 (0.597- 0.870; P=0.001), respectively. There was no difference in the procedural success between lung cancer and extrathoracic malignancies and tumor treatment before the procedure.

CONCLUSION

Mixed lesions, tumor size over 54.5 mm, and a degree of stenosis over 92% are risk factors for unsuccessful endoluminal obstruction procedures. These parameters should be considered when selecting patients for ET interventions.

Forbearance with endobronchial stenting: cognisance before conviction

Endobronchial stenting is an important aspect of the practice of interventional pulmonology. The most common indication for stenting is the management of clinically significant airway stenosis. The list of endobronchial stents available on the market continues to grow. More recently, patient-specific 3D-printed airway stents have been approved for use. Airway stenting should be considered only when all other options have been exhausted. Due to the environment of the airways and the stent-airway wall interactions, stent-related complications are common. Although stents can be placed in various clinical scenarios, they should only be placed in scenarios with proven clinical benefit. The unwarranted placement of a stent can expose the patient to complications with little or no clinical benefit. This article reviews and outlines the key principles of endobronchial stenting and important clinical scenarios in which stenting should be avoided.

Central airway stenting in oncology

Introduction. Malignant central airway obstruction and malignant tracheoesophageal fistula in the context of tumor development are potentially life-threatening conditions which usually require immediate intervention. Airway stenting is one of the safest and most effective methods of airway patency restoration in patients with malignant obstruction of the central airways and restoration of continuity in patients with malignant tracheoesophageal fistula.

Aim. To evaluate the significance of self-expandable metal stents in palliative treatment of patients with malignant central airway obstruction and malignant tracheoesophageal fistula.

Materials and methods. Between 2017 and 2021 at the N. N. Blokhin National Medical Research Center of Oncology, 55 patients were observed and treated and underwent trachea stenting per the results of bronchoscopy in combination with esophagogastroduodenoscopy. The 1st group included 25 patients with malignant tracheoesophageal fistulas, the 2nd group included 30 patients with malignant central airway obstruction.

Results. In the 1st group, stenting was successful in 25 (100 %) cases which allowed to adequately seal the fistula. Stent migration was observed in 1 (4 %) patient with tracheoesophageal fistula in the context of stenosing cancer of the thoracic esophagus. In the 2nd group, stenting was successful in 30 (100 %) cases. Stent migration was not observed in this patient group. In both groups, there were no complications after stent implantation. Installation of tracheal stent allowed to improve patients’ quality of life and provide a possibility for successful special treatment through low-trauma manipulation.

Conclusion. According to the obtained data, endoscopic trachea stenting is the most important method of palliative treatment of tumor-related trachea lesions with development of tracheoesophageal fistulas, malignant central airway obstructions and associated sub- and decompensated pulmonary insufficiency.

Safety and Efficacy of Dexmedetomidine for Bronchoscopy: A Systematic Review and Meta-Analysis

(1) Background: Anesthetic sedatives are widely used for bronchoscopy, and controversy surrounds the safety and efficacy of dexmedetomidine compared to other sedatives. The aim of this study is to evaluate the safety and efficacy of dexmedetomidine in bronchoscopy through a systematic review. (2) Methods: PubMed, Embase, Google Scholar, and Cochrane Library electronic databases were searched for a randomized controlled study of dexmedetomidine (Group D) or other sedative drugs (Group C) for bronchoscopy. Data extraction, quality assessment, and risk of bias analysis were performed in accordance with the preferred reporting items for systematic review and meta-analysis requirements. Meta-analysis was performed using RevMan 5.2. (3) Results: Nine studies were included, with a total of 765 cases. Compared to Group C, the incidence of hypoxemia (OR = 0.40, 95% CI (0.25, 0.64) p = 0.0001, I² = 8%) and tachycardia (OR = 0.44, 95% CI (0.26,0.74), p = 0.002, I² = 14%) were lower, but bradycardia (OR = 3.71, 95% CI (1.84, 7.47), p = 0.0002, I² = 0%) was higher in Group D; no significant difference was observed in other outcome indicators. (4) Conclusions: Dexmedetomidine reduces the incidence of hypoxemia and tachycardia during bronchoscopy but is more likely to provoke bradycardia.

Trends and an Online Survey on the Use of Rigid Bronchoscopy in Korea

BACKGROUND

Although almost all interventional pulmonologists agree that rigid bronchoscopy is irreplaceable in the field of interventional pulmonology, less is known about the types of diseases that the procedure is used for and what difficulties the operators face during the procedure. The purpose of this study is to evaluate what diseases rigid bronchoscopy is used for, whether it is widely used, and what challenges the operators face in Korea.

METHODS

We enrolled 14 hospitals in this retrospective cohort of patients who underwent rigid bronchoscopy between 2003 and 2020. An online survey was conducted with 14 operators to investigate the difficulties associated with the procedure.

RESULTS

While the number of new patients at Samsung Medical Center (SMC) increased from 189 in 2003-2005 to 468 in 2018-2020, that of other institutions increased from 0 to 238. The proportion of SMC patients in the total started at 100% and steadily decreased to 59.2%. The proportion of malignancy as the indication for the procedure steadily increased from 29.1% to 43.0%, whereas post-tuberculous stenosis (25.4% to 12.9%) and post-intubation stenosis (19.0% to 10.9%) steadily decreased (all P for trends < 0.001). In the online survey, half of the respondents stated that over the past year they performed less than one procedure per month. The fewer the procedures performed within the last year, the more likely collaboration with other departments was viewed as a recent obstacle (Spearman correlation coefficient, r_s = -0.740, P = 0.003) and recent administrative difficulties were encountered (r_s = -0.616, P = 0.019).

CONCLUSION

This study demonstrated that the number of patients undergoing rigid bronchoscopy has been increasing, especially among cancer patients. For this procedure to be used more widely, it will be important for beginners to systematically learn about the procedure itself as well as to achieve multidisciplinary consultation.

[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.

First-In-Human Computer-Optimized Endobronchial Ultrasound-Guided Interstitial Photodynamic Therapy for Patients With Extrabronchial or Endobronchial Obstructing Malignancies

Objective

Patients with inoperable extrabronchial or endobronchial tumors who are not candidates for curative radiotherapy have dire prognoses with no effective long-term treatment options. To reveal that our computer-optimized interstitial photodynamic therapy (I-PDT) is safe and potentially effective in the treatment of patients with inoperable extra or endobronchial malignancies inducing central airway obstructions.

Methods

High-spatial resolution computer simulations were used to personalize the light dose rate and dose for each tumor. Endobronchial ultrasound with a transbronchial needle was used to place the optical fibers within the tumor according to an individualized plan. The primary and secondary end points were safety and overall survival, respectively. An exploratory end point evaluated changes in immune markers.

Results

Eight patients received I-PDT with planning, and five of these received additional external beam PDT. Two additional patients received external beam PDT. The treatment was declared safe. Three of 10 patients are alive at 26.3, 12, and 8.3 months, respectively, after I-PDT. The treatments were able to deliver a prescribed light dose rate and dose to 87% to 100% and 18% to 92% of the tumor volumes, respectively. A marked increase in the proportion of monocytic myeloid-derived suppressor cells expressing programmed death-ligand 1 was measured in four of seven patients.

Conclusions

Image-guided light dosimetry for I-PDT with linear endobronchial ultrasound transbronchial needle is safe and potentially beneficial in increasing overall survival of patients. I-PDT has a positive effect on the immune response including an increase in the proportion of programmed death-ligand 1-expressing monocytic myeloid-derived suppressor cells.

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.

Malignant Central Airway Obstruction: What's New?

Malignant central airway obstruction (MCAO) is a debilitating and life-limiting complication that occurs in an unfortunately large number of individuals with advanced intrathoracic cancer. Although the management of MCAO is multimodal and interdisciplinary, the task of providing patients with prompt palliation falls increasingly on the shoulders of interventional pulmonologists. While a variety of tools and techniques are available for the management of malignant obstructive lesions, advancements and evolution in this therapeutic venue have been somewhat sluggish and limited when compared with other branches of interventional pulmonary medicine (e.g., the early diagnosis of peripheral lung nodules). Indeed, one pragmatic, albeit somewhat uncharitable, reading of this article's title might suggest a wry smile and shug of the shoulders as to imply that relatively little has changed in recent years. That said, the spectrum of interventions for MCAO continues to expand, even if at a less impressive clip. Herein, we present on MCAO and its endoscopic and nonendoscopic management-that which is old, that which is new, and that which is still on the horizon.

[Bronchoscopic treatment of malignant central airway obstruction: A cohort study, long-term survival and complications]

INTRODUCTION

Interventional bronchoscopy is now the standard treatment for tracheobronchial narrowing due to tumor. The objective of our study was to analyze long-term survival and complications occurring in patients with malignant airway obstruction.

METHODS

We retrospectively studied the data from 93 patients treated between 2008 and 2019.

RESULTS

One hundred and eleven therapeutic bronchoscopies were performed. Sixty-seven patients had primary lung cancer, in 17 had tumors of another origin and 9 patients had benign or local lung tumors. Thulium laser was frequently used prior to tumor enucleation and to restore hemostasis. Seventy-one silicone stents were inserted. The death rate at the time of the procedure was 1.8% and immediate complication occurred in 9.9% of the patients. Long-term survival was significantly better for patients with cancer from other origins than in those with primary lung cancer (615.5days versus 177.9days). On the other hand, there was no significant difference in long-term survival between patients with locally advanced and metastatic lung cancer with endobronchial lesions treated by stent and those who were not (234.2days versus 164.6days). All patients with benign or with locally malignant tumors were still alive.

CONCLUSION

Therapeutic bronchoscopy increases the long-term survival of patients with malignant airway obstruction. The risk-benefit ratio was favorable.

Central airway obstruction: is it time to move forward?

INTRODUCTION

Central airway obstruction (CAO) represents a pathological condition that can lead to airflow limitation of the trachea, main stem bronchi, bronchus intermedius or lobar bronchus.

MAIN BODY

It is a common clinical situation consensually considered under-diagnosed. Management of patients with CAO can be difficult and deciding on the best treatment approach represents a medical challenge. This work intends to review CAO classifications, causes, treatments and its therapeutic limitations, approaching benign and malign presentations. Three illustrative cases are further presented, supporting the clinical problem under review.

CONCLUSION

Management of CAO still remains a challenge. The available options are not always effective nor free from complications. A new generation of costume-tailored airway stents, associated with stem cell-based therapy, could be an option in specific clinical situations.

Predictors of survival and technical success of bronchoscopic interventions in malignant airway obstruction

Background

Malignant airway obstruction (MAO) leads to quality of life impairment and increased mortality. Interventional bronchoscopy allows airway patency restoring, leading to a better survival. We investigated predictors of survival and successful bronchoscopic intervention among MAO patients.

Methods

This observational prospective study enrolled 100 patients who were newly diagnosed with MAO. Survival was estimated with Kaplan-Meier method and curves compared by log-rank test. Multivariate analyses were performed using Cox proportional hazard models. Univariate and multivariate logistic regression were used for odds ratio calculation.

Results

A proportion of 73% of the patients were male with a median age was 62.5 years (range, 21–88 years). Lung cancer was the most common primary malignancy (74%). The majority had single (61%), endoluminal (62%) lesions and were classified as grade III in Myer Cotton scale (57%). The most used techniques comprised mechanical debulking (n=81) and laser therapy (n=68). Twenty-two airway stents were placed. While eleven patients were considered untreatable, technical success was achieved in 78%. Haemorrhage was the most common acute complication (16%). No deaths occurred as a result of the procedure. Median global survival was 8 months. Adjusting for age and Eastern Cooperative Oncology Group Performance Status (ECOG), extrinsic compression or mixed airway obstructions [hazard ratio (HR) =2.075; P=0.012], successful bronchoscopic intervention (HR =0.468; P=0.025) and initiation of cancer treatment (HR =0.373; P=0.006) were independent predictors of survival. The absence of distal airway patency on thoracic CT was independently associated with failure of the intervention [odds ratio (OR) =0.013; P<0.001].

Conclusions

Interventional bronchoscopy has proven to be an efficient and safe strategy to manage MAO patients. The patients who benefit the most in terms of survival are those with purely endoluminal lesions, in whom technical success was achieved and those whose cancer-specific treatment was initiated. Distal airway patency on thoracic CT predicts the technical success of bronchoscopic intervention.

Secondary pulmonary malignancies requiring interventional bronchoscopic procedures

Background

In this study, we aimed to share our singlecenter experience and to investigate the effect of interventional bronchoscopic procedures on secondary pulmonary malignancies in terms of complications, success, and survival rates.

Methods

A total of 83 patients (42 males, 41 females; mean age: 57.8±15.2 years; range, 18 to 94 years) with secondary pulmonary malignancies who underwent interventional bronchoscopic procedures between January 2009 and December 2019 were retrospectively reviewed. Data including demographic and clinical characteristics of the patients, complications, and success and survival rates were recorded.

Results

The most common secondary pulmonary malignancies were kidney and thyroid tumors with the complaints of cough, shortness of breath, and hemoptysis. The mean duration before the diagnosis was 34.7±52.8 (range, 0.1 to 219.3) months, and the mean survival after the diagnosis were 10±13.1 (range, 0.2 to 44.4) months. A total of 92% of the patients had an airway obstruction of >50% and the interventional bronchoscopic procedures such as argon plasma coagulation, laser, cryo, and mechanical resection were successful in achieving airway patency. Laser application was found to significantly improve survival (p=0.015). Acute complication rate was 8.4% and mortality rate was 0%.

Conclusion

In patients with tracheobronchial lesions due to secondary pulmonary malignancies, interventional bronchoscopic procedures, regardless of the stage of the disease, provide rapid palliation in life-threatening symptoms such as dyspnea and hemoptysis due to airway obstruction, prolonging patient"s survival and gain time for additional treatments to take effect for primary disease.

Overview of Interventional Pulmonology for Radiologists

Interventional pulmonology is a growing field specializing in minimally invasive procedures of the mediastinum, lungs, airways, and pleura. These procedures have both diagnostic and therapeutic indications and are performed for benign and malignant diseases. Endobronchial US has been combined with transbronchial needle aspiration to extend tissue sampling beyond the airways and into the lungs and mediastinum. Recent innovations extending the peripheral access of bronchoscopy include electromagnetic navigational bronchoscopy and thinner bronchoscopes. An important indication for therapeutic bronchoscopy is the relief of central airway obstruction, which may be severe and life threatening. Techniques for restoring patency of the central airways include mechanical debulking and multiple modalities for ablation, stent placement, and balloon bronchoplasty. Bronchoscopic lung volume reduction improves quality of life in certain patients with severe emphysema and is an important less invasive alternative to lung volume reduction surgery. Bronchial thermoplasty is likewise a nonpharmacologic treatment in patients with severe uncontrolled asthma. Many of these procedures have unique selection criteria that require precise evaluations at preprocedure imaging. Postprocedure imaging is also essential in determining outcome success and the presence of complications. Radiologists should be familiar with these procedures as well as the relevant imaging features in both planning and later surveillance. Evolving techniques that may become more widely available in the near future include robotic-assisted bronchoscopy, bronchoscopic transparenchymal nodule access, transbronchial cryobiopsy, ablation of early-stage cancers, and endobronchial intratumoral chemotherapy. An invited commentary by Wayne et al is available online. ^©RSNA, 2021.

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.

Risk-score model to predict prognosis of malignant airway obstruction after interventional bronchoscopy

Background

Interventional bronchoscopy exhibits substantial effects for patients with malignant airway obstruction (MAO), while little information is available regarding the potential prognostic factors for these patients.

Methods

Between October 31, 2016, and July 31, 2019, a total of 150 patients undergoing interventional bronchoscopy and histologically-confirmed MAO were collected, in which 112 eligible participants formed the cohort for survival study. External validation cohort from another independent institution comprised 33 MAO patients with therapeutic bronchoscopy. The least absolute shrinkage and selection operator regression (LASSO) was applied to the model development dataset for selecting features correlated with MAO survival for inclusion in the Cox regression from which we elaborated the risk score system. A nomogram algorithm was also utilized.

Results

In our study, we observed a significant decline of stenosis rate after interventional bronchoscopy from 71.7%±2.1% to 36.6%±2.7% (P<0.001) and interventional bronchoscopy dilated airway effectively. Patients in our study undergoing interventional bronchoscopy had a median survival time of 614.000 days (95% CI: 269.876–958.124). Patients receiving distinct therapeutic methods of interventional bronchoscopy had different prognosis (P=0.022), and patients receiving treatment of electrocoagulation in combination with stenting and electrosurgical snare had worse survival than those receiving other options. Multivariate Cox analysis revealed that nonsmoking status, adenoid cystic carcinoma, and low preoperative stenosis length, as independent predictive factors for better overall survival (OS) of MAO patients. Then, the nomogram based on Cox regression and risk score system based on results from LASSO regression were elaborated respectively. Importantly, this risk score system was proved to have better performance than the nomogram and other single biomarkers such as traditional staging system (area under the curve 0.855 vs. 0.392–0.739). Survival curves showed that patients with the higher risk-score had poorer prognosis than those with lower risk-score (third quantile of OS: 126.000 days, 95% CI: 73.588–178.412 vs. 532.000 days, 95% CI: 0.000–1,110.372; P<0.001).

Conclusions

Nonsmoking status, adenoid cystic carcinoma, and low preoperative stenosis length, were independent predictive factors for better OS of MAO patients. We proposed a nomogram and risk score system for survival prediction of MAO patients undergoing interventional bronchoscopy with good performance.

Venovenous extracorporeal membrane oxygenation during high-risk airway interventions

OBJECTIVES

Practice patterns for the use of extracorporeal membrane oxygenation (ECMO) during high-risk airway interventions vary, and data are limited. We aim to characterize our recent experience using ECMO for procedural support during whole-lung lavage (WLL) and high-risk bronchoscopy for central airway obstruction (CAO).

METHODS

We performed a retrospective cohort study of adults who received ECMO during WLL and high-risk bronchoscopy from 1 July 2018 to 30 March 2020. Our primary end point was successful completion of the intervention. Secondary end points included ECMO-associated complications and hospital survival.

RESULTS

Eight patients received venovenous ECMO for respiratory support during 9 interventions; 3 WLLs for pulmonary alveolar proteinosis were performed in 2 patients, and 6 patients underwent 6 bronchoscopic interventions for CAO. We initiated ECMO prior to the intervention in 8 cases and during the intervention in 1 case for respiratory decompensation. All 9 interventions were successfully completed. Median ECMO duration was 17.8 h (interquartile range, 15.9-26.6) for the pulmonary alveolar proteinosis group and 1.9 h (interquartile range, 1.4-8.1) for the CAO group. There was 1 cannula-associated deep vein thrombosis; there were no other ECMO complications. Seven patients (87.5%) and 4 (50.0%) patients survived to discharge and 1 year postintervention, respectively.

CONCLUSIONS

Use of venovenous ECMO to facilitate high-risk airway interventions is safe and feasible. Planned preprocedural ECMO initiation may prevent avoidable respiratory emergencies and extend therapeutic airway interventions to patients otherwise considered too high risk to treat. Guidelines are needed to inform the utilization of ECMO during high-risk bronchoscopy and other airway interventions.

The (Hour)glass Half-Full: Modified Silicone Hourglass Stents for the Treatment of Central Airway Obstruction

Central airway obstruction often presents with airway narrowing of differing internal diameters. Conventional straight stents do not fit these airways well and are prone to migration. We present a series of cases where hourglass-shaped silicone stents were customized intra-operatively to fit airway obstructions of both malignant and non-malignant etiologies and to improve patient performance status. Modified hourglass stents are a versatile tool to manage inoperable airway obstruction with unique anatomical characteristics.

Efficacy and Survival after Palliative Radiotherapy for Malignant Pulmonary Obstruction

Introduction: The purpose of this study was to determine the efficacy of palliative radiotherapy (PRT) for patients with pulmonary obstruction from advanced malignancy and identify factors associated with lung re-expansion and survival. Materials and Methods: We reviewed all patients treated with PRT for malignant pulmonary obstruction (n = 108) at our institution between 2010 and 2018. Radiographic evidence of lung re-expansion was determined through review of follow-up CT or chest X-ray. Cumulative incidence of re-expansion and overall survival (OS) were estimated using competing risk methodology. Clinical characteristics were evaluated for association with re-expansion, OS, and early mortality. Treatment time to remaining life ratio (TT:RL) was evaluated as a novel metric for palliative treatment. Results: Eighty-one percent of patients had collapse of an entire lung lobe, 46% had Eastern Cooperative Oncology Group (ECOG) performance status 3-4, and 64% were inpatient at consultation. Eighty-four patients had follow-up imaging available, and 25 (23%) of all patients had lung re-expansion at median time of 35 days. Rates of death without re-expansion were 38% and 65% at 30 and 90 days, respectively. Median OS was 56 days. Death within 30 days of PRT occurred in 38%. Inpatients and larger tumors trended toward lower rates of re-expansion. Notable factors associated with OS were re-expansion, nonlung histology, tumor size, and performance status. Median TT:RL was 0.11 and significantly higher for subgroups: ECOG 3-4 (0.19), inpatients (0.16), patients with larger tumors (0.14), those unfit for systemic therapy (0.17), and with 10-fraction PRT (0.14). Conclusion: One-fourth of patients experienced re-expansion after PRT for malignant pulmonary obstruction. Survival is poor and a significant proportion of remaining life may be spent on treatment. Careful consideration of these clinical factors is recommended when considering PRT fractionation.

Contributions of Airway Stent for Long-term Outcome in Patients With Malignant Central Airway Stenosis or Obstruction

BACKGROUND

Although an airway stent is used for malignant central airway stenosis or obstruction, long-term outcomes are unknown. In this study, we retrospectively analyzed the clinical features of patients who required stenting for malignant central airway stenosis or obstruction.

PATIENTS AND METHODS

We retrospectively analyzed clinical data from 116 patients with stenting for central airway stenosis or obstruction who underwent treatment at Toho University Hospital from 1998 to 2018. We evaluated the clinical features, prognoses, and complications for stenting in these patients.

RESULTS

The distribution of the 116 patients was as follows: lung cancer, 53; esophageal cancer, 40; thyroid cancer, 8; and others, 15. Patients with thyroid cancer had a significantly higher rate of complications after stenting than patients with lung cancer (P=0.0062), esophageal cancer (P=0.0029), and others (P=0.0062). Patients with esophageal cancer had a significantly worse prognosis than patients with lung and thyroid cancer. In patients with lung cancer the prognosis was significantly different between patients who underwent additional treatment for lung cancer after stenting and patients with no treatment (P=0.0398), and patients who received chemoradiotherapy for lung cancer after stenting had a significantly better prognosis than patients with no treatment (P=0.0306).

CONCLUSION

Stenting for airway stenosis/obstruction may improve prognosis in patients with lung or thyroid cancer, especially if patients with lung cancer undergo additional treatments after stenting, although airway stenting for patients with esophageal cancer was palliative. New treatment strategies may be necessary for patients with esophageal cancer after stenting to improve prognosis.

Esophageal Cancer, Central Airway Obstruction, and Lots More: A Collaborative Approach to a Challenging Scenario

Esophageal cancer is the most common cause of extrapulmonary malignant central airway obstruction (MCAO). MCAO is usually managed by a multidisciplinary approach involving tumor debulking, stent placement, and palliative radiotherapy. MCAO is a challenge in itself; here, it becomes even more challenging as it was accompanied by grade 3 oral submucous fibrosis, nasal synechiae, and multiple enlarged cervical nodes causing excessive compression of the trachea along with acute hypercapnic respiratory failure. Herein, a 65-year-old woman with multiple challenges, where death was imminent, managed with a collaborative approach involving awake nasal intubation in the sitting position and placement of a stent via a flexible bronchoscope, as rigid bronchoscopy was not possible in view of limited mouth opening. Overcoming these challenges led to completing the procedure successfully and palliating the symptoms.

External fixation of airway stents for upper tracheal stenosis and tracheoesophageal fistula

OBJECTIVES

Stent migration is a common complication of airway stent placement for upper tracheal stenosis and tracheoesophageal fistula. Although several researchers have reported that external fixation is effective in preventing stent migration, the usefulness and safety of external fixation have not been proved because their cohorts were small. We therefore investigated the efficacy and safety of external fixation during upper tracheal stenting.

METHODS

Records of patients who underwent airway stent placement from May 2007 to August 2018 in a single centre were retrospectively reviewed. We included only patients whose stent had been placed in the upper trachea with external fixation to the tracheal wall. The primary endpoint of this study was the rate of stent migration.

RESULTS

Altogether, 51 procedures were performed in 45 patients (32 males, 13 females; median age 60 years, range 14-91 years). The median follow-up period was 9 months (range 0.3-90 months). Among the procedures, 15 were performed for benign disease and 36 for malignancy. Stents were composed of either silicone (n = 42) or metal (n = 9). Stent migration occurred in 3 (6%) patients. The stents with migration were all composed of silicone. Other sequelae were granulation tissue formation in 10 (20%) patients, sputum obstruction in 6 (12%), cellulitis in 3 (6%) and pneumonia in 1 (2%).

CONCLUSIONS

External fixation was an effective method for preventing migration of airway stents placed for upper tracheal stenosis and tracheoesophageal fistula. The complications were acceptable in terms of safety.

Variable Learning Curve of Basic Rigid Bronchoscopy in Trainees

BACKGROUND

Despite increased use of rigid bronchoscopy (RB) for therapeutic indications and recommendations from professional societies to use performance-based competency, an assessment tool has not been utilized to measure the competency of trainees to perform RB in clinical settings.

OBJECTIVES

The aim of the study was to evaluate a previously developed assessment tool - Rigid Bronchoscopy Tool for Assessment of Skills and Competence (RIGID-TASC) - for determining the RB learning curve of interventional pulmonary (IP) trainees in the clinical setting and explore the variability of learning curve of trainees.

METHODS

IP fellows at 4 institutions were enrolled. After preclinical simulation training, all RBs performed in patients were scored by faculty using RIGID-TASC until competency threshold was achieved. Competency threshold was defined as unassisted RB intubation and navigation through the central airways on 3 consecutive patients at the first attempt with a minimum score of 89. A regression-based model was devised to construct and compare the learning curves.

RESULTS

Twelve IP fellows performed 178 RBs. Trainees reached the competency threshold between 5 and 24 RBs, with a median of 15 RBs (95% CI, 6-21). There were differences among trainees in learning curve parameters including starting point, slope, and inflection point, as demonstrated by the curve-fitting model. Subtasks that required the highest number of procedures (median = 10) to gain competency included ability to intubate at the first attempt and intubation time of <60 s.

CONCLUSIONS

Trainees acquire RB skills at a variable pace, and RIGID-TASC can be used to assess learning curve of IP trainees in clinical settings.

Customization of stent design for treating malignant airway stenosis with the aid of three-dimensional printing

Background

The treatment of malignant stenosis involving the carina or bronchi is challenging due to complicated anatomy with individual variation, which makes it necessary to customize stents for each patient. Therefore, this study aims to evaluate the feasibility of a novel metallic segmented airway stent customized with the aid of three-dimensional (3D) printing for such cases.

Methods

The stents were individually customized with the aid of a 3D printed mold based on computed tomography (CT) images according to the anatomical features of the airway. A segmented design was applied on the junction part of the main stem and the branches to fit the dynamic changes of the carina angle. In 12 patients with airway stenosis caused by malignancies including esophageal cancer (EC) and lung cancer (LC), the stents were implanted. The technical and clinical success of the stenting procedure, Hugh-Jones (HJ) classification, Karnofsky performance status (KPS), and stent-related complications of patients were evaluated.

Results

The stenting procedure was technically successful in all patients, and 11 patients showed significant palliation of dyspnea after stenting. The HJ and KPS classification of patients after stent insertion improved significantly compared with those before stenting (P=0.003 and P=0.006, respectively). During follow-up, granulation tissue proliferation and sputum retention were found in two and four patients, respectively.

Conclusions

This study shows that the implantation of a novel stent designed with the aid of 3D printing is feasible for relieving dyspnea and improving performance status of patients with inoperable malignant stenosis involving the carina or bronchi.

The value of endobronchial cryotherapy in the management of malignant endobronchial obstruction in patients with inoperable NSCLC: a prospective analysis of clinical and survival outcomes

Background

Malignant endobronchial obstruction (MEBO) is the most debilitating complication in non-small cell lung cancer (NSCLC). The therapeutic role of cryotherapy and its impact on survival has not been well addressed. This is to clarify whether the combination of endobronchial cryotherapy (EBCT) and chemoradiotherapy (CRT) improved symptoms, respiratory functions, performance status, and survival outcomes in inoperable NSCLC with symptomatic MEBO compared to that obtained by CRT alone.

Results

A prospective cohort study included 60 cases presented to Qena University Hospital, Egypt, between December 2016 and May 2019. They were divided into two groups. Group A included 30 patients who were managed with EBCT plus CRT. Group B included 30 patients who were managed with CRT alone. The outcomes assessed were symptoms relief, respiratory function tests (RFT), performance status, and survival outcomes at baseline and 4 weeks of follow-up. Group A patients showed a highly significant improvement in symptoms (cough, dyspnea, and hemoptysis), RFT, 6MWD test, and arterial blood gases, compared to group B. The mean Karnofsky score increased from 57.33±5.67% at baseline to 60.67±6.39% post-EBCT (P=0.036); group A was significantly improved compared to group B (P=0.04). The Kaplan-Meier median survival for all patients was 9.7±0.4 months (95% CI= 8.86–10.54), and group A cases (10.77±0.44 months, 95% CI= 9.9–11.6) was significantly longer than that of group B cases (8.6±0.68 months, 95% CI= 7.3–9.97; T test = 2.631, P=0.011).

Conclusion

The use of EBCT with CRT for the management of MEBO in symptomatic patients with inoperable NSCLC is an efficient and safe procedure. EBCT improves clinical outcomes, RFT, performance status, and median survival.

Trial registration

ClinTrial.Gov registration: NCT04710459 on 4/3/2021.

Effectiveness and safety of a newly designed partially covered tracheal metallic Y-shaped stent for the treatment of high cervical gastro-tracheal or tracheo-esophageal fistula: A retrospective observational study

The aim of this study was to evaluate the effectiveness and safety of a partially covered metallic tracheal Y-shaped stent for the treatment of high cervical gastro-tracheal fistula (GTF) and tracheo-esophageal fistula (TEF). From January 2017 to January 2019, 16 patients with high cervical GTF and TEF received partially covered metallic Y-shaped stent placement under fluoroscopic guidance. The technical and clinical success rates, incidence of major complications, and survival outcomes were analyzed. Eastern Cooperative Oncology Group (ECOG) score and quality of life (SF-36 questionnaire) were compared pre and post stent placement. Technical and clinical success rates were 100% and 81.3%, respectively. Major complications (severe tumor ingrowth, mucostasis, hyperplastic granulation tissue) occurred in 7/16 (43.8%) patients. ECOG score and 5 of the 8 domains of the SF-36 (physical function, role physical, general health, vitality, social function) were significantly improved at 1 month after treatment (P < .01). During the median follow-up period of 8.3 months, 9 patients were alive. Median overall survival was 10.3 months (95% CI, 8.0-12.6). The newly designed partially covered tracheal Y-shaped stent appears to be effective and safe for treatment of high cervical GTF and TEF.

Long-term prognostic factors of clinical success after interventional bronchoscopy in patients with scarring central airway stenosis

Background

Scarring central airway stenosis (SCAS) is a potentially life-threatening condition with debilitating symptoms. Interventional bronchoscopy is increasingly used to relieve symptoms in patients with SCAS, but recurrent stenosis is frequently observed. Little data exist on the long-term prognosis of interventional bronchoscopy for SCAS. We aimed to assess the prognostic factors of bronchoscopic interventions in patients with SCAS to optimize treatment.

Methods

This was a retrospective study that enrolled 119 consecutive patients with SCAS from January 2010 to April 2019 at our institution. Long-term clinical success was defined as airway stenosis < 50%, no limitation of physical activity, and a stable condition for > 12 months after the last interventional procedure. We compared patients’ demographics, airway stenosis characteristics, and interventional procedures between the successful and unsuccessful groups, and identified significant predictors of long-term outcome with univariate and multivariate logistic regression.

Results

A total of 119 patients with 577 therapeutic bronchoscopies were included. Seventy-five (63%) patients were considered to have long-term clinical success. Older age, male gender, smoking, elevated C-reactive protein level, subglottic stenosis, stent or T-tube implantation, previous interventional treatment, and multiple procedures per year were potentially associated with unsuccessful long-term outcomes in the univariate analysis. Current smoker status (odds ratio [OR] 5.70, 95% confidence interval [CI] 1.35–24.17, P = 0.018), subglottic stenosis (OR 4.35, 95% CI 1.31–14.46, P = 0.017), and stent implantation (OR 4.96, 95% CI 1.33–18.48, P = 0.017) were associated with decreased odds of long-term success in the multivariate logistic regression analysis. Of note, there was no significant difference in odds of success between former smokers and nonsmokers.

Conclusions

Current smoker status, subglottic stenosis, and stent implantation are independent factors associated with reduced long-term efficacy of interventional bronchoscopy for SCAS. Smoking cessation should be encouraged to improve the outcome of therapeutic bronchoscopy.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12890-021-01434-5.

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.