Complications of Silicone Stent Insertion in Patients With Expiratory Central Airway Collapse

doi:10.1016/j.athoracsur.2007.07.026

The Annals of Thoracic Surgery

Volume 84, Issue 6, December 2007, Pages 1870-1877

https://doi.org/10.1016/j.athoracsur.2007.07.026 Get rights and content

Background

Silicone stent insertion is an alternative treatment for expiratory central airway collapse. This study evaluates the complications (mucus plugging, migration, and granulation tissue) associated with stenting in patients who failed medical therapy and were not surgical candidates.

Methods

Chart review from 15 consecutive patients treated by silicone stent insertion was done over a 2-year period. Outcomes included (1) changes in functional class, extent and severity of airway collapse (graded from 1 to 4 by using a multidimensional system), procedure- and stent-related complications at 48 hours after stent insertion; (2) frequency of stent-related complications; and (3) frequency of emergent flexible and rigid bronchoscopy (scheduled or emergent) over the follow-up period.

Results

Mean functional class and severity and extent of airway collapse significantly improved within 48 hours after treatment (p < 0.05). There were no perioperative deaths. Stent-related complications within 48 hours after stent insertion occurred in 3 patients (1 granulation, 1 migration, and 1 mucus plugging). The mean duration of follow-up for the 12 patients who underwent clinical and bronchoscopic follow-up was 188 days. Twenty-six stent-related complications (12 mucus plugs, 8 migrations, and 6 granulation tissues) were seen in 10 of the 12 patients. Five emergent flexible bronchoscopies and 14 rigid bronchoscopies (6 of which were emergent) were performed during the follow-up period.

Conclusions

Silicone stent insertion improves functional status immediately after intervention in patients with expiratory central airway collapse, but is associated with a high rate of stent-related complications and need for repeat bronchoscopic interventions.

Section snippets

Patients and Methods

Patients with a known diagnosis of expiratory central airway collapse were extracted from the interventional pulmonology database at University of California, Irvine Medical Center (UCIMC). All patients had been referred to our institution for airway stent insertion after conservative medical therapy including bronchodilators and continuous positive airway pressure failed and were deemed not to be candidates for surgery. Medical records, bronchoscopy photos, and videos of 15 consecutive

Results

Between 2003 and 2005, 15 patients with expiratory central airway collapse (11 males and 4 females) were referred to UCIMC for silicone stent insertion. The mean age (±SD) was 61.6 years (±15.2; range, 29 to 89). Presenting symptoms, underlying etiology, morphologic types as well as functional class, extent of airway narrowing, and severity of airway collapse before and immediately after stent insertion are noted in Table 2. Reasons for inoperability were (1) surgery not indicated (patients 1,

Comment

Treatment for patients with expiratory central airway collapse depends on severity of functional impairment, etiology, severity of airway narrowing, and extent of airway collapse. Many patients present with signs and symptoms of respiratory insufficiency that must be treated emergently. In less severe cases, conservative therapy with bronchodilators or continuous positive airway pressure may improve symptoms [20, 21]. Other times, patients are diagnosed while relatively asymptomatic and

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Tracheobronchomalacia is usually characterized by more than 50% expiratory narrowing in diameter of the trachea and the bronchi. The expiratory collapse includes two entities: (1) the TBM related to the weakness of the cartilaginous rings, and (2) the Excessive Dynamic Airway Collapse (EDAC) due to the excessive bulging of the posterior membrane. Patients have nonspecific respiratory symptoms like dyspnea and cough. Diagnosis is confirmed by dynamic tests: flexible bronchoscopy and/or computed tomographic scan of the chest. There are different forms of tracheobronchomalacia in adults: primary (genetic, idiopathic) or secondary to trauma, tracheotomy, intubation, surgery, transplantation, emphysema, infection, inflammation, chronic bronchitis, extrinsic compression; or undiagnosed in childhood vascular rings. Some management algorithms have been proposed, but no specific recommendation was established. Only symptomatic patients should be treated. Medical treatments and noninvasive positive pressure ventilation should be the first line therapy, after evaluation of various quality measures (functional status, performance status, dyspnea and quality of life scores). If symptoms persist, therapeutic bronchoscopy permits: (1) patient's selection by stent trial to determine whether patient benefit for surgical airway stabilization; (2) malacic airways stenting in patients who are not surgical candidates, improving QOL despite a high complication rate; (3) the management of stent-related complication (obstruction, plugging, migration granuloma); (4) alternative therapeutics like thermo-ablative solution. Lasty, the development of new types of stents would reduce the complication rates. These different options remained discussed.
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We retrospectively reviewed prospectively collected clinical data from 42 patients who underwent robotic tracheobronchoplasty from May 2016 to December 2017. The Institutional Review Board or equivalent ethics committee of the Northwell Health approved the study protocol and publication of data. Patient written consent for the publication of the study data was waived by the Institutional Review Board.
A total of 42 patients underwent robotic tracheobronchoplasty during the study period. Median total follow-up is 40 months. There was 1 death since surgery from an unrelated disease. Significant decreases in St George's Respiratory Questionnaire total score (preoperative mean: 64.01, postoperative mean: 38.91, P = .002), St George's Respiratory Questionnaire symptom score (preoperative median: 82.6, postoperative median: 43.99, P < .001), and St George's Respiratory Questionnaire impact score (preoperative median: 55.78, postoperative median: 25.95, P < .001) were apparent at a median follow-up of 13 months. Comparison of preoperative and postoperative pulmonary function tests revealed a significant increase in percent predicted forced expiratory volume in 1 second (preoperative median: 74% vs postoperative median: 82%, P = .001), forced vital capacity (preoperative median: 68.5% vs postoperative median: 80.63%, P < .001), and peak expiratory flow (preoperative median: 61.5% vs postoperative median: 75%, P = .02) measured at a median follow-up of 29 months.
Robotic tracheobronchoplasty is associated with low intermediate-term mortality. Robotic tracheobronchoplasty results in significant improvement in quality of life and postoperative pulmonary function. Longer-term follow-up is necessary to continue to elucidate the effect of robotic tracheobronchoplasty on halting pathologic progression of tracheobronchomalacia and to determine the long-term impact of tracheobronchoplasty on symptomatic and functional improvement.
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Original articleGeneral thoracicComplications of Silicone Stent Insertion in Patients With Expiratory Central Airway Collapse

Background

Methods

Results

Conclusions

Section snippets

Patients and Methods

Results

Comment

Ann Thorac Surg

Chest

Chest

Chest

Chest

Chest

J Pediatr Surg

J Thorac Cardioovasc Surg

Chest

J Pediatr Surg

Acquired tracheobronchomalaciaA clinical study with bronchological correlations

Ann Clin Res

Acquired tracheobronchomalacia

Ann Clin Res

Respiratory failure due to tracheobronchomalacia

Thorax

Tracheobronchomalacia and excessive dynamic airway collapse

Respirology

Tracheobronchomalacia: dynamic airway evaluation with multidetector CT

AJR Am J Roentgenol

Multiplanar and three-dimensional imaging of the central airways with multidetector CT

AJR Am J Roentgenol

Original article
General thoracic
Complications of Silicone Stent Insertion in Patients With Expiratory Central Airway Collapse