Fiberoptic Bronchoscopic Cryotherapy in the Management of Tracheobronchial Obstruction

doi:10.1378/chest.110.3.718

Chest

Volume 110, Issue 3, September 1996, Pages 718-723

https://doi.org/10.1378/chest.110.3.718 Get rights and content

Cryotherapy is used for endoscopic management of tracheobronchial obstruction (TBO). This study describes the use of a flexible cryoprobe for cryotherapy using nitrous oxide as a cryogen through a fiberoptic bronchoscope. The study group consisted of 22 patients, ages ranging from 28 to 82 years. Twenty patients had malignant TBO and two had bronchial obstruction (BO) following lung transplantation. Benign BO was first dilated with a balloon and followed with cryotherapy. Eighteen of the 20 malignant endobronchial lesions were completely removed. In three of these patients, the airway remained occluded due to extrinsic compression. Cryotherapy offers an alternative to Nd:YAG laser in the management of TBO. Cryotherapy offers other advantages such as being inexpensive, safe for the operator, and safe for other members of the team. Similarly for the patient, there is no danger of bronchial wall perforation or endobronchial fires, cryotherapy can be done under local anesthesia with conscious sedation, and it can be performed in an endoscopy suite.

Section snippets

Materials and Methods

All endoscopic treatments were carried out with a flexible fiberoptic bronchoscope with a working channel of 2.6 mm (BF−IT 10; Olympus America; Melville, NY) using the flexible cryoprobe. The cryoprobe has an operating diameter of 2.4 mm, length of 90 cm, and the length of a tip is 7 mm (ERBE USA Inc; Marietta, Ga) (Fig 1). These features allow for application of cryotherapy through the working channel of a flexible fiberoptic bronchoscope (BF−IT 10). The cryoprobe employs the Joule−Thompson

Patients

The study group consisted of patients with endobronchial lesions previously determined by a flexible bronchoscopy. These lesions were malignant tumors or bronchial granulomatous tissue causing obstruction. These airway lesions were not amenable to surgery. These patients were symptomatic (dyspnea, hemoptysis, fevers, or postobstructive pneumonia). Patients were excluded if they were in acute respiratory distress, had a central obstructing lesion that was eminently causing respiratory distress,

Results

The results were judged by the clinical response and the endoscopic appearance. In the patients with malignant tracheobronchial lesions, one patient could not be reevaluated because of early death (3 days postprocedure). In one patient, none of the intraluminal tumor could be removed despite three sessions. In the rest of the 18 patients, all the endobronchial components of the tumor were removed. However, in three of these patients, extrinsic compression occluded the airway despite removal of

Complications

There were three minor and one major complication. Two patients experienced bronchospasm during the bronchoscopy, thus, the procedure had to be aborted prematurely. Subsequently, the patients received adequate pretreatment with inhaled bronchodilator and/or steroids; the procedure was well tolerated. In one patient, after removal of the endobronchial tumor, 200 mL of purulent drainage came out from the obstructed lobe (Fig 2). There were no prior signs or symptoms of postobstructive pneumonia.

Discussion

Treatments for lung cancer include surgical resection, radiation therapy, and chemotherapy. Tracheobronchial obstruction may occur as an initial presentation or recur after initial therapy. Airway obstruction may present with dyspnea or hemoptysis. Nd:YAG laser photoresections through either a rigid or fiberoptic bronchoscope have been used extensively to relieve obstruction, dyspnea, and improve the quality of life.4, 5, 6, 7, 8

Cryotherapy has been used in the treatment of malignant and benign

Acknowledgment

We acknowledge technical assistance of Cherry Smith from the pulmonary endoscopy suite at Indiana University Hospital, Indiana University Medical Center, Indianapolis.

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Granulation tissue-induced tracheal stenosis (mainly secondary to intubation or lung transplantation) is one of the most common etiologies of benign airway obstructions. Recurrence rates after standard treatment options (surgical resection and/or endobronchial interventions) can inadvertently worsen the stricture through the stimulation of more granulation tissue generation (via increased fibroblast activity and roliferation). Low-dose radiotherapy could be a promising tool to prevent granulation tissue formation after surgery and/or endobronchial interventions regarding its established role in the treatment of keloids or hypertrophic scars, two benign diseases with similar a pathophysiology to tracheal stenosis. This study reviews case reports and small series that used endobronchial brachytherapy (EBBT) or external beam radiotherapy (EBRT) for the management of refractory granulation tissue-induced tracheal stenosis after surgery and/or endobronchial interventions.
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Ablation techniques that have been reported include cryotherapy, electrocautery, argon plasma coagulation, laser, brachytherapy, or photodynamic therapy. Although stenting provides immediate improvement in the stenosis, it should be reserved for refractory cases given the complications of airway stents.14,16,67–72 Dilation is often the first therapeutic maneuver performed in bronchial stenosis and can be performed using either balloon bronchoplasty or rigid dilation.

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: Manuscript received July 12, 1995; revision accepted May 6, 1996.

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clinical investigationsFiberoptic Bronchoscopic Cryotherapy in the Management of Tracheobronchial Obstruction

Section snippets

Materials and Methods

Patients

Results

Complications

Discussion

Acknowledgment

Chest

Chest

Chest

Chest

Chest

Chest

Int J Radiat Oncol Biol Phys

Int J Radiat Oncol Biol Phys

Chest

Chest

Chest

Cryobiology

Cryobiology

Chest

Radiotherapy in the management of locally advanced lung cancer of all cell types

Cancer

clinical investigations
Fiberoptic Bronchoscopic Cryotherapy in the Management of Tracheobronchial Obstruction