IBS20.02 Airway Stenosis

Abstract

Tracheal stenosis is suspected in individuals with risk factors presenting with signs and symptoms of airway narrowing. The condition may be suspected based on spirometry with a flow-volume loop and CT imaging of the neck and chest but fiberoptic bronchoscopy is required to confirm the presence and severity of tracheal stenosis. The symptoms of tracheal stenosis are similar to those of other conditions so it is important to carefully evaluate patients history. The symptoms of tracheal stenosis typically are wheezing, coughing or shortness of breath, cornage, upper respiratory infections, asthma that doesn’t respond to treatment. Benign tracheal stenoses are more commonly the result of an injury to the trachea due to prolonged intubation or tracheostomy but also Infections (tuberculosis), autoimmune disorders such as Granulomatosis with polyangiitisand amyloidosis or radiation therapy to the neck or chest. The morphological classification of airway stenosis includes granulomas, pseudoglottic stenosis, and “true stenosis” divided into web-like and complex stenoses. Web-like stenoses are circumferential strictures of the trachea involving the mucosa of a short segment (maximum 1 cm long)without any damage to the cartilages. Complex stenosesare sleeve strictures of the trachea more than 1 cm long, often associated with various degrees of cartilage involvement, malacia and inflammation. Several treatment options that can be used for tracheal stenosis depending on the cause, location and severity of the tracheal narrowing. Resection and anastomosis of the involved tract of the trachea is the gold standard treatment. Interventional Pulmonology (IP) offers minimally invasive techniques. Some IP treatment options can provide immediate relief but are considered temporary solutions, while others can provide a better long-term solution. Short-term treatment options for the condition include laser surgery and mechanical dilation with rigid scopes.Treatment options that are generally considered to work long term include stenting and tracheal reconstruction when only a short portion of the trachea is involved. Choice of procedure depends on the exact location and extent of the stenosis, but also on patient age and comorbidities.The most common treatment options for tracheal stenosis include: In 2007 Cavaliere et al. published the results of Laser Assisted Mechanical Dilation in 113 post-intubation tracheal stenosesTab 1Patient carachterstics Therapeutic bronchoscopies were performed using rigid bronchoscopes (Efer, Dumon-Harrel type; FR) and general anesthesia.Endoscopic treatment was based on the use of three main techniques: laser photo-resection (multiple radial incisions), gentle dilation and removable silicon stents.SexAge(Y)Cause of stenosisType of stenosisM 4750±21 (12-84)Intubation 38Tracheotomy 35Web-like 13Complex 60 Open table in a new tab View Large Image Figure ViewerDownload Hi-res image Download (PPT) Most web-like stenoses were successfully treated with Laser Assisted Mechanical Dilation (LAMD) alone; among complex stenoses LAMD was sufficient to treat 13 patients (22%), whereas 47 patients (78%) required stent placement: 22 had their stent removed after one year and did not require any further therapy, 13 inoperable patients required permanent stent and 12 were referred to surgery after failure of multiple endoscopic treatments. No permanent complications secondary to endoscopic treatment were observed. Forty-eight patients (66%) obtained a stable, good result with the endoscopic procedure, 13 (18%) required a permanent stent while 12 patients (16%) were referred to surgery. These authors indicate that bronchoscopic treatment of post-intubation tracheal stenoses can be considered a safe first-line therapy, leaving some selected cases and the relapsing stenosis for surgical resection. 1.Shapshay SM, Beamis JF, Jr, Hybels RL, Bohigian RK. Endoscopic treatment of subglottic and tracheal stenosis by radial laser incision and dilation. Ann Otol Rhinol Laryngol. 1987;96:661–664. 2. Bacon JL, Patterson CM, Madden BP. Indications and interventional options for non-resectable tracheal stenosis. J Thorac Dis. 2014;6:258–70. 3. Galluccio G, Lucantoni G, Battistoni P, Paone G, Batzella S, Lucifora V et al. Interventional endoscopy in the management of benign tracheal stenoses: definitive treatment at long-term follow-up. Eur J Cardiothorac Surg. 2009;35:429–33. 4. Murgu SD, Colt HG, Mukai D, Brenner M. Multimodal imaging guidance for laser ablation in tracheal stenosis. Laryngoscope. 2010;120:1840–6. 5. Cavaliere S, Bezzi M, Toninelli C, Foccoli P Management of post-intubation tracheal stenoses using the endoscopic approach. Follow-up of 73consecutive patients over a four-year period. Monaldi arch Chest Dis 2007 Jun; 67(2):73-80