Endobronchial Procedures Research Articles

Management of Chronic Obstructive Pulmonary Disease (COPD) Exacerbations in Hospitalized Patients From Admission to Discharge: A Comprehensive Review of Therapeutic Interventions.

Chronic obstructive pulmonary disease (COPD) is a common and debilitating condition that often necessitates hospitalization for exacerbations. Since COPD exacerbations can cause significant morbidity and mortality, managing them is crucial for patient care. Effective management of COPD exacerbations is essential to prevent complications, as COPD exacerbations are associated with increased healthcare costs and decreased quality of life. This review aims to comprehensively discuss the management of COPD exacerbations, covering various pharmacologic and non-pharmacologic strategies. These include inhaled bronchodilators, systemic steroids, antibiotics, invasive and non-invasive ventilation, oxygen therapy, smoking cessation, immunization with pneumococcal vaccine, inhalers at discharge, pulmonary rehabilitation, long-term oxygen therapy (LTOT), ambulatory oxygen therapy, short-burst oxygen therapy, extracorporeal membrane oxygenation (ECMO), lung volume reduction surgery (LVRS), endobronchial procedures, and lung transplant. It is drawn upon various sources, including clinical studies, systemic reviews, and observational studies, to provide a comprehensive overview of current practices and identify areas for future research and innovation in managing COPD exacerbations. Addressing these areas of interest can improve patient outcomes and quality of life.

Personalized Treatment for Patients With Lung Cancer.

Lung cancer is the most common cause of death among all types of cancer in Germany, with an annual death rate of 45 000 patients. Over the past 15 years, innovations in diagnosis and treatment have prolonged the survival of patients with non-small-cell lung cancer in all tumor stages. This review of the diagnosis and treatment of lung cancer is based on current national and international guidelines, and on prospective trials with the highest possible level of evidence that were retrieved by a selective search of the literature. Improved outcomes in patients with non-small-cell lung cancer (85% of new diagnoses) were achieved with the aid of precise diagnostic techniques, including functional imaging and endobronchial procedures for localized disease stage. Contemporary surgical and radio-oncological technologies reduce the morbidity and expand the boundaries of local therapy. Molecular pathology, including the assessment of predictive biomarkers, is an integral part of the diagnostic evaluation of non-small-cell lung cancer in all tumor stages; it enables stratified cytotoxic/molecularly targeted treatments and immunotherapies and improves patient-reported outcomes. The percentage of long-term survivors in the metastatic stage has doubled by the introduction of immunotherapy. In contrast, there has been no major improvement in the survival of patients with small-cell lung cancer (15% of new diagnoses). In addition to the implementation of lung cancer screening in high-risk populations, the further development and consistent implementation of personalized diagnosis and treatment in certified lung cancer centers can be expected to prolong survival and improve the patients' quality of life.

Personalized Treatment for Patients With Lung Cancer.

Lung cancer is the most common cause of death among all types of cancer in Germany, with an annual death rate of 45 000 patients. Over the past 15 years, innovations in diagnosis and treatment have prolonged the survival of patients with non-small-cell lung cancer in all tumor stages. This review of the diagnosis and treatment of lung cancer is based on current national and international guidelines, and on prospective trials with the highest possible level of evidence that were retrieved by a selective search of the literature. Improved outcomes in patients with non-small-cell lung cancer (85% of new diagnoses) were achieved with the aid of precise diagnostic techniques, including functional imaging and endobronchial procedures for localized disease stage. Contemporary surgical and radio-oncological technologies reduce the morbidity and expand the boundaries of local therapy. Molecular pathology, including the assessment of predictive biomarkers, is an integral part of the diagnostic evaluation of non-small-cell lung cancer in all tumor stages; it enables stratified cytotoxic/molecularly targeted treatments and immunotherapies and improves patient-reported outcomes. The percentage of long-term survivors in the metastatic stage has doubled by the introduction of immunotherapy. In contrast, there has been no major improvement in the survival of patients with small-cell lung cancer (15% of new diagnoses). In addition to the implementation of lung cancer screening in high-risk populations, the further development and consistent implementation of personalized diagnosis and treatment in certified lung cancer centers can be expected to prolong survival and improve the patients' quality of life.

Imaging of therapeutic airway interventions in thoracic oncology

Tracheobronchial obstruction, haemoptysis, and airway fistulas caused by airway involvement by primary or metastatic malignancies may result in dyspnoea, wheezing, stridor, hypoxaemia, and obstructive atelectasis or pneumonia, and can lead to life-threatening respiratory failure if untreated. Complex minimally invasive endobronchial interventions are being used increasingly to treat cancer patients with tracheobronchial conditions with curative or, most often, palliative intent, to improve symptoms and quality of life. The selection of the appropriate treatment strategy depends on multiple factors, including tumour characteristics, whether the lesion is predominately endobronchial, shows extrinsic compression, or a combination of both, the patient's clinical status, the urgency of the clinical scenario, physician expertise, and availability of tools. Pre-procedure multidetector computed tomography (MDCT) imaging can aid in the most appropriate selection of bronchoscopic treatment. Follow-up imaging is invaluable for the early recognition and management of any potential complication. This article reviews the most commonly used endobronchial procedures in the oncological setting and illustrates the role of MDCT in planning, assisting, and follow-up of endobronchial therapeutic procedures.

The Effectiveness of Endobronchial Ultrasound-Guided Transbronchial Needle Aspiration in Patients With Undiagnosed Lung Cancer

Objectives: Conventional bronchoscopic techniques and computed tomography-guided transthoracic needle aspiration are widely used in the diagnosis of lung cancer. In some patients diagnosis can be challenging. Endobronchial ultrasound-guided transbronchial needle aspiration can be used in the diagnosis of lung cancer after procedures have failed to provide a diagnosis. We aimed to show the effectiveness of Endobronchial ultrasound-guided transbronchial needle aspiration in the diagnosis of lung cancer in view of the literature and to share the experience from Turkey.
 Material and Methods: This was a retrospective study conducted between 2014 and 2019. Forty-five patients who were suspected of having lung cancer and underwent Endobronchial ultrasound because diagnosis was not confirmed using methods such as bronchoscopy, computed tomography transthoracic needle aspiration, and peripheral lymph node excision, were included in the study.
 Results: Three hundred sixty-eight Endobronchial ultrasound procedures were performed. Forty-five patients met the inclusion criteria and were included in the study. Using Endobronchial ultrasound, samples were taken from only mass in eight patients (17.8%), lymph nodes in 30 patients (66.7%), and mass + lymph node in seven (15.5%) patients. Minor complications were seen in five (11.1%) patients and no major complications were seen. Definitive diagnosis was obtained in 35 (77.7%) patients with Endobronchial ultrasound guided transbronchial needle aspiration. Non-small cell lung cancer was identified in 16 patients (45.7%), small cell lung cancer was seen in 15 (42.8%) patients. Seven of ten undiagnosed patients underwent surgical procedures.
 Conclusion: Endobronchial ultrasound, is an effective and safe method for diagnosing lung cancer after undiagnosed procedures. In selected cases, it can be the first choice for the diagnosis of lung cancer.

Sonic hedgehog signalling as a potential endobronchial biomarker in COPD

BackgroundThe hedgehog (HH) pathway has been associated with chronic obstructive pulmonary disease (COPD) in genome-wide association studies and recent studies suggest that HH signalling could be altered in COPD. We therefore used minimally invasive endobronchial procedures to assess activation of the HH pathway including the main transcription factor, Gli2, and the ligand, Sonic HH (Shh).MethodsThirty non-COPD patients and 28 COPD patients were included. Bronchial brushings, bronchoalveolar lavage fluid (BALF) and bronchial biopsies were obtained from fiberoptic bronchoscopy. Characterization of cell populations and subcellular localization were evaluated by immunostaining. ELISA and RNAseq analysis were performed to identify Shh proteins in BAL and transcripts on lung tissues from non-COPD and COPD patients with validation in an external and independent cohort.ResultsCompared to non-COPD patients, COPD patients exhibited a larger proportion of basal cells in bronchial brushings (26 ± 11% vs 13 ± 6%; p < 0.0001). Airway basal cells of COPD subjects presented less intense nuclear staining for Gli2 in bronchial brushings and biopsies (p < 0.05). Bronchial BALF from COPD patients contained lower Shh concentrations than non-COPD BALF (12.5 vs 40.9 pg/mL; p = 0.002); SHH transcripts were also reduced in COPD lungs in the validation cohort (p = 0.0001).ConclusionThis study demonstrates the feasibility of assessing HH pathway activation in respiratory samples collected by bronchoscopy and identifies impaired bronchial epithelial HH signalling in COPD.

English

English

Thoracic aortic aneurysms exerting high extrinsic pressure on the airway

BackgroundThoracic aortic aneurysms, although mostly asymptomatic, are life threatening owing to the risk of rupture. Moreover, the extrinsic pressure of a ruptured aneurysm may encroach the mediastinum.Case presentationA 74-year-old woman diagnosed with ruptured descending thoracic aortic aneurysm compressing the lower trachea and both main bronchi underwent thoracic endovascular aortic repair; however, the extrinsic pressure on the airway persisted. Following failing of endobronchial silicon stents insertion, extracorporeal membrane oxygenation support was required, and endobronchial metallic stents were inserted. The patients’ hypoventilation resolved, and the patient was withdrawn from the ventilator.ConclusionsTechnological improvement in endovascular or endobronchial procedures has provided more options for managing complex cases. However, we must be aware of how high the extrinsic pressure might be before management and take steps to minimize complications.

Utility and safety of endobronchial ultrasound-guided transbronchial needle aspiration and endoscopic ultrasound with an echobronchoscope-guided fine needle aspiration in children with mediastinal pathology.

Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) and endoscopic ultrasound with an echobronchoscope-guided fine needle aspiration (EUS-B-FNA) are useful modalities in the evaluation of mediastinal pathologies in adults. However, sparse data are available in children. To describe the utility and safety of EBUS-TBNA and EUS-B-FNA in children with mediastinal pathologies of unknown etiology. Chart review. Pediatric Chest and Tuberculosis Clinics, Department of Pediatrics, AIIMS, New Delhi from May 2015 to March 2018. Children <18 years of age with mediastinal pathologies of undefined etiology. Case records of children who underwent EBUS-TBNA and EUS-B-FNA were reviewed. Data on demographic profile, clinical features, laboratory investigations, the technique of EBUS-TBNA/ EUS -B- FNA, complications, and findings were collected. Thirty children (19 males) with mean (SD) age of 9.6 (±3.5) years underwent endobronchial procedures. Median (IQR) weight(kg) and height(cm) were 29(19.5,35) and 134(125,150) respectively. Tuberculosis was the most common preprocedure clinical diagnosis(73.3%), followed by lymphoma(13.3%). Presenting features were fever (80%), cough (53.3%), hepatomegaly (13%), peripheral lymphadenopathy (21.7%), and positive tuberculin skin test (63.3%). Approximately one fourth were on antitubercular therapy without definite evidence of TB. Conscious sedation was used for the procedures: midazolam and fentanyl (n = 22), propofol(n = 8). Transesophageal, transtracheal, and both routes were used in 20(66.6%), 7(23.3%), and 3(10.1%), respectively. Lymph-nodes were sampled in 24 children (subcarinal in 16, right paratracheal in 4 and both in 4). Mean (SD) size of lymph node (in cm) on EBUS was 1.93(±0.5) and median (IQR) number of FNAC needle passes per node were 2(2,4). The diagnosis was confirmed in 11 (36.6%, tuberculosis in 10 by GeneXpert/MGIT/cytopath and lymphoma in one) patients. Only 3.3% had a minor complication. EBUS-TBNA and EUS-B-FNA are helpful in children with undiagnosed mediastinal pathology with fair diagnostic yield and excellent patient safety profile.

TRANSLATION OF A NOVEL 3D NAVIGATION AUGMENTED FLUOROSCOPY APPROACH FOR ENDOBRONCHIAL PROCEDURES BASED ON CBCT

SESSION TITLE: Interventional Pulmonology Investigations SESSION TYPE: Original Investigations PRESENTED ON: 10/10/2018 03:45 PM - 04:45 PM PURPOSE: To develop and characterize a novel navigation approach for endobronchial procedures based on Cone Beam Computed Tomography (CBCT) and Augmented Fluoroscopy from bench to bedside. METHODS: An endobronchial navigation software prototype was developed that can generate a 3D airway segmentation, tumor segmentation and 3D airway navigation path planning based on CBCT (XperCT, Philips), without electromagnetic (EM) tracking. All models (airways, targets, pathways) can be superimposed on X-ray to generate an augmented fluoroscopy view with real-time updates based upon table motion, magnification, or C-arm rotation. The navigation prototype was characterized and optimized using non-bronchoscopy devices (endovascular guidewires, catheters and steerable sheaths) in bench models (a 3D printed airway and an ex vivo breathable swine lung) and in an animal model (swine, n=3, approved by Animal Care and Use Committee). Two operators were asked to navigate to predefined lung segments and locations were confirmed with CBCT and 2D X-ray at two orthogonal angles. 9 complex clinical transbronchial biopsies of parenchymal lung lesions were retrospective reported (under an IRB-approved clinical protocol) using combinations of fluoroscopy, augmented fluoroscopy, CBCT, CBCT derived 3D models, EM navigation, and finally off-label miniature hardware without direct optical endoscopy. Clinical cases used previously FDA cleared software (OncoSuite, Philips), off-label for lung applications, whereas pre-clinical studies utilized a prototype software specific for lung. RESULTS: In the bench model, 10/10 (100%) navigation tasks were successful. In the animal model, navigation success was 21/24 targets (87%). In the clinical case series, CBCT and augmented fluoroscopy enabled correct guidance of the bronchoscope to peripheral and central lung lesions for biopsy. 8/9 (88.9%) patients, had accurate on-target navigation confirmed via CBCT and/or by histopathological or microbiological results. Pulmonologists found that the lesion segmentation was helpful in 9 of 9 cases (100%), including in 3 cases with fluoroscopic invisible/obscured lesions. The 9th case that failed with EM tracking with conventional guidance and CBCT guidance was successfully biopsied (confirmed with CBCT) using an off-label endovascular steerable sheath and a standard bronchoscopy aspirating needle without bronchoscopic navigation. CONCLUSIONS: CBCT derived 3D road mapping navigation for bronchoscopic procedures using augmented fluoroscopy is feasible and may be used with or without optical bronchoscopic tools. The impact upon workflow, outcomes, and cost are undefined as are the potential roles for these tools in clinical care. CLINICAL IMPLICATIONS: Real time derived navigation tools, such as CBCT image guidance and augmented fluoroscopy, may complement bronchial navigation for small and difficult to access peripheral lung nodules. DISCLOSURES: PI on grant to UCI relationship with Philips Healthcare Please note: $20001 - $100000 Added 06/03/2018 by Nadine Abi-Jaoudeh, source=Web Response, value=money to UCI Pi on grant to UCI relationship with Teclison Cheery Pharma Please note: >$100000 Added 06/03/2018 by Nadine Abi-Jaoudeh, source=Web Response, value=grant to UCI PI on grant to UCI relationship with Sillajen Please note: $5001 - $20000 Added 06/03/2018 by Nadine Abi-Jaoudeh, source=Web Response, value=grant money to UCI no disclosure on file for Robert Browning; No relevant relationships by Quirina de Ruiter, source=Web Response no disclosure on file for Joseph Fontana; No relevant relationships by john karanian, source=Web Response CRADA between NIH and Philips relationship with Philips Healthcare Please note: >$100000 Added 06/11/2018 by William Pritchard, source=Web Response, value=Grant/Research Support No relevant relationships by Alessandro Radaelli, source=Web Response No relevant relationships by Stephanie Schampaert, source=Web Response Employee relationship with Philips Please note: >$100000 Added 06/04/2018 by Imramsjah van der Bom, source=Web Response, value=Salary no disclosure on file for Bradford Wood; no disclosure on file for Sheng Xu

Endobronchial Ultrasound in Suspected Non-Malignant Mediastinal Lymphadenopathy.

Endobronchial ultrasound (EBUS) bronchoscopy with transbronchial needle aspiration (TBNA) is a well-established tool in mediastinal staging in lung cancer and gains importance in exploration of non-malignant lymphadenopathy. The aim of this study was to evaluate the role of EBUS-TBNA in suspected non-malignant diseases. A retrospective, single-center, observation analysis of endobronchial ultrasound bronchoscopy procedures was performed in a university medical center between March 2013 and July 2015. All patients with suspected non-malignant mediastinal lymphadenopathy were included. Cytopathological and microbiological results of EBUS were compared to clinical diagnosis 6 months after procedure and performance of EBUS was contrasted to malignant indications. During study period, 333 EBUS bronchoscopies in 315 patients with mediastinal lymphadenopathy were performed. 111 out of 315 (35 %) patients had neither primary signs nor history of a malignant disease, categorised as patients with suspected non-malignant disease. 245 lymph nodes were sampled (median size 15 mm [IQR10 - 19]). Preferred station for TBNA was lymph node station 7 (38 %). Cytopathological findings revealed non-specific inflammation (n = 81; 70 %), carcinoma (n = 7; 6 %), epithelioid cell granulomas (n = 20; 17 %). 7 samples (6 %) were non-representative. Microbiologic testing of lymph nodes identified 3 infections (Mycobacteria tuberculosis [n = 2] and Nocardia nova [n = 1]) relevant to antibiotic therapy. Minor adverse events were observed in 9 out of 115 (8 %) patients. Sensitivity of EBUS-TBNA intervention in suspected non-malignant disease was 76 % and specificity 96 %. EBUS-TBNA revealed a specific cause for suspected non-malignant lymphadenopathy in one-third of cases and was associated with excellent specificity. Predominant specific causes were granuloma, besides from tumor. In 3 patients pathogen could be isolated by TBNA.

Procedural Sedation and the Risk of Hypoxemia

Background: Today’s hospital care shows an increase in therapeutic and diagnostic procedures performed outside the operating room under procedural sedation, rather than in the operating room. Yet, despite this shift in attitudes, there is evident paucity of studies examining the nature of the interventions performed under procedural sedation. The primary objective of this study was the identification of interventions performed under sedation outside the operating room, focusing on those associated with hypoxemia below SpO2 90%. Methods: From January the 1st 2011 up to December the 31st 2013, 2,328 diagnostic procedures in the outpatient setting of a general hospital were retrospectively analysed for hypoxemia with SpO2 below 90% and below 85% for at least one minute and SpO2 below 90% over 2 min. The assessed interventions were classified as endobronchial, in airway, and not in airway interventions. Absolute risk differences in desaturation among the three groups were calculated using the Wilson procedure. Results: Endobronchial procedures were statistically significant associated with a higher prevalence of hypoxemia compared to the other two interventions. The absolute risk difference with the in-airway group and not-inairway group was 20.2% (95%CI 13.0 to 27.9) and 21.3% (95% 14.0 to 29.2), respectively. The difference remained significant after correction for confounding by two established risk factors, BMI and ASA classification. Conclusion: Endobronchial procedures were associated with significantly more frequent and longer periods of hypoxemia. Thus, it can be concluded that, during procedural sedation, the type of invasive procedure is an important factor in estimating the a priori risk of hypoxemia.

Survival and Complications After Interventional Bronchoscopy in Malignant Central Airway Obstruction

Patients with malignant airway obstruction may need endobronchial intervention to relieve the associated symptoms. We report our experience of interventional bronchoscopy with regard to complications and survival. A total of 257 patients (167 men, 90 women, median age 67 y) were treated with 360 endobronchial procedures at our department in the period from 1998 to 2009. Kaplan-Meier and Cox regression methods were used for survival analysis. The log-rank test was used for comparison. Median survival after interventional bronchoscopy was 15 weeks. Eighteen patients died within 2 weeks after the procedure. Survival in the primary lung and metastatic cancer groups was 15 and 18 weeks, respectively (P=0.25). Survival in patients with small-cell lung carcinoma and nonsmall-cell lung carcinoma was 7 and 17 weeks, respectively (P=0.04). Serious complications such as bleeding (5), pneumothorax (1), and airway obstruction during the procedure (1) were rare (1.9%). All cases of serious hemorrhage occurred in patients with metastases from renal carcinoma. Life expectancy in patients with malignant airway obstruction is short. There was no difference in survival between patients with primary and metastatic lung disease. Bronchoscopic treatment is safe and serious complications are rare. Serious hemorrhage is frequent when treating lung metastases from renal carcinoma.

Effect of Segmental Bronchoalveolar Lavage on Quantitative Computed Tomography of the Lung

With employment of both multidetector computed tomography (MDCT) and endobronchial procedures in multicenter studies, effects of timing of endobronchial procedures on quantitative imaging (Q-MDCT) metrics is a question of increasing importance. Six subjects were studied via MDCT at baseline, immediately following and at 4 hours and 24 hours post-bronchoalveolar lavage (BAL) (right middle lobe and lingula). Through quantitative image analysis, non-air, or "tissue" volume (TV) in each lung and lobe was recorded. Change in TV from baseline was used to infer retention and redistribution of lavage fluid. Bronchoscopist reported unrecovered BAL volume correlated well with Q-MDCT for whole lung measures, but less well with individual lobes indicating redistribution. TV in all lobes except the right lower lobe differed significantly (P < .05) from baseline immediately post lavage. At 24 hours, all lobes except the left lower lobe (small 1% mean difference at 24 hours) returned to baseline. These findings suggest fluid movement affecting Q-MDCT metrics between lobes and between lungs before eventual resolution, and preclude protocols involving the lavage of one lung and imaging of the other to avoid interactions. We demonstrate that Q-MDCT is sensitive to lavage fluid retention and redistribution, and endobronchial procedures should not precede Q-MDCT imaging by less than 24 hours.

General anesthesia in a patient with known bronchial anthracofibrosis -A case report-

Bronchial anthracosis was recently defined in the English radiology literature as a luminal narrowing associated with anthracotic pigmentation on bronchoscopy without a relevant history of pneumoconiosis or smoking. Anthracosis refers to the presence of carbon particles in the lungs, not to a disorder per se. Anthracofibrotic lesions carry the potential risk of massive hemorrhage during endobronchial procedures. This report describes a case of general anesthesia for a left modified radical mastectomy due to an intraductal carcinoma in a patient with known bronchial anthracofibrosis.

Intravenous anaesthesia for thoracic procedures

Total intravenous anesthesia (TIVA) is indicated for procedures in which inhalational anesthetics may not be safely or effectively delivered, including endobronchial procedures using flexible or rigid bronchoscopy and proximal airway-disrupting surgeries. TIVA may also be beneficial in lung volume reduction surgery, lung transplantation, and thymectomy. TIVA is safer and more practical for thoracic procedures performed outside of the operating room, such as off-site locations, military field, or impoverished areas of the world. Target-controlled infusion (TCI) is a relatively new delivery system for TIVA that is based on pharmacokinetic models to optimize intravenous anesthetic delivery. TCI has many advantages over conventional calculator pumps but is not currently available in the United States. Because well-established MAC-type systems for intravenous anesthetics are not available, anesthetic depth monitors are useful in monitoring patients undergoing TIVA. Propofol, dexmedetomidine, ketamine, lidocaine, and remifentanil may be used in combination with anesthetic depth monitoring to execute an effective TIVA regimen. This chapter reviews the balanced TIVA technique currently used at the University of Texas MD Anderson Cancer Center.

Intravenous anesthesia for thoracic procedures

The article reviews the rationale for using intravenous anesthesia for thoracic operations, the drugs and equipment required, and the methodology involved. Recent studies examining whether total intravenous anesthesia offers a physiological advantage over inhalational anesthesia for thoracic surgery remain inconclusive. Nevertheless, total intravenous anesthesia is preferable for certain thoracic procedures incompatible with effective delivery of inhalational anesthetics. Additionally, total intravenous anesthesia offers advantages in procedures conducted in nonideal environments, such as offsite or austere scenarios. Total intravenous anesthesia is indicated for procedures in which inhalational anesthetics may not be safely or effectively delivered, including endobronchial procedures using flexible or rigid bronchoscopy and proximal airway-disrupting surgeries. Total intravenous anesthesia may be beneficial in lung volume reduction surgery, lung transplantation and thymectomy. Total intravenous anesthesia is safer and more practical for thoracic procedures performed outside of the operating room, such as offsite locations, military field or impoverished areas of the world. Propofol, dexmedetomidine, ketamine and remifentanil may be used in combination with anesthetic depth monitoring to execute an effective total intravenous anesthesia regimen. Target-controlled infusion may improve the delivery of total intravenous anesthesia and is a focus for future research. This article reviews the balanced total intravenous anesthesia technique currently used at the University of Texas M.D. Anderson Cancer Center.

Is Autofluorescence Bronchoscopy Needed to Diagnose Early Bronchogenic Carcinoma?

Is Autofluorescence Bronchoscopy Needed to Diagnose Early Bronchogenic Carcinoma?

Palliative management of malignant airway obstruction

Background Obstruction of the airway due to unresectable malignant disease is a frightening condition that portends a poor prognosis. Endobronchial treatment modalities were reviewed to determine the most effective management strategy. Methods A 12-year retrospective review (1988 to 1999) of 121 consecutive patients with inoperable malignant airway obstruction (MAO) was performed. Sixty-five patients received high-dose-rate brachytherapy (HDR) alone, 32 received HDR plus neodymium:yttrium-aluminum garnet laser (YAG) therapy, 16 received YAG only, 4 patients were stented, and 4 received photodynamic therapy (PDT). Follow-up was obtained by chart review and contact. Results Seventy-seven men and 44 women, median age 62 years (range 30 to 86 years), underwent 378 endobronchial procedures for relief of MAO. Good to excellent results were achieved in 77% (93/121) of patients. Seventy-two percent (23/32) of patients undergoing HDR plus YAG received a good to excellent result. All 8 patients receiving either stents or PDT had good to excellent palliation. There were no intraoperative deaths, but there were two in-hospital deaths. Complications occurred in 4% (5/121) of patients. Forty-four percent (53/121) of our patients were lost to follow-up. Mean survival was 6.7 months after the last treatment. Conclusions Temporary relief of inoperable MAO can be accomplished with a number of endobronchial treatments used either singularly or in combination. The majority of patients managed with HDR, YAG, or HDR plus YAG received good to excellent short-term palliation.

CRYOTHERAPY, ELECTROCAUTERY, AND BRACHYTHERAPY

Since it was first used 70 years ago, brachytherapy has become an effective tool in the treatment with tracheal bronchial malignancy including primary and recurrent bronchogenic carcinoma and metastatic carcinoma. The technique has evolved from interstitial implantation of radioactive sources directly to the tumor using rigid bronchoscopy to intraluminal placement of a radioactive source into a polyethylene afterloading catheter placed using FB. Intraluminal brachytherapy is effective in palliating complications caused by malignant endobronchial tumors such as dyspnea, hemoptysis, intractable cough, atelectasis, and postobstructive pneumonia. Brachytherapy may be combined with external beam radiation, Nd:YAG laser therapy, and chemotherapy to enhance the palliative treatments of patients. The risk of severe complications from brachytherapy may be caused more by location of tumor being treated rather than those fractionations scheme. When tumor involves the mainstem bronchi and upper lobes, it seems prudent to obtain CT to exclude tumor invasion of the pulmonary arteries or considerable destruction of the bronchial wall and mediastinal invasion of the tumor. Patients with findings such as these should not be treated with endobronchial brachytherapy or treated with LDR brachytherapy. Brachytherapy is proved to be effective and a safe palliative treatment for endobronchial malignancies, but further investigations are necessary to determine the optimal dose scheme and its efficiency in bronchogenic carcinoma and combined with external beam radiation therapy or surgery or other endobronchial procedures such as Nd:YAG laser or cryotherapy.