Tracheobronchial Stent Placement Research Articles

Analysis of the Application Effect of Tracheal Stent Placement in the Nutritional Support Treatment of Tracheoesophageal Fistula

Objective: To evaluate and analyze the application effect of tracheal stent placement in nutritional support therapy for tracheoesophageal fistula. Methods: Clinical data of 32 patients who underwent nutritional support therapy for tracheoesophageal fistula in our hospital from September 2021 to September 2022 were collected, and all patients underwent tracheal silicone stenting, comparing dyspnea classification and Karnofsky score before and after stenting, and conducting post-treatment follow-up. Results: In 32 patients with tracheoesophageal fistula, dyspnea grading improved from grades III and IV to grades 0 to II. Before treatment, 10 patients (31.06%) were in grade IV, 17 patients (53.12%) were in grade III, and five patients (15.62) were in grade II; after treatment, 13 patients (40.63%) were in grade I, 12 patients (37.50%) were in grade I, and seven patients (21.87%) were in grade 0 (P < 0.05); Karnofsky score (37.52 ± 4.86 before treatment) improved significantly to 71.39 ± 8.24 one week after treatment (P < 0.05). Nine patients with tracheoesophageal fistula were placed with silicone Y14-10-10 stent, 11 with silicone 18-14-14 stent, three with silicone Y15-12-12, and seven with silicone stent 16-13-13. Conclusion: Silicone tracheobronchial stent placement for the treatment of tracheoesophageal fistula is technically feasible, simple, and safe, with reliable near-term efficacy, and is worthy of popularization and application.

A combination of tracheoplasty and tracheal stenting is an acceptable method of treating severe congenital tracheobronchial stenosis under extracorporeal membrane oxygenation

BackgroundCongenital tracheobronchial stenosis (CTBS) is a rare congenital condition characterized by complete cartilage rings covering varying lengths of the major airway. In this study, we reviewed the outcomes of patients with CTBS receiving surgical tracheoplasty in our institute. MethodsWe retrospectively analyzed the outcomes of consecutive patients with CTBS operated between 2006 and 2017 when extracorporeal membrane oxygenation (ECMO) was used perioperatively. ResultsIn total, 11 patients (median follow-up period, 4.2 years; interquartile range, 1.6–5.4) were included. Seven were symptomatic in the neonatal period, 10 had cardiorespiratory anomalies, 7 required preoperative bronchoscopic balloon dilatation, and 1 required preoperative stent placement. Slide tracheoplasty (STP) was performed in 9 patients, and 2 underwent pericardial patch tracheoplasty. Seven patients required postoperative balloon dilatation, and 6 required postoperative stent placement. Early stenting provided immediate ventilatory improvement in all patients and facilitated successful extubation in a median of 4 days after stenting in 80% of the patients. ConclusionsUnder ECMO, severe CTBS could be successfully treated through a combination of tracheoplasty and bronchoscopic management. STP provided excellent results for solitary trachea stenosis with a minimum diameter of ≥3 mm. In selected patients, postoperative tracheobronchial stent placement was crucial in minimizing the ECMO duration and facilitating extubation. Level of EvidenceIV

Biphasic Cuirass Ventilation During Anesthesia for Tracheobronchial Stent Insertion or Removal by a Rigid Bronchoscope: A Case Report.

Airway management and ventilation during a tracheobronchial stenting procedure are challenging given that mandatory positive pressure ventilation cannot be fully achieved while using a rigid bronchoscope due to leakage from the scope tip. Biphasic cuirass ventilation is a negative pressure ventilation method using an external cuirass fitted to the anterior chest, which could assist in spontaneous breathing and ventilation support. We report 3 successful anesthesia cases in which we could maintain adequate ventilation and oxygenation, supported by biphasic cuirass ventilation, in patients undergoing tracheobronchial stent placement or removal procedures using rigid bronchoscopy.

Novel strategy of stents in thyroid mass: a case series report of managing severely dyspneic patients

BackgroundTracheal and bronchial stenosis is a life-threatening condition causing difficulty in breathing and even severe respiratory distress. The silicone tracheobronchial stents were placed using the rigid bronchoscopy into the trachea of severe dyspneic patients and they exhibited symptomatic improvement as well as a rise in the saturation of oxygen. The bronchial stents were applicable to many extensive malignant airway stenosis patients, such as those with esophageal cancer, lung cancer, and laryngeal cancer. But the effectiveness of bronchial stents for thyroid cancer is not certain.Case presentationHere, we report 3 emergency patients with a thyroid mass referred to our hospital because of grade 4 dyspnea according to the American Thoracic Society shortness of breath guidelines. The main clinical symptoms were severe dyspnea and stridor. The radiographic examination and tomographic examination showed the narrowing and displacement of the trachea. To the best of our knowledge, ideal airway management for the massive thyroid mass was considered to be temporary tracheobronchial stent placement pre-operation.ConclusionIn our study, we applied the tracheobronchial stent to massive thyroid mass patients with dyspnea and aimed to not only improve preoperative airway obstruction but also to protect the potential airway collapse from post-operative tracheomalacia following extubation. We found that application of tracheobronchial stents may provide a new strategy to dyspneic patients with huge thyroid mass.

Numerical analysis of airflow alteration in central airways following tracheobronchial stent placement

The computational fluid dynamics method, which provides an estimation of the pressure drop in the airway before and after the stent implantation, is proposed in this study. This method is based on the finite volume model. The pressure field was solved by the Navier-Stokes equations. The proposed methodology was evaluated in seven health people (control group) and in fourteen patients who were assigned in two groups, in which one was tracheal stenosis and the other was bronchial stenosis. The results showed that the pressure drop after tracheal stent implantation became significantly smaller. For bronchial stent implantation cases, the airway resistance improved insignificantly.

Abstract No. 256: Outcomes of tracheobronchial temporary partial covered stent placement for benign disease

Abstract No. 256: Outcomes of tracheobronchial temporary partial covered stent placement for benign disease

One-lung ventilation in a patient with stenting for tracheobronchial stenosis caused by esophageal cancer

We have provided general anesthesia for a 53-year-old man scheduled to undergo lymph node removal for right mediastinal lymph node metastases caused by esophageal cancer. One year prior, acute respiratory failure occurred because of stenosis of the carinal bifurcation resulting from advanced esophageal cancer with tracheal invasion. The patient underwent placement of tracheobronchial stents (Spiral Z Stent) in two locations (left main bronchus and trachea/right main bronchus), followed by radiotherapy and chemotherapy. In the present case, after an 8.5-mm-ID tracheal tube was placed under bronchoscopic guidance, a 7.0 Fr. bronchial blocker (Arndt Endobronchial Blocker; Cook, Bloomington, IN, USA) was carefully inserted into the stent in the right main bronchus. Next, 3ml air was injected into the blocker cuff, and left-sided one-lung ventilation was performed. After surgery was completed, the bronchial blocker was removed under bronchoscopic guidance. We confirmed there was no tracheobronchial injury nor stent displacement or deformation, then removed the tracheal tube. Even in patients with tracheobronchial stent placement, one-lung ventilation can be safely and reliably performed by selecting an appropriate bronchial blocker, along with careful insertion into the stent and frequent checking of the blocker position.

Removal of metallic tracheobronchial stents in lung transplantation with flexible bronchoscopy

BackgroundAirway complications are among the most challenging problems after lung transplantation, and Self-Expandable Metallic Stents (SEMS) are used to treat airway complications such as stenosis or malacia at the bronchial anastomosis sites. Several transplantation centers are reluctant to use SEMS since their removal is sometimes needed and usually requires the use of rigid bronchoscopy under general anesthesia. The objective of the current report is to describe our experience in SEMS retrieval by flexible bronchoscopy under conscious sedation.MethodsA retrospective review was done of patients requiring tracheobronchial stent placement after lung transplantation in which the SEMS had to be removed. The retrieval procedure was done by flexible bronchoscopy on a day-care ambulatory basis.ResultsBetween January 2004 and January 2010, out of 305 lung transplantation patients, 24 (7.8%) underwent SEMS placement. Indications included bronchial stenosis in 20 and bronchomalacia in 4. In six patients (25%) the SEMS had to be removed due to excessive granulation tissue formation and stent obstruction. The average time from SEMS placement to retrieval was 30 months (range 16-48 months). The stent was completely removed in five patients and partially removed in one patient; no major complications were encountered, and all patients were discharged within 3 hours of the procedure. In all procedures, new SEMS was successfully re-inserted thereafter.ConclusionsThe retrieval of SEMS in patients that underwent lung transplantation can be effectively and safely done under conscious sedation using flexible bronchoscopy on a day-care basis, this observation should encourage increasing usage of SEMS in highly selected patients.

Clinical Experience With a New Removable Tracheobronchial Stent in the Management of Airway Complications After Lung Transplantation

Airway complications are among the most challenging problems after lung transplantation. This article describes the use of a new tracheobronchial stent that can be placed and removed easily by flexible bronchoscopy. A retrospective review was done of 24 consecutive patients requiring tracheobronchial stent placement after lung transplantation. A new self-expanding hybrid nitinol stent was used, and changes in airway diameter and spirometry were assessed. Stent related complications were recorded. Between February 2007 and April 2008, 24 patients underwent stent placement, and 49 stents were placed for 36 anastomoses at risk. Indications included bronchial stenosis in 12, bronchomalacia in 12, bronchial stenosis plus bronchomalacia in 20, and partial bronchial dehiscence in 5. Adjunctive procedures included electrocautery in 1, balloon dilatation in 7, and electrocautery plus balloon dilatation in 4. The average degree of stenosis decreased from 80% to 20%. After stent placement, the average increase was 0.28 liters in forced vital capacity and 0.44 liters in forced expiratory volume in 1 second. Complications included granulation tissue formation in 10 stents, migration in 9, thick mucus formation in 2, and fracture in 3. Airway complications in lung transplant patients were effectively palliated. Our complication rate with this new stent is comparable with other airway stents. This stent has the advantage of easy removability during flexible bronchoscopy if complications from the stent outweigh the benefits of palliation.

Endobronchial Stent Placement for the Management of Airway Complications after Lung Transplantation

To retrospectively evaluate the efficacy and complications of endobronchial stent placement for the management of airway complications following lung transplant. From 1992 to 2003, tracheobronchial stenting was performed on 25 lung transplant recipients (16 male and 9 female; mean age 51.6 years; range 21-65 years). A total of 27 lesions were treated and 27 stents were deployed (nine bronchomalacia, 12 bronchial stenosis, three bronchial stenosis and bronchomalacia both and three anastomotic dehiscence). The clinical and bronchoscopic follow-up ranged from 1 month to 69 months. The technical success was 100%. Eighty-four percent of patients had immediate relief in dyspnea. The overall complication rate following stent placement was 0.049 per patient per month (23 complications/471 patient months). Stent migration and granulation tissue formation were the most frequent complications. The mean percentage change in FEV-1 was significantly greater than zero at 1 month and 6 months (P<.05) post-stent placement. The mean percentage change in FEV-1 was marginally greater than zero at 12 months (P=.07).The mean percentage change in FVC was marginally greater than zero at 1 month and 6 months (P=.08) post-stent. It was not significantly greater than zero at 12 months (P=1.00). Tracheobronchial stent placement provides effective palliation of postoperative airway complications in lung transplant with morbidity that can be managed effectively by available treatment options. Airway stenting may be used as a primary management option for airway complications after lung transplantation as a large number of patients are not suitable candidates for repeat surgery.

Cystic Intracranial Plasma Cell Granuloma

Relapsing polychondritis (RP) is a rare systemic disease characterized by recurrent inflammation of the cartilaginous structures and connective tissue. Central nervous system lesions in association with RP have occasionally been reported, but intracranial mass lesions have not been described. The authors report the first such case, in which a 51-year-old man presented with parasagittal meningeal plasma cell granuloma with RP. The mass was subtotally resected and adjuvant radiotherapy was administered. The patient did not experience any recurrence of the lesion during an 8-year follow-up period. In this case, the exact diagnosis of RP was made based on symptoms of respiratory tract chondritis, which was successfully treated by the placement of tracheobronchial stents.

Outcomes of Tracheobronchial Stent Placement for Benign Disease

To retrospectively determine long-term outcomes in patients who have undergone tracheobronchial stent placement for benign diseases. Institutional Review Board approval was obtained for this retrospective HIPAA-compliant study, with waiver of informed consent. Forty patients (22 female, 18 male; mean age, 52.0 years) who were treated with metallic airway stents for benign stenosis were identified from an interventional radiology database. Causes of airway stenosis included transplant stricture (n = 13), tracheal tube injury (n = 10), inflammation (n = 6), tracheobronchomalacia (n = 4), infection (n = 3), and extrinsic compression (n = 4). Follow-up, which ranged from 6 to 2473 days, was performed by means of chart review for deceased patients and by means of clinical visit or telephone interview for surviving patients. Survival, primary patency, and assisted patency were estimated by using the Kaplan-Meier product limits method. Initial technical success was achieved in all cases. Symptomatic improvement was present in 39 of 40 cases. At review, 15 patients were alive and had clinical improvement, 18 had died of comorbid causes, one had died of uncertain causes, three had undergone subsequent airway surgery, two had undergone airway stent retrieval, and one was lost to follow-up. Survival at 1, 2, 3, 4, 5, and 6 years was 79%, 76%, 51%, 47%, 38%, and 23%, respectively. Loss of primary patency was most rapid during the 1st year. With repeat intervention, assisted patency was 90% at 6.8 years. Attrition of tracheobronchial stent patency is most rapid during the 1st year, and a high rate of long-term patency can be achieved with secondary interventions. Metallic airway stents are well-tolerated and useful adjuncts for management of select benign tracheobronchial stenoses.

Perioperative management for placement of tracheobronchial stents

Tracheobronchial stenting was performed under general anesthesia, with (six patients) or without (two patients) muscle relaxant, in eight patients suffering from carcinoma. All patients had presented preoperatively with dyspnea, exhibiting Hugh-Jones grade 4 or 5. Three patients had been mechanically ventilated before the procedure. The procedure was performed under general anesthesia with flexible bronchoscopic guidance. Stent placement was performed either through an orotracheal tube (four patients) or through a transtracheal tube (two patients) in those who had no upper tracheal stenosis, while it was performed through a laryngeal mask airway in two patients with upper tracheal stenosis. During the procedure, arterial hemoglobin oxygen saturation (Sp(O(2)) decreased in all patients, despite fraction of inspired oxygen (FI(O(2)) being maintained at 1.0. Except for two patients, one of whom developed superior vena cava syndrome and one, tension pneumothorax after stent placement, there were no complications resulting from stent placement. Six patients were weaned from mechanical ventilation (0-24 days after the procedure). Two of the three patients who had been on mechanical ventilation preoperatively could not be weaned. Stent insertion is an effective treatment for tracheobronchial stenosis, but its indications in patients with malignancy who have been mechanically ventilated prior to stenting should further be evaluated.

Meningeal plasma cell granuloma with relapsing polychondritis

Relapsing polychondritis (RP) is a rare systemic disease characterized by recurrent inflammation of the cartilaginous structures and connective tissue. Central nervous system lesions in association with RP have occasionally been reported, but intracranial mass lesions have not been described. The authors report the first such case, in which a 51-year-old man presented with parasagittal meningeal plasma cell granuloma with RP. The mass was subtotally resected and adjuvant radiotherapy was administered. The patient did not experience any recurrence of the lesion during an 8-year follow-up period. In this case, the exact diagnosis of RP was made based on symptoms of respiratory tract chondritis, which was successfully treated by the placement of tracheobronchial stents.

Stent placement for tracheobronchial disease

Early treatment for airway stenoses or occlusions involved open repair with the attendant risks of thoracotomy or sternotomy. With the advent of rigid and, more recently, flexible bronchoscopy, the placement of airway stents has come to the forefront in the treatment of benign and malignant tracheobronchial disease. This paper describes the history of surgical and endoluminal treatment of airway disease and discusses the indications and contraindications for airway stent placement. The advantages and limitations of such therapy are reviewed as well as the procedural details and the imaging evaluation and follow-up of patients undergoing endoluminal treatment. Although the placement of tracheobronchial stents is now primarily performed by interventional pulmonologists, imaging anatomically complex airway disease also requires the skills of an accomplished cross-sectional radiologist. Additionally, interventional radiologists using fluoroscopic guidance and alternative access routes to the airways can salvage failed bronchoscopic procedures and primarily treat selected cases. Due to the importance of pre- and post-procedural imaging in these patients, radiologists should be aware of airway anatomy suitable for stent placement and the appearance of various complications of this procedure.

Management of tracheobronchial strictures.

Recently, the use of tracheobronchial stents has increased greatly sue to the advantages of easy placement and prompt airway relief. in addition, trachebronchial stents provide an alternative to open surgical procedures in select patients with benign tracheobronchial stenosis or obstruction, in particular those with tracheobronchial tuberculosis. This paper review the indications for tracheobronchial stent placement, appropriate stent selection, pre-procedure evaluation, and the results of stent placement for benign and malignant tracheobronchial strictures.

Clinical Outcomes with Airway Stents for Proximal versus Distal Malignant Tracheobronchial Obstructions

This study evaluates the outcome of tracheobronchial stent placement in symptomatic patients with malignant disease. From 1993 to 2002, 30 patients had stents placed for malignant strictures. Five of 30 patients underwent stent placement distal to the mainstem bronchi, 13 received stents in both the proximal and distal airways, and 12 received stents in only the proximal airways. Clinical response and survival were determined from the patients' medical records. A positive clinical response was judged to have occurred if the patient improved in two of these three categories: subjective symptoms (patient-reported), objective signs (clinician-reported), and postprocedural imaging. The condition of 29 of 30 patients improved within 4 weeks of stent placement. The mean survival duration after stent placement was 261 days (SD, 395.1 days). The location of stent placement was not associated with significant differences in clinical improvement or survival (P =.51). Eight patients had additional airway segments that were too diffusely involved in which to place a stent or could not be recanalized. Mean survival in this group with incomplete stent placement was significantly reduced at 24.9 days (SD, 23.1 days), compared with 345.5 days (SD, 436 days) for the remaining patients who underwent complete stent placement (P <.05). Four patients lived less than 10 days after the procedure and three patients (75%) had mediastinal invasion. Tracheobronchial stent placement effectively palliates malignant airway obstruction, and clinical improvement is independent of the location in which the stent is implanted. When patients had diffuse or highly obstructive airway involvement and underwent incomplete stent placement, clinical response was also satisfactory, even though survival was worse. Patients with mediastinal invasion were poor candidates for stent placement as a result of their short survival.

Malignant Tracheobronchial Strictures: Palliation with Covered Retrievable Expandable Nitinol Stent

To evaluate the safety and clinical effectiveness of a covered retrievable expandable nitinol stent for the treatment of malignant tracheobronchial stricture and/or esophagorespiratory fistula (ERF). With fluoroscopic guidance, stents were placed in 35 symptomatic patients with malignant tracheobronchial stricture and/or ERF in most cases caused by lung or esophageal cancer. The site of stricture was most commonly at the trachea or left main bronchus. If there were complications, the stent was removed with a retrieval set. Nine patients had combined symptomatic ERF. A total of 47 tracheobronchial stents were placed and were technically successful and well-tolerated in all patients. Improvement of dyspnea was achieved in 92% of the patients (24 of 26 patients). Associated ERF in nine patients was effectively treated with tracheobronchial stent placement with or without esophageal stent placement. Stent migration, tumor overgrowth, symptomatic sputum retention, and hemoptysis occurred in 17% (6/35), 6% (2/35), 20% (7/35), and 17% (6/35) of patients, respectively. There were no documented cases of tumor ingrowth. Stent removal was performed easily in five patients when stent migration (n = 2), severe pain (n = 1), tumor overgrowth (n = 1), or persistent gastrobronchial fistula (n = 1) developed. All patients died 2 days to 26 weeks (mean, 9.62 weeks) after stent placement because of disease progression (n = 18), pneumonia (n = 9), hemoptysis (n = 5), or unknown cause (n = 3). Use of a covered retrievable expandable nitinol stent is a safe and effective method for relieving dyspnea. This procedure contributed to improved quality of life for patients with malignant tracheobronchial stricture and/or ERF. Stent retrievability was useful in resolving stent-related complications.

Benign Tracheobronchial Stenoses: Changes in Short-Term and Long-Term Pulmonary Function Testing After Expandable Metallic Stent Placement

To determine the short- and long-term improvement in airflow dynamics in patients undergoing tracheobronchial stent placement for benign airway stenoses. Twenty-two patients underwent 34 tracheal and/or bronchial stent placement procedures for benign airway stenoses and had the results of pulmonary function tests available. Stent placement indications included bronchomalacia after lung transplantation (n = 11), postintubation stenoses (n = 6), relapsing polychondritis (n = 2), and 1 each of tracheomalacia, tracheal compression, and histoplasmosis. Six patients underwent more than one stent placement procedure (range: 2-7 procedures). The mean forced expiratory volume in one second (FEV(1) ), forced expiratory flow rate in the midportion of the forced vital capacity curve (FEF(25-75) ), forced vital capacity, and peak flow (PF) rate obtained before stent placement were compared with those immediately after stent placement and with those measurements most remote from stent placement using the paired two-tailed test. All patients reported improved respiratory function immediately after stent placement. The mean FEV(1), FEF(25-75), and PF rate improved significantly (p < 0.001, p = 0.002, and p = 0.009, respectively) after stent placement. On long-term follow-up averaging 15 months after stent placement, these parameters declined despite patients' subjective sense of improvement. Segregating the population into transplant and nontransplant airway stenosis etiologies, however, FEF(25-75) and PF rate remained significantly improved (p = 0.045, p = 0.027, respectively), over the long term for the latter. FEV increased after subsequent stent placements for patients receiving multiple stents. Stent placement for benign tracheobronchial stenoses provides significant immediate improvement in airflow dynamics. Long-term improvement in airflow obstruction may be expected, and additional stent placements may further improve pulmonary function.

Interventional Bronchoscopy

Interventional Bronchoscopy Edited by C.T. Bolliger and P.N. Mathur. Switzerland: Karger, 2000, 257 pp., $172.25. The field of interventional bronchoscopy is rapidly progressing. With this new growth, pulmonologists, especially interventional bronchoscopists, must keep abreast of the rapid developments in technology and the various techniques of therapeutic modalities. Because most of the indications, contraindications, and techniques of endobronchoscopic modalities are still evolving, together with a new generation of pulmonologists trying to gain experience in this field, this book by Bolliger and Mathur could not have come at a better time. It is an excellent, concise monograph encompassing the field of interventional bronchoscopy from the days of development of the bronchoscope to its modern use in various endobronchial diseases.emtpy The book is organized into five sections. The first section begins with the general aspects of bronchoscopy starting from its inception, from the days of Killian to the present day of modern bronchoscopy. With the forgotten art of rigid bronchoscopy, Dr. John Beamis has written an outstanding review on the modern use of the rigid bronchoscope. The various techniques of performing rigid bronchoscopy are supplemented with stepwise illustrations of the actual technique. The next chapter deals with the expertise, personnel, and equipment required as well as the maintenance of this equipment, making this chapter a must-read for the technical support staff of a bronchoscopy suite. The last two chapters in this section deal with the functional evaluation of the patient before and after endoscopy. This includes administration of anesthesia and preoperative evaluation for interventional bronchoscopy. How these investigations impact interventional strategies, technical success rates, and outcome is discussed at length.emtpy The second section deals with diagnostic bronchoscopy, including techniques of transbronchial needle aspiration and endobronchial ultrasound. The technique of transbronchial needle aspiration is very well explained by leading authorities in this field. Color figures and line diagrams add a great deal to this chapter. The authors think that the reader would acquire a better understanding, greater confidence, and improved yield with this important diagnostic tool. The evolving role of endobronchial ultrasound in airway and mediastinal diseases is depicted beautifully in the figures, which are very well described in the legends. The description clearly illustrates the addition of a new technique in pulmonologists' armamentarium and its research potential.emtpy The third section consists of thorough discussions of various therapeutic endobronchoscopic techniques, including foreign body removal, laser therapy, electrocautery, argon plasma coagulator, cryotherapy , brachytherapy, photodynamic therapy, and placement of tracheobronchial stents. All these techniques are very well described by well-known authorities on these techniques. The precise description of techniques is complemented with color photographs and references. The concluding chapter, which is certainly a highlight of this section, deals with the multimodality treatment of lung cancer, and it gives a concise and excellent review of managing terminal cancer by combining the traditional methods, like radiotherapy and chemotherapy, with the new endobronchial therapeutic modalities. The chapter adequately illustrates the role of endoscopic procedures in the management of advanced lung cancer. Although the authors briefly describe the role of flexible bronchoscopy in endoscopic procedures, better-detailed descriptions of actual techniques and safeguards would have been more appropriate because most of the centers still lack the expertise of using the rigid bronchoscope.emtpy The fourth section deals with the new techniques coming into the realm of pulmonologists and intensivists. The chapter on percutaneous dilatational tracheostomy and long-term transtracheal oxygen therapy are precise, easy to read, and supported by properly placed figures and tables that are helpful to the beginner. The reader will also be happy to see the chapter on image-guided interventional procedures in the thorax, which also adequately compares the yield of these procedures to those of traditional procedures.emtpy The last section deals with the potential future uses of bronchoscopy and includes autofluorescence bronchoscopy, virtual bronchoscopy, and the use of optical, diagnostic, and therapeutic technologies in pulmonary medicine and gene therapy in lung cancer. The illustration of virtual bronchoscopic images provides the reader with a practical approach, which in the future may take the place of conventional bronchoscopy as the standard of evaluating bronchial lesions.emtpy Apart from the lack of an adequate description of the use of flexible bronchoscopes in endobronchial therapeutic techniques, this book really provides a comprehensive and up-to-date overview of endobronchial therapeutic modalities and is highly recommended for those individuals who are currently performing the interventional procedures or who are planning to learn them in the future. This book is also recommended for pulmonologists who are not in the field of interventional bronchoscopy, but who want to learn about the various ways in which they can help their patients. Sandeep Mehrishi, M.D. Interventional Pulmonary Unit,Nassau University Medical Center,East Meadow, New York, U.S.A. Suhail Raoof, M.D. Pulmonary and Critical Care Medicine,Nassau University Medical Center,East Meadow, New York, U.S.A.