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provided by Elsevier - Publisher Connector Session IV: Training/Education/Technology Lagisetty and Gangadharan

Tracheobronchoplasty for the treatment of

Kiran H. Lagisetty, MD, and Sidhu P. Gangadharan, MD

Patients with tracheobronchomalacia (TBM) typically pres- Before consideration for surgical repair, patients should ent with dyspnea, recurrent infections, intractable cough, or undergo a thorough screening of symptoms and functional retained secretions. Airway stabilization may be accom- status. This evaluation typically involves pulmonary func- plished with silicone stenting, which provides patients tion tests, 6-minute walk test (6MWT), and determination with symptom relief in a minimally invasive manner. How- of Karnofsky performance status, American Thoracic Soci- ever, this technique is not without complications, which ety (ATS) dyspnea score, and respiratory-affected quality of mostly occur by 3 weeks. Surgical stabilization is the defin- life based on the St George Respiratory Questionnaire itive treatment of TBM.1 We review the evaluation of TBM (SGRQ). Significant derangement of the patient’s func- and options for treatment. tional status and quality of life is necessary before consider- ing potential intervention. CLINICAL EVALUATION To be considered for interventions to stabilize the airway, TREATMENT OPTIONS patients must have documented severe TBM. Severe and Endoscopic stabilization of the central airways is accom- diffuse TBM is manifest by complete or near-complete col- plished by placement of a Y-shaped silicone stent. Tubular lapse of the and bilateral bronchi. This is best diag- silicone stents have been found to have high rates of migra- nosed via functional and dynamic computed tion. The Y-stent is placed via rigid bronchoscopy under gen- tomography scanning. Functional bronchoscopy is per- eral anesthesia. Patients are then evaluated 2 weeks after this formed under light sedation to allow for the patient to follow procedure for improvement of symptoms. In our initial series commands. The airway should be evaluated initially in the of 58 patients treated with silicone stents, we demonstrated proximal trachea, and the patient is coached to perform that stenting improved the SGRQ score, Karnofsky perfor- forced inspiratory and expiratory maneuvers. These maneu- mance status, ATS dyspnea score, and baseline dyspnea in- vers are then repeated in the distal trachea and the proximal dex/transitional dyspnea index.3 These patients had an bilateral mainstem bronchi. Bronchoscopic estimates of the average age of 69 years, and nearly all (n ¼ 57) patients pre- degrees of collapsibility are recorded at each station. sented with dyspnea as the sole symptom or along with In addition to bronchoscopy, dynamic computed tomogra- cough and recurrent infection. Complications from stent phy should be performed according to a central airway proto- placement typically occurred with longer dwell time, and in- col, which includes end-inspiratory and dynamic expiratory ¼ 2 cluded stent obstruction from mucus plugging (n 21), in- imaging. Scout images are initially taken to determine the fection (n ¼ 14), stent migration (n ¼ 10), severe cough area of coverage, including the trachea and central bronchi. (n ¼ 3), subglottic edema (n ¼ 3), and stent breakage (n ¼ 1). The helical scanning is performed in a craniocaudal direction In another series of 94 patients with TBM and chronic ob- during both end-expiratory and dynamic-expiratory phases. structive pulmonary disease, 49% were able to achieve The percentage of luminal collapse is determined by subtract- symptomatic relief after stent placement.4 When these pa- ing the estimated dynamic expiratory cross-sectional area tients were stratified by Global Initiative for Chronic Ob- from the end-inspiratory cross-sectional area, divided by structive Disease stage, all patients except for those the end-inspiratory cross-sectional area. Although the defini- in stage 1 demonstrated an increase in forced expiratory tion of malacia is greater than 50% cross-sectional luminal volume in 1 second (FEV1). This study also determined collapse, symptomatic TBM, which will require treatment, that operative intervention had the greatest advantage in % % is typically 95 to 100 . the group of patients undergoing surgical intervention.

From the Division of Thoracic and Interventional Pulmonology, Beth Israel Because of the complications associated with chronic Deaconess Medical Center, Harvard Medical School, Boston, Mass. stent placement, definitive treatment with surgical stabiliza- Disclosures: Authors have nothing to disclose with regard to commercial support. tion is considered for those patients with marked improve- Presented at the 3rd International Minimally Invasive Thoracic Surgery Summit, Bos- ton, Massachusetts, October 7-8, 2011. ment after a stent trial. If patients report minimal Received for publication Nov 17, 2011; revisions received May 10, 2012; accepted improvement of dyspnea with a stent, it is less likely that for publication May 15, 2012; available ahead of print June 7, 2012. surgery will yield a positive outcome. Surgical intervention Address for reprints: Sidhu P. Gangadharan, MD, Chest Disease Center, Thoracic Surgery Beth Israel Deaconess Medical Center, 185 Pilgrim Rd, W/DC 201, involves the stabilization of the posterior membranous wall Boston, MA 02215 (E-mail: [email protected]). of the intrathoracic trachea up to the thoracic inlet and both J Thorac Cardiovasc Surg 2012;144:S58-9 mainstem bronchi and intermedius. In contradis- 0022-5223/$36.00 Copyright Ó 2012 by The American Association for Thoracic Surgery tinction to stent stabilization, the repair is completely extra- doi:10.1016/j.jtcvs.2012.05.025 luminal. The stabilization is achieved by suturing

S58 The Journal of Thoracic and Cardiovascular Surgery c September 2012 Lagisetty and Gangadharan Session IV: Training/Education/Technology

a polypropylene mesh to the membranous walls of the air- orally administered stanozolol are potentially interesting al- way for it to act as a splint. ternative therapies.6,7 These interventions will need further Multiple rows of sutures typically are used to anchor the study to define their applicability. mesh to the airway, and case durations average approxi- mately 6 hours. Patients generally spend the first 48 to 72 CONCLUSIONS hours in the intensive care unit, and the average length of Appropriate treatment of severe, diffuse TBM involves stay is 8 days. Despite the arduous nature of the operation a coordinated effort among pulmonologists, radiologists, and recuperation, approximately 75% of these patients and surgeons. Anatomic definition of TBM with dynamic can be discharged, without the need for a stay at a rehabili- computed tomography and functional bronchoscopy, as tation facility.1 well as evaluation of the severity of its impact via subjective Complications were observed in 38% of patients in our assessment tools and 6MWT, helps identify patients who series, the most common being the development of new may benefit from treatment. Silicone stents are used as a trial postoperative respiratory infection, which occurred in to see whether more definitive surgical stabilization will 22%.1 Other complications include prolonged mechanical yield benefit. Tracheobronchoplasty is an effective and ventilation or reintubation, tracheostomy tube placement, safe intervention for TBM. Further study should be directed atrial fibrillation, and hemothorax. The mortality rate is to prospective analysis of the benefit of treatment and 3%, despite the multiple comorbidities and pulmonary in- the development of more reliable assays of objective sufficiency that many of these patients have. outcomes. When the functional outcomes of these patients were evaluated, statistically significant improvements were seen References in Karnofsky performance status (62 12 vs 76 14, 1. Gangadharan SP, Bakhos CT, Majid A, Kent MS, Michaud G, Ernst A, et al. P<.001), ATS dyspnea score (3.06 0.6 vs 1.65 1.01, Technical aspects and outcomes of tracheobronchoplasty for severe tracheobron- < < chomalacia. Ann Thorac Surg. 2011;91:1574-81. P .001), SGRQ (74 13 vs 46 21, P .001), and 2. Lee EY, Litmanovich D, Boiselle PM. Multidetector CT evaluation of tracheo- 6MWT (987 502 vs 1187 347 feet, P<.005). We did bronchomalacia. Radiol Clin North Am. 2009;47:261-9. 3. Ernst A, Majid A, Feller-Kopman D, Guerrero J, Boiselle P, Loring SH, et al. Air- not detect an improvement in FEV1, although in a series way stabilization with silicone stents for treating adult tracheobronchomalacia: of 14 patients who underwent tracheobronchoplasty, Wright a prospective observational study. Chest. 2007;132:609-16. 5 and colleagues demonstrated a statistically significant in- 4. Ernst A, Odell DD, Michaud G, Majid A, Herth FF, Gangadharan SP. Central air- way stabilization for tracheobronchomalacia improves quality of life in patients crease in FEV1 from 51.2% to 73.5% (P ¼ .0009). Forced % % ¼ with chronic obstructive pulmonary disease. Chest. 2011;140:1162-8. vital capacity increased from 68 to 79.8 (P .01), and 5. Wright CD, Grillo HC, Hammoud ZT, Wain JC, Gaissert HA, Zaydfudim V, et al. predicted peak expiratory flow rate increased from 49% to Tracheoplasty for expiratory collapse of central airways. Ann Thorac Surg. 2005; 70% (P <.0001). Long-term quality of life assessment in 80:259-66. 6. Dutau H, Maldonado F, Breen DP, Colchen A. Endoscopic successful manage- that study revealed that 7 patients reported greater than ment of tracheobronchomalacia with laser: apropos of a Mounier-Kuhn syndrome. 75% subjective improvement in symptoms. Eur J Cardiothorac Surg. 2011;39:e186-8. Stabilization of the central airways using endoscopy with 7. Adamama-Moraitou KK, Pardali D, Athanasiou LV, Prassinos NN, Kritsepi M, Rallis TS. Conservative management of canine tracheal collapse with stanozolol: yttrium aluminum perovskite laser treatment and animal a double blinded, placebo control clinical trial. Int J Immunopathol Pharmacol. models demonstrating cure of tracheal collapse with 2011;24:111-8.

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