Ann Thorac Surg 1998;66:2100-2102
© 1998 The Society of Thoracic Surgeons
Case Reports
Daily and long-term balloon dilation via minitracheostomy in cicatric bronchial stenosis
Hiroaki Nomori, MDa,
Hirotoshi Horio, MDa,
Keiichi Suemasu, MDa
a Department of Thoracic Surgery, Saiseikai Central Hospital, Tokyo, Japan
Accepted for publication May 27, 1998.
Address reprint requests to Dr Nomori, Department of Thoracic Surgery, Saiseikai Central Hospital, 1-4-17 Mita, Minato-ku, Tokyo 108, Japan
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Abstract
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We developed balloon dilation for bronchial stenosis via minitracheostomy. The balloon catheter was introduced via minitracheostomy into the stenotic bronchus. The balloon was inflated 4 hours per day. We conducted this procedure for a tuberculous cicatric stenosis of the left lower lobe bronchus. The bronchus was sufficiently dilated after eight applications. Compared with conventional balloon dilation via the mouth, the patient had less discomfort and could undergo treatment for a longer time and more frequently.
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Introduction
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Several methods have been developed to dilate benign tracheobronchial stenosis, including the laser, bougienage, the stent, surgery, and the balloon [1–6]. Of these, balloon dilation involves lower risk and is the least invasive but is often less effective because of the weak dilation provided, especially in cases of hard bronchial stenosis such as tuberculous cicatric stenosis. To treat this difficult condition, we developed daily and long-term balloon dilation via minitracheostomy.
A 27-year-old man complained of a dry cough from August 1996, but chest x-ray and computed tomographic findings were normal except for mild left lower lobe infiltration. In May 1997, a sputum examination showed Ziehl-Neelsen-positive bacilli, and bronchoscopy showed widespread ulceration of the left main and lower lobe bronchi. The diagnosis was endobronchial tuberculosis, and patient was given systemic medication of antituberculous drugs (rifampicin, 450 mg; isoniazid, 300 mg; and ethambutol, 750 mg/d). By August 1997, the ulcerative bronchial lesion had disappeared but stenosis remained. In October 1997, he was admitted to our hospital for treatment.
Chest x-ray on admission showed no abnormal findings. Computed tomography showed stenosis of the left lower lobe bronchus, which was 3 mm in diameter in chest tomography (Fig 1). Bronchoscopy showed marked cicatric stenosis of the left basal and apical lower lobe bronchi (B6) (Fig 2). The left main bronchus, which was 7 mm in diameter in chest tomography, also showed mild cicatric stenosis. Bronchoscopy-guided balloon dilation was undertaken for the left lower lobe bronchial stenosis using a 6 F angioplastic balloon catheter (10 mm in diameter, 40 mm long; Cook, Co, Bloomington, IN). The bronchus, however, could not be dilated in 10 minutes of balloon inflation because stenosis was hard. Because of the limited anesthetic time, no further balloon dilation could be done. We therefore decided on daily and long-term balloon dilation via minitracheostomy.
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Fig 2. Bronchoscopic image shows cicatric stenosis of the left basal (a) and apical lower lobe bronchi (B6) (b).
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A minitracheostomy tube (Mini-Trach II; Portex Ltd, Kent, UK) was introduced through the cricothyroid membrane. The following dilation protocol was used: (1) the tracheobronchus was anesthetized using 1% xylocaine through a minitracheostomy tube; (2) a guide wire was inserted into the basal lobe bronchus through this tube by using x-ray fluoroscopic imaging; (3) the balloon catheter was introduced over the guide wire; (4) the balloon was placed in the middle of the stenosis and inflated with a dilute contrast medium by hand pressure; (5) the wire was removed; (6) the outside balloon catheter was fixed on the anterior chest (Fig 3); and (7) the balloon was deflated 4 hours later and the catheter removed. This procedure was repeated 12 times during 3 weeks for basal lobe bronchial stenosis, using the same balloon catheter as in the initial approach. For the apical lower lobe bronchus (B6), where the catheter was difficult to introduce during fluoroscopic imaging, the catheter was inserted into the bronchus using a bronchoscope 3 mm in diameter via a minitracheostomy tube (BF 3C20; Olympus, Tokyo, Japan). The balloon was inflated for 4 hours, repeated 3 times. During balloon inflation, the patient was allowed to walk around. Broad spectrum antibiotics and nonsteroid anti-inflammatory drugs were administered during treatment, and antituberculosis drug medication continued.
Slight airway bleeding was seen only at the first dilation. Oxygen saturation was greater than 94%, and the patient complained of a slight cough but no dyspnea on exertion during the procedure. Bronchoscopy after the fourth dilation of the left basal lobe bronchus showed mild dilation with diffuse erosion and several longitudinal ulcerations of the bronchus; maximal dilation was obtained after eight treatments in the findings of bronchoscopy and tomography (Fig 4). Tomography showed bronchial dilation of the basal lobe bronchus to 7 mm in diameter and a bronchoscope 6.3 mm in diameter could be easily passed through the bronchus. Because no further dilation occurred after 8 times, treatment was discontinued after 12 times. The apical lower lobe bronchus (B6) was dilated sufficiently after three times (Fig 4). During treatment, the patient had no fever or hemoptysis, and chest x-ray revealed no abnormal findings. Pulmonary function tests before and 3 months after treatment showed vital capacity had increased from 3.9 to 4.4 and the functional expiratory volume in one second from 3.1 to 3.8. Seven months after the last dilation, bronchoscopy showed both the left basal lobe and apical lower lobe bronchi dilated without restenosis.
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Fig 4. Bronchoscopic image after treatment shows the sufficiently dilated left basal (a) and apical lower lobe bronchi (B6) (b).
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Comment
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Balloon dilation to treat bronchial stenosis was conventionally conducted by introducing a balloon catheter through the mouth using bronchoscopy. This method does not sufficiently dilate hard stenosis, however, because balloon dilation was too weak, and frequency and time are limited. Nakamura and associates [7] reported a case of balloon dilation for tuberculous stenosis of the left main bronchus, dilation was only from 4.6 to 6.0 mm after one balloon inflation. In the present case, the bronchus could not be dilated by the first 10-minute balloon inflation because of stenosis hardness. We, therefore, conducted daily, long-term balloon dilation via minitracheostomy, which produced sufficient dilation. Although longer-term follow-up is required for drawing definite conclusions, stenosis had not recurred in the 7-month follow-up period.
Compared with conventional balloon dilation, our procedure had the following advantages: (1) the balloon can be inflated for a longer time; (2) the procedure can be repeated easily on a daily basis until dilation is sufficient; (3) the patient has less discomfort because the catheter is introduced via the trachea, not the mouth or nose; (4) the cost is lower because bronchoscopy is not required for bronchi; and (5) the procedure can be done in the outpatient clinic, because of its minimal invasiveness. Although we needed to use bronchoscopy through a minitracheostomy tube for the apical lower lobe bronchus (B6) in the present case, we believe a balloon catheter can be introduced into most bronchi by using a guide wire during x-ray fluoroscopic imaging. Complications in guide wire use, such as pneumothorax or bronchial bleeding, should be rare because of the soft tip of the guide wire and the use of x-ray fluoroscopic imaging. Although complications of minitracheostomy tube insertion, such as surgical emphysema, hemorrhage, misplacement, and displacement, have been reported [8], they are rare.
Atherosclerotic arteries have been treated by balloon angioplasty, and the balloon dilation mechanism has been widely studied. Kinney and associates [9] examined the angioplasty mechanism using atherosclerotic arteries from cadavers and demonstrated that arteries were dilated by longitudinal tearing and stretching of the artery wall. Our procedure caused slight airway bleeding only at the first balloon dilation and longitudinal ulceration after four times. We thus surmise that the bronchus is dilated by longitudinal tearing of the cicatric tissue as in balloon angioplasty.
Just as "water wears away the hardest stone," we are sure that weak dilation conducted daily and over the long term via minitracheostomy will eventually dilate most hard bronchial stenosis.
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References
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Abstract
Introduction
