Ann Thorac Surg 2006;82:1897-1898
© 2006 The Society of Thoracic Surgeons
Case Reports
Inherent Problems of Tracheo-Bronchial Stenting in Patients With Tracheostomy
Joerg Lindenmann, MD*,
Christian Porubsky, MD,
Veronika Matzi, MD,
Alfred Maier, MD,
Freyja Maria Smolle-Juettner, MD
Division of Thoracic and Hyperbaric Surgery, Department of Surgery, University Medical School, Graz, Austria
Accepted for publication March 13, 2006.
* Address correspondence to Dr Lindenmann, Department of Surgery, Division of Thoracic and Hyperbaric Surgery, University Medical School Graz, Auenbruggerplatz 29, Graz, 8036 Austria. (Email: jo.lindenmann{at}meduni-graz.at).
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Abstract
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In cases of permanent tracheostomy after laryngectomy, tracheo-bronchial stenting may cause serious respiratory problems due to the absence of airway humidification and the inability to cough forcefully. We report 2 patients with permanent tracheostomy who underwent stenting and developed recurrent episodes of asphyxia due to stent obstruction by dried mucus. The indication for stenting of the airways must be established with great care in patients with permanent tracheostomy.
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Introduction
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Tracheo-bronchial stenting is an option to preserve the patency of the airways in cases of stenosis or for sealing respiratory-digestive fistulae [1–5]. The accumulation of mucus in the airways is an inherent problem of stenting. As the mucociliary clearance is disrupted, liquefaction of the bronchial content is required to achieve efficient coughing.
We report 2 patients with permanent tracheostomy who needed tracheal stenting and developed recurrent episodes of life-threatening asphyxia due to stent obstruction.
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Case Reports
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Patient 1
A 60-year-old man suffering from severe chronic obstructive lung disease had undergone permanent tracheostomy after laryngectomy. He required positive pressure ventilation due to complete inspiratory collapse of the tracheal wall from a site distal to the end of the tracheal cannula down to the tracheal bifurcation. Weaning was impossible. External irradiation of the neck caused severe radiation injury to the skin, which ruled out surgical options of tracheal stabilization.
A coated self-expandable metal stent (model UPC/18-4/16/95 [Boston Scientific, Natick, MA]) was inserted. Positive pressure ventilation was discontinued within 24 hours by reducing the level of continuous positive airway pressure from 8, to 5, and 3 cm H20, until the patient simply breathed 1 L/min of oxygen through a humidifier connected to the tracheal cannula. Inhalation, physiotherapy, and mucolytic substances were administered to prevent clogging of the stent. Biphasic stridor developed immediately when continuous humidification was stopped. At re-bronchoscopy the stent was subtotally occluded by dried mucus. After removal and clearing, mucolytic treatment and inhalation were intensified, and continuous humidification was resumed. However, when humidification was discontinued for a few hours, stent obstruction reoccurred.
The patient underwent an elaborate remobilization and physiotherapy program that led him to gain 5 kg of weight and significantly improved his general condition. The next step consisted of stepwise weaning from humidification. Two-hour intervals during which the humidifier was switched off were extended by 30 minutes every week until 5 sessions of inhalation therapy per day were achieved. Humidification at night was discontinued in a similar fashion. Eventually the patient was able to sleep undisturbed after the last inhalation therapy at 10 PM.
Patient 2
A 55-year-old man had undergone laryngectomy and cervical irradiation for laryngeal carcinoma. He was admitted with a second primary in the upper third of the esophagus, presenting as a bulky tumor with an esophagotracheal fistula 6 cm proximal to the tracheal bifurcation. Furthermore, multiple pulmonary metastases causing intermittent hemoptysis were found.
The fistula was sealed successfully by insertion of a coated self-expandable metal stent (model UPC/18-4/16/95 [Boston Scientific]) into the esophagus. However, the tumor bulk was thrust against the membranous wall by the expanded stent. Dyspnea subsided after insertion of another self-expandable coated metal stent between the lower margin of the tracheal cannula and the bifurcation. Physiotherapy, inhalation and mucolytic medication were administered. Stent clogging by dried hemorrhagic mucus occurred repeatedly, requiring removal and clearing every 2 to 5 days. Only when bleeding from the metastases had been stopped by angiographic embolization, did the stent remain patent.
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Comment
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One of the main problems of tracheo-bronchial stenting is mucus accumulating in the airways distal to the stent because the mucociliary clearance is disrupted at its lower margin. Patients with stents have to overcome this problem by forceful expectoration while inhalation therapy and mucolytic substances ensure sufficient liquefaction of the bronchial contents.
In both patients described in this report, the absence of a functioning glottis reduced their ability to build up the intrathoracic pressure required for forceful expectoration. During physiotherapy they were advised to intermittently place a finger on the cannula outlet after maximum inspiration. However, stent obstruction is caused by other factors as well.
The first patient reported herein initially lacked the strength to expectorate mucus properly due to chronic obstructive lung disease. When airway humidification was discontinued, drying of the mucus within the stent caused asphyxia. Only after he regained his strength, was the patient able to overcome the problem.
The second patient was able to expectorate once the tracheal stenosis had been stented. However, recurrent episodes of tracheo-bronchial bleeding produced thin layers of clotted blood on the inner surface of the stent, where they dried due to lack of humidity. The problem subsided as soon as bleeding was stopped by angiographic embolization of the pulmonary metastases.
In conclusion, the two cases reported in this study underline the problem of an inert surface within the tracheobronchial tree, which presents as an obstacle to bronchial clearing. After total laryngectomy, lack of humidification of the inspired air or the impaired ability to expectorate forcefully, or both, may create a precarious situation after stenting.
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References
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- van den Bongard HJ, Boot H, Baas P, Taal BG. The role of parallel stent insertion in patients with esophagorespiratory fistulas Gastrointest Endosc 2002;55:110-115.[Medline]
- Alexiou C, Neuhaus H, Kau RJ, Hauck R, Classen M. Treatment of an esophagorespiratory fistula by insertion of an esophageal Montgomery and tracheal dynamic stent after failure of conventional endoprosthesis ORL J Otorhinolaryngol Relat Spec 1998;60:51-54.[Medline]
- Dimofte G, Crumpei F, Grigoras M, Isloi A, Grigoras I. Stenting for cervical tracheo-esophageal malignant fistula: a case report Rom J Gastroenterol 2002;11:153-158.[Medline]
- Tomaselli F, Maier A, Sankin O, Woltsche M, Pinter H, Smolle-Juttner FM. Successful endoscopical sealing of malignant esophageotracheal fistulae by using a covered self-expandable stenting system Eur J Cardiothorac Surg 2001;20:734-738.[Abstract/Free Full Text]
- Hu G, Wie L, Sun Y, Zhu J, Zhou J. A study on the application of Nickle- Titanium alloys stent for prevention and treatment tracheostomal stenosis after total laryngectomy Lin Chuang Er Bi Yan Hou Ke Za Zhi 2003;17:476-477.[Medline]
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Abstract
Introduction
