Ann Thorac Surg 2006;82:e43-e45
© 2006 The Society of Thoracic Surgeons
How To Do It
Awake Tracheobronchial Dilation Without the Use of Rigid Bronchoscopy
Andrew C. Chang, MD*,
Allan Pickens, MD,
Mark B. Orringer, MD
Section of Thoracic Surgery, Department of Surgery, University of Michigan Medical Center, Ann Arbor, Michigan
Accepted for publication August 1, 2006.
* Address correspondence to Dr Chang, University of Michigan, TC2120G/0344, 1500 East Medical Center Dr, Ann Arbor, MI 48109 (Email: andrwchg{at}umich.edu).
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Abstract
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Benign tracheal strictures have been treated by repeated dilations using rigid bronchoscopy and general anesthesia. An alternative approach using conscious sedation, fluoroscopy, flexible bronchoscopy, and Savary-Gilliard esophageal dilators (Cook Endoscopy, Inc, Winston-Salem, NC) is reported. All patients undergoing dilation while awake had lesions due to inflammatory disease or lesions that were not amenable to resection. This method may be less traumatic than rigid bronchoscopy and can be accomplished on an outpatient basis without the use of general anesthesia.
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Introduction
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Tracheobronchial obstruction can be managed by various endobronchial techniques, including serial dilation of stenoses with blunt-tipped rigid bronchoscopes. Initial dilation of tight stenoses can be difficult if there is a significant discrepancy between the stenosis and bronchoscope, but it can be accomplished using a variety of esophageal dilators, generally in conjunction with rigid bronchoscopy under general anesthesia [1, 2]. A single-center experience using flexible bronchoscopy and wire-guided esophageal dilators in the management of unresectable benign airway strictures is reported.
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Technique
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Approval for this retrospective study, with waiver of consent, was provided by the Institutional Review Boards of the University of Michigan. Patients were included if they underwent bronchoscopic treatment by dilation alone. Patients undergoing additional concurrent endobronchial intervention such as laser ablation or airway stenting required general anesthesia and were excluded from this analysis. For patients undergoing both techniques, rigid bronchoscopy with dilation was initially performed to establish the nature and degree of airway stenosis, followed by repeat dilation during awake bronchoscopy if airway stenosis recurred. Outcomes including need for repeat airway dilation, need for more extensive operation, or death were identified.
Estimation of post-dilation airway caliber was determined by size of the largest Savary-Gilliard dilator (Cook Endoscopy, Inc) or by the size of the largest rigid bronchoscope successfully passed. Improvement was determined by amelioration of patient symptoms and the need for repeated dilations.
Rigid bronchoscopy with general anesthesia was performed using 6-mm, 7-mm, or 8-mm Jackson bronchoscopes (Teleflex Medical, Research Triangle Park, NC) corresponding to outer diameters of 24-French, 27-French, and 30-French, rotating the blunt-tipped bronchoscope with steady pressure through the airway stricture. If the stricture was too narrow to accept a 6-mm bronchoscope, metal, olive-tipped dilators (Pilling-Weck, Horsham, PA) were passed until either the 7-mm or 8-mm rigid bronchoscope could be passed. Jet or closed-circuit ventilation was maintained.
Conscious intravenous sedation with appropriate monitoring and topical airway anesthesia was established. A 15-French flexible video bronchoscope (Pentax Medical, Montvale, NJ) was inserted perorally. A Savary-Gilliard guidewire (Cook Endoscopy, Inc) was passed beyond the stenosis, positioning the spring-tip within the right or left mainstem bronchus. Communication was maintained with the patient throughout the procedure. Skin markers were placed indicating the proximal extent of the stricture (Fig 1A). A dilator was advanced over the guidewire until the dilator’s radio-opaque marker was visualized by fluoroscopy passing beyond the stricture (Fig 1B), and was left in place for several seconds only, which was to minimize patient discomfort. Airway examination was repeated to confirm adequate dilation and hemostasis.
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Fig 1. Dilatation of right mainstem bronchial anastomotic tracheomalacia, 9 weeks following bilateral pulmonary transplantation (patient 15). (A) Skin marker placement (white arrow) corresponding to the stricture’s proximal extent, and passage of guidewire (arrowhead). (B) The radio-opaque marker (black arrow) on a Savary-Gilliard dilator indicates the point of maximal dilation.
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Between January 2002 and September 2005, 15 consecutive patients required bronchoscopy and dilation alone for tracheobronchial stenoses, as reported in Table 1. The median age for this group was 56 years (range, 28–78 yrs), with diagnoses as listed. Five patients underwent rigid bronchoscopy and dilation (rigid), 6 patients underwent awake bronchoscopy with wire-guided dilation (Savary), and 4 underwent both procedures (both).
Patients tolerated awake Savary guidewire dilation with a median dilator size of 33-French. The maximal size passed by rigid bronchoscopy was with the 8-mm (outer diameter 30-French) bronchoscope (Fig 2). No patient experienced pneumothorax, bleeding, respiratory distress, any other procedural complication, or mortality. No significant difference was observed regarding the number of patients requiring repeat intervention regardless of technique. Of the 4 patients requiring repeated Savary airway dilation after the initial dilation, one patient (No. 4) ultimately underwent redo tracheal resection and reconstruction and another patient (No. 15) required stent placement for right mainstem bronchial anastomotic stricture. Overall median follow-up was 340 days (range, 23–1,243 days).
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Fig 2. Maximal dilator (French) passed during rigid ( ) and awake Savary dilator (°) bronchoscopy. Solid line indicates median maximum size of dilators passed for each group.
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Comment
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This study demonstrates that awake flexible bronchoscopy with wire-guided dilation is effective and safe. We have used this technique for patients with proximal airway stenoses, including the trachea and mainstem bronchi. Our practice has been to use rigid bronchoscopes up to 8 mm, although larger-sized rigid bronchoscopes are available, because larger caliber rigid instruments may result in greater risk of upper airway trauma [2, 3]. Recent reports have described the use of balloon dilators with and without fluoroscopic guidance [4, 5]. We believe that the use of the tapered Savary-Gilliard dilator results in gradual and complete dilation of benign stenoses. Although evaluation of the long-term durability of awake dilation is necessary, its application should be considered in the management of airway stenosis, particularly for benign inoperable disease.
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References
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- Stephens K, Wood D. Bronchoscopic management of central airway obstruction J Thorac Cardiovasc Surg 2000;119:289-296.[Abstract/Free Full Text]
- Venuta F, Rendina EA, De Giacomo T, et al. Operative endoscopy of the airway with the old-fashioned esophageal dilators Ann Thorac Surg 2005;79:718-719.[Abstract/Free Full Text]
- Grillo HC. Urgent treatment of tracheal obstructionIn: Grillo HC, editor. Surgery of the trachea and bronchi. Hamilton, Ontario: BC Decker Inc; 2004. pp. 473.
- Sheski F, Mathur P. Long-term results of fiberoptic bronchoscopic balloon dilation in the management of benign tracheobronchial stenosis Chest 1998;114:796-800.
- Mayse ML, Greenheck J, Friedman M, Kovitz KL. Successful bronchoscopic balloon dilation of nonmalignant tracheobronchial obstruction without fluoroscopy Chest 2004;126:634-637.
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Abstract
Introduction
