Central Airway Obstruction: Benign Strictures, Tracheobronchomalacia, and Malignancy-related Obstruction

doi:10.1016/j.chest.2016.02.001

CHEST

Volume 150, Issue 2, August 2016, Pages 426-441

https://doi.org/10.1016/j.chest.2016.02.001 Get rights and content

The purpose of this article is to provide an update on methods for palliating symptoms in patients with histologically benign and malignant central airway obstruction. We review the published literature within the past decade on postintubation, posttracheostomy, and TB- and transplant-related airway strictures; tracheobronchomalacia; and malignant airway obstruction. We review terminology, classification systems, and parameters that impact treatment decisions. The focus is on how airway stent insertion fits into the best algorithm of care. Several case series and cohort studies demonstrate that airway stents improve dyspnea, lung function, and quality of life in patients with airway obstruction. Airway stenting, however, is associated with high rates of adverse events and should be used only when curative open surgical interventions are not feasible or are contraindicated.

Section snippets

Histologically Benign Airway Strictures

Benign strictures constitute the majority of benign forms of CAO and include airway stenosis mainly related to postintubation tracheal stenosis (PITS), posttracheostomy tracheal stenosis (PTTS), post-TB infection, and transplant-related and idiopathic stenoses. In this section, we describe classification systems and qualitative and quantitative parameters relevant to treatment and define physiologic rationales and outcomes of stent insertion for these entities.

Expiratory Central Airway Collapse

Expiratory central airway collapse (ECAC) includes tracheobronchomalacia (TBM) and excessive dynamic airway collapse (EDAC).³⁷ Issues related to terminology, classification systems, airflow dynamics, and management are discussed in this section.

Malignant CAO

Malignant CAO can be palliated and, therefore, requires prompt recognition and intervention.⁷¹ It is seen most commonly in patients with locally advanced lung cancer, although airway metastases may occur, mostly from thyroid, breast, or colon cancer; melanoma; or renal carcinoma. In patients with lung cancer for which surgery is considered curative, resection is the preferred management of CAO. In all other patients, the goal of CAO management is to restore airway patency to improve symptoms or

Conclusions

The histological type, mechanisms of obstruction, extent, location, morphology, degree of airway narrowing, and patient functional status are factors that determine the need for open surgical or bronchoscopic interventions in patients with CAO. We believe that the original articles published in the past decade support the use of airway stents in the following specific circumstances:

1.
For patients with inoperable, symptomatic complex PITS and PTTS, and post-TB stenosis, silicone stent insertion

Acknowledgments

Financial/nonfinancial disclosures: None declared.

Additional information: The e-Appendix and e-Tables can be found in the Supplemental Materials section of the online article.

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Airway fibrosis is among the pathological manifestations of benign central airway obstruction noted in the absence of effective treatments and requires new drug targets to be developed. Slit guidance ligand 2–roundabout guidance receptor 1 (Slit2–Robo1) is involved in fibrosis and organ development. However, its significance in airway fibrosis has not yet been reported. The study explored how the recombinant protein Slit2 functions in transforming growth factor-β1 (TGF-β1)-mediated airway fibrosis in vivo and in vitro. In this study, Slit2 expression initially increased in the tracheal granulation tissues of patients with tracheobronchial stenosis but decreased in the fibrotic tissue. In primary rat tracheal fibroblasts (RTFs), recombinant Slit2 inhibited the expression of extracellular matrices such as Timp1, α-SMA, and COL1A2, whereas recombinant TGF-β1 promoted the expression of Robo1, α-SMA, and COL1A2. Slit2 and TGF-β1 played a mutual inhibitory role in RTFs. Slit2 supplementation and Robo1 downregulation inhibited excessive extracellular matrix (ECM) deposition induced by TGF-β1 in RTFs via the TGF-β1/Smad3 pathway. Ultimately, exogenous Slit2 and Robo1 knockdown-mediated attenuation of airway fibrosis were validated in a trauma-induced rat airway obstruction model. These findings demonstrate that recombinant Slit2 alleviated pathologic tracheobronchial healing by attenuating excessive ECM deposition. Slit2–Robo1 is an attractive target for further exploring the mechanisms and treatment of benign central airway obstruction.
Benign tracheal stenosis caused by an endotracheal tube left in place for 24h: A case report
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Stomaplasties were widely used to prevent or revise stomal stenosis, however, a previous tracheostomy can limit the choice of some techniques. This study aims to deal with this condition through a novel and simple technique called “Collar stomaplasty”.
This study involved 43 patients submitted for laryngectomy between 2017 and 2020. A tracheostomy 6–31 days prior to laryngectomy was performed in all cases. The collar stomaplasty, shaping the previous tracheostomy and surrounding skin, included 17 cases and the traditional X-shaped stomaplasty included 26 cases. Fisher's exact test was applied in an intergroup comparison of complications.
One out of the collar stomaplasty group demonstrated perioperative stomal infection and avascular necrosis (5.9%). Another developed stomal stenosis (5.9%). In the X-shaped stomaplasty group, necrosis at the tip of the tracheal flap occurred in 14 cases (53.8%), and stomal stenosis occurred in 5 cases (19.2%). A statistically significance occurred in stomal necrosis (p<0.05) while no statistically difference is observed in stomal stenosis (p>0.05) between these two groups.
The collar stomaplasty technique creates a laryngectomy tracheostoma by remodeling a previous tracheostomy. A wide and stable stoma, which facilitates stomal care, can be accomplished by this simple technique.
Stenotic geometry effects on airflow dynamics and respiration for central airway obstruction
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The quantitative relationship between tracheal anatomy and ventilation function can be analyzed by using engineering-derived methods, including mathematical modeling and numerical simulations. In order to provide quantitative functional evaluation for patients with tracheobronchial stenosis, we here propose an aerodynamics-based assessment method by applying computational fluid dynamics analysis on synthetic and patient-specific airway models.
By using 3D reconstruction of tracheobronchial tree and computational fluid dynamics simulations, the aerodynamic environment from the stenotic central airway down to the 4th-6th bifurcation of the tracheobronchial tree is examined in both synthetic and patient-derived models. The effects of stenotic anatomy (the degree of stenosis, stenotic length and location) on the aerodynamic parameters, including pressure drop, area-average velocity, volume flow rate, wall shear stress and airflow resistance, are investigated on three-dimensional models of tracheobronchial tree.
The results from 36 synthetic models demonstrate that 70% constriction marks the onset of a precipitous decrease in airflow relative to a normal airway. The analyses of simulation results of 8 patient-specific models indicate that the Myer-Cotton stenosis grading system can be interpreted in terms of aerodynamics-derived description, such as flow resistance. The tracheal stenosis significantly influences the resistance of peripheral bronchi, especially for patients with severe stenosis.
The present study forms a systematic framework for future development of more robust, bioengineering-informed evaluation methods for quantitative assessment of respiratory function of patients with central airway obstruction.
Interventionnal bronchoscopy for the treatment of tracheobronchomalacia
2023, Revue des Maladies Respiratoires
Le collapsus trachéobronchique expiratoire regroupe la trachéobronchomalacie, maladie des anneaux cartilagineux et le collapsus dynamique excessif des voies aériennes, bombement majeur de la membraneuse au niveau la paroi postérieure. La symptomatologie repose sur des signes respiratoires peu spécifiques comme la dyspnée, la toux ou les difficultés d’expectoration. Le diagnostic est obtenu lors d’épreuves dynamiques, par l’endoscopie bronchique et/ou le scanner. La trachéobronchomalacie peut être primaire (génétique, idiopathique) ou secondaire liée à un traumatisme, une trachéotomie, une intubation, une intervention chirurgicale, une transplantation, un emphysème, une infection, une inflammation, une bronchite chronique, une compression extrinsèque ou à des anneaux vasculaires non diagnostiqués dans l’enfance. Certains algorithmes décisionnels thérapeutiques ont été proposés, mais aucune recommandation précise n’a été établie. Le traitement, d’abord médical (prise en charge de la pathologie sous-jacente, parfois associée à la ventilation non invasive), est réservé aux malades symptomatiques, après évaluation du retentissement de la maladie (statut fonctionnel et perfomance status du malade, évaluation des symptômes et de la qualité de vie par différents scores). Si les symptômes persistent, d’autres traitements sont discutés. Au sein de l’arsenal thérapeutique, la bronchoscopie interventionnelle permet : (1) la sélection des malades pouvant bénéficier du traitement chirurgical de référence, avec la mise en place d’une endoprothèse comme test thérapeutique avant trachéobronchoplastie ; (2) la pose d’endoprothèses dans les voies aériennes chez les malades non chirurgicaux, dans le but d'obtenir une amélioration des symptômes et de la qualité de vie, au prix d’effets secondaires majeurs liés aux endoprothèses ; (3) la prise en charge de la majorité des complications associées aux endoprothèses (obstruction, granulomes, migration fracture) ; (4) des alternatives thérapeutiques avec la possibilité de techniques thermo-ablatives. Enfin, le développement de nouvelles endoprothèses pourrait permettre de diminuer le taux de complications. Ces différentes options restent encore très discutées à l’heure actuelle.
Tracheobronchomalacia is usually characterized by more than 50% expiratory narrowing in diameter of the trachea and the bronchi. The expiratory collapse includes two entities: (1) the TBM related to the weakness of the cartilaginous rings, and (2) the Excessive Dynamic Airway Collapse (EDAC) due to the excessive bulging of the posterior membrane. Patients have nonspecific respiratory symptoms like dyspnea and cough. Diagnosis is confirmed by dynamic tests: flexible bronchoscopy and/or computed tomographic scan of the chest. There are different forms of tracheobronchomalacia in adults: primary (genetic, idiopathic) or secondary to trauma, tracheotomy, intubation, surgery, transplantation, emphysema, infection, inflammation, chronic bronchitis, extrinsic compression; or undiagnosed in childhood vascular rings. Some management algorithms have been proposed, but no specific recommendation was established. Only symptomatic patients should be treated. Medical treatments and noninvasive positive pressure ventilation should be the first line therapy, after evaluation of various quality measures (functional status, performance status, dyspnea and quality of life scores). If symptoms persist, therapeutic bronchoscopy permits: (1) patient's selection by stent trial to determine whether patient benefit for surgical airway stabilization; (2) malacic airways stenting in patients who are not surgical candidates, improving QOL despite a high complication rate; (3) the management of stent-related complication (obstruction, plugging, migration granuloma); (4) alternative therapeutics like thermo-ablative solution. Lasty, the development of new types of stents would reduce the complication rates. These different options remained discussed.
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: FUNDING/SUPPORT: The authors have reported to CHEST that no funding was received for this study.

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CHEST

Recent Advances in Chest MedicineCentral Airway Obstruction: Benign Strictures, Tracheobronchomalacia, and Malignancy-related Obstruction

Section snippets

Histologically Benign Airway Strictures

Expiratory Central Airway Collapse

Malignant CAO

Conclusions

Acknowledgments

Current approaches to assessing the degree of airway narrowing in central airway obstruction

Ann Am Thorac Soc

A proposed classification system of central airway stenosis

Eur Respir J

A proposed grading system for post-intubation tracheal stenosis

Tanaffos

Subglottic stenosis: retrospective analysis and proposal for standard reporting system

Ann Otol Rhinol Laryngol

Laryngotracheal reconstruction in the adult: a ten year experience

Ann Otol Rhinol Laryngol

Classification of laryngotracheal stenosis

Laryngoscope

A proposed system for documenting the functional outcome of adult laryngotracheal stenosis

Clin Otolaryngol

Evaluation of obstructing lesions of the trachea and larynx by flow-volume loops

Am Rev Respir Dis

Evaluation of tracheobronchial lesions with spiral CT: comparison between virtual endoscopy and bronchoscopy

Radiol Med

Combined optical coherence tomography and endobronchial ultrasonography for laser-assisted treatment of postintubation laryngotracheal stenosis

Ann Otol Rhinol Laryngol

Morphometric bronchoscopy in adults with central airway obstruction: case illustrations and review of the literature

Laryngoscope

Indications and results of sleeve carinal resection

Eur J Cardiothorac Surg

Risk factors for adult laryngotracheal stenosis: a review of 74 cases

Ann Otol Rhinol Laryngol

Causes and consequences of adult laryngotracheal stenosis

Laryngoscope

Proposed grading system for subglottic stenosis based on endotracheal tube sizes

Ann Otol Rhinol Laryngol

Therapeutic bronchoscopy for malignant central airway obstruction: success rates and impact on dyspnea and quality of life

Chest

Tracheal stenosis: a flow dynamics study

J Appl Physiol (1985)

Sensitivity and responsiveness of the Medical Research Council dyspnoea scale to the presence and treatment of adult laryngotracheal stenosis

Clin Otolaryngol

Management of intractable and extensive tracheal stenosis by implantation of cartilage graft

J Pediatr Surg

Tracheal replacement with aortic allografts

N Engl J Med

Clinical transplantation of a tissue-engineered airway

Lancet

Outcome of surgical treatment for proximal long segment post intubation tracheal stenosis

J Cardiothorac Surg

Stenting allows weaning and extubation in ventilator- or tracheostomy dependency secondary to benign airway disease

Respir Med

Outcomes, health-care resources use, and costs of endoscopic removal of metallic airway stents

Chest

Airway stenting for benign tracheal stenosis: what is really behind the choice of the stent?

Eur J Cardiothorac Surg

Prognostic factors for endotracheal silicone stenting in the management of inoperable post-intubation tracheal stenosis

Yonsei Med J

Results of interventional bronchoscopy in the management of postoperative tracheobronchial stenosis

J Thorac Cardiovasc Surg

Bilateral bronchial anastomosis in double lung and heart-lung transplantations

Eur J Cardiothorac Surg

A comparative analysis of bronchial stricture after lung transplantation in recipients with and without early acute rejection

Ann Thorac Surg

Airway stenoses after lung transplantation: incidence, management, and outcome

J Thorac Cardiovasc Surg

The management of bronchus intermedius complications after lung transplantation: a retrospective study

J Cardiothorac Surg

Novel biodegradable stents in the treatment of bronchial stenosis after lung transplantation

Eur J Cardiothorac Surg

Bronchoscopic assessment of the evolution of endobronchial tuberculosis

Chest

Factors predicting outcome following airway stenting for post-tuberculosis tracheobronchial stenosis

Respirology

Comparison of natural and Dumon airway stents for the management of benign tracheobronchial stenoses

Respirology

Tracheobronchomalacia and excessive dynamic airway collapse

Clin Chest Med

Recent Advances in Chest Medicine
Central Airway Obstruction: Benign Strictures, Tracheobronchomalacia, and Malignancy-related Obstruction