Airway Interventions in the Tracheobronchial Tree

Erik Folch, MD, MSc; Atul C. Mehta, MD

Semin Respir Crit Care Med. 2008;29(4):441-452.

Balloon Bronchoplasty

Balloon bronchoplasty involves the use of balloons for symptomatic airway stenosis, including that resulting from intubation, infection, radiation, malignancy, sarcoidosis, Wegener granulomatosis, or inhalational injury, as well as idiopathic stenosis.^[54]

Flexible and rigid bronchoscopy can be used while maintaining a protected airway. Special balloons with various diameters are available for gastrointestinal and vascular procedures. The balloon is usually filled with saline until full deployment is reached with the help of a pressure-measuring syringe, to a prespecified pressure unit ranging from 6 to 12 atm in adults. Inflation diameter ranges from 4 to 20 mm, with a length of 4 to 8 cm. The final desired diameter is usually the normal diameter immediately proximal or distal to the stenosis. Each dilation can be maintained for 15 to 60 s and repeated two to three times, with sequentially larger-diameter balloons (Figure 3E).

Complications are those of bronchoscopy, and recurrence of stenosis, pain, and, albeit rarely, airway tear or rupture.^[12,54] Published results of balloon dilation in nonmalignant stenosis are shown in Table 4 .^{[55,56,57,58,59,60,61,62,63,64,65,66,67,68,69,70]}

A recent tool based on balloon technology uses a 120 cm single-lumen polyethylene tube of 2 mm outer diameter, with a distal balloon mounted, and surrounded by a hexagonal mesh structure made of 0.3 mm polyurethane fibers. The catheter is inserted into the airway, the balloon is inflated at the level of an endoluminal tumor, the polyurethane fibers exert a shearing force over the tissue, and the pieces may be aspirated or removed with forceps after the balloon is deflated and retrieved. A small number of successful cases have been recently reported in the literature.^[71,72]

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Table 1. Advantages and Disadvantages of Flexible and Rigid Bronchoscopes in Foreign Body Removal
Flexible Bronchoscope	Rigid Bronchoscope
Moderate sedation (conscious sedation)	Need for general anesthesia
More accessible to all pulmonologists	Requires specialized training
Access to peripheral airways	Limited to large airways
Better suction	Better control of airway
Can be used in most patients	Contraindicated in craniofacial trauma or cervical spine lesions
Difficulty removing large objects without removing the bronchoscope	Can remove objects of any size through the lumen of the rigid bronchoscope
Difficult removal of sharp objects	Easier removal of sharp objects

Table 2. "Rule of Four" for Successful Outcome for Endobronchial Laser Therapy
Duration of collapse	< 4 weeks
Length of lesion	< 4 cm
Distance
Endotracheal tube to lesion	> 4 cm
Fiber tip to lesion (noncontact)	4 mm
Bronchoscope to fiber tip	4 mm
FiO₂	≥ 40%
Power (watts)
Noncontact	40 W
Contact	4 W
Pulse duration	0.4 s
Number of pulses between cleaning	40
Operating room time	< 4 h
Laser team members	4

Table 3. Outcomes of Endobronchial Electrosurgery in Malignant and Benign Diseases
Study (first author)	N	Bronchoscope	Immediate Response (%)	Malignancy
Hooper^[23]	4	Flexible	100	4/4
Gerasin^[26]	14	Flexible	71	6/12
Hooper^[25]	18	Flexible	100	13/18
Ledingham^[27]	15	Rigid	73	15/15
Petrou^[28]	29	Rigid	96	28/29
Pedersen^[28a]	10	Rigid	90	10/10
Sutedja^[29]	17	Flexible	88	17/17
Homason^[30]	32	Rigid/flexible	84	27/32
Sutedja^[31]	56	Flexible	69	49/56
Coulter^[32]	38	Flexible	89	13/38

Table 4. Published Results of Balloon Dilatation in Nonmalignant Tracheobronchial Stenosis
Study (first author)	N	Immediate Success %	Long-Term Success %	Mean Follow-up (months)
Ferreti^[55]	16	68	56	21.6
Lee^[56]	15	73	73	36
Hebra^[57]	37	90	54	2
Fouty^[58]	6	100	83	13.6
Sheski^[59]	14	71	71	24.5
Nakamura^[60]	2	100	NA	8
Mehta^[61]	18	67	67	32
Keller^[62]	3	100	NA	NA
Jaffe^[63]	6	67	NA	NA
Fowler^[64]	1	100	100	6
Carlin^[65,†]	2	100	100	14
Carre^{[66,**,††]}	8	100	50	9.2
De Gracia^[67,**]	9	94	55	36.3
Chhajed^[68,**,ƒ]	26	NA	NA	NA
Susanto^{[69,**,††]}	11	NA	NA	NA
Orons^[70]	5	100	29	6

**Lung transplant recipients.
^ƒAuthors quantified benefit in mean forced expiratory volume in 1 second (FEV1) change.
^†One case was due to malignancy.
^††Patients required multimodality therapy with significant improvement long term.

Table 5. Advantages and Disadvantages of the Different Types of Stents Available
	Silicone Stents	Metal Stents	Hybrid Stents
Deployment[*]	Rigid bronchoscope	Flexible or rigid	Flexible or rigid
Adjustment[*]	Simple	Difficult	Difficult
Removal[*]	Simple	Difficult	Difficult
Ingrowth	Minimal or none	Frequent	Minimal
Cost	Least expensive	Moderately expensive	Very expensive
Inner diameter	Decreased	Maintained	Maintained
Expansion	Controlled	Expansion may cause airway damage	Variable expansion
Migration	Common	Infrequent	Variable

* The difficulties with deployment, adjustment, and removal are operator and institution dependent.

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Airway Interventions in the Tracheobronchial Tree

Balloon Bronchoplasty

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