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University Hospital Basel, Basel, Switzerland
Correspondence to: Prashant N. Chhajed, MD, FCCP, Division of Respiratory Medicine, University Hospital Basel, Petersgraben 4, CH-4031 Basel, Switzerland; e-mail: chhajed{at}hotmail.com
To the Editor:
We read with interest the guidelines from the American College of Chest Physicians on interventional pulmonary procedures (May 2003).1 The document is well focused on the diversity of interventional pulmonary techniques that are now available to our patients. It also refers to the use of rigid bronchoscopes of increasing diameter to achieve dilatation of airway strictures. However, the use of rigid bronchoscopy for dilatation of airway stenosis has largely been replaced by flexible bronchoscopy and balloon dilatation.2 3 4 5 This document does not include this important procedure of balloon dilatation using the flexible bronchoscope, which is often performed in the endoscopic management of benign and malignant airway stenosis. This procedure may be solely therapeutic or used in combination with stent placement, laser therapy, or other interventional bronchoscopic procedures.
Bronchoscopic balloon dilatation may be performed via the rigid or flexible bronchoscope. The balloon can be precisely placed across the stenosis and gradually inflated to impart radially directed forces. It is performed under local anesthesia and sedation when performed via flexible bronchoscopy. It can be closely monitored using fluoroscopy guidance or under direct bronchoscopic vision, may be repeated, and is a safe procedure.3 4 The choice of balloon size is based on the bronchoscopic assessment of the stenosis and as demonstrated on radiographic studies such as CT. The balloon is inserted in the airway directly through the working channel of the bronchoscope or over a guidewire. The inflation syringe is used to inflate and deflate the balloon and to monitor the balloon pressure. Balloon inflation may be carried out either using normal saline solution or a radiopaque solution (eg, urograffin 10 mL plus normal saline solution 10 mL) when fluoroscopy is used to monitor the dilatation.2 When fluoroscopy is used, the "waist" caused by the stricture serves as a guide to the accurate placement of the balloon catheter, and its opening up serves as a marker of the degree of dilatation achieved. Inflation of the balloon is usually maintained for 30 to 120 s, keeping a close watch on the pulse oximeter and vital parameters.2 4 If necessary, the procedure is repeated either with the same balloon or one with a larger diameter.
Benign Lesions
Benign tracheobronchial stenosis in the adult patient can be a complication of a variety of diseases, which include tuberculosis and sarcoidosis; trauma; following endotracheal intubation; tracheostomy or bronchial sleeve resection; and after radiation or fibrosing mediastinitis.2
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Depending on the site of the lesion and severity of the narrowing, stenosis may cause symptoms of dyspnea, stridor, wheeze, cough, or recurrent respiratory tract infections. It is estimated that 
50% of patients treated with balloon dilatation may not need any other form of therapeutic intervention, and hence it may be a reasonable first option to restore airway lumen in benign stenosis.2
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Lung Transplantation
Of the 31 lung transplant recipients who underwent dilatation for stenosis or combined stenosis and bronchomalacia, 8 patients (26%) did not need subsequent stent placement.3 Although majority of the patients with stenosis needed stent placement, the complications associated with its use in lung transplant recipients are well described3 ; therefore, it is desirable to limit its use whenever possible. Dilatation of airway stenosis before stent placement also allows the assessment of the extent of the lesion, the degree of inflammation, and the status of the bronchial tree distal to the stenosis. For stenotic lesions in lung transplant recipients, balloon dilatation has been recommended on at least two occasions prior to stent insertion, or more than two occasions if required in the presence of significant inflammation.3 In the presence of inflammation, balloon dilatation allows time for the inflammatory stricture to mature into a fibrous stricture, which is more suitable for metallic stent placement.3
Malignant Lesions
In a prospective study, 78 consecutive patients underwent 126 bronchoscopic balloon dilatation procedures for malignant lesions.5 The usefulness of bronchoscopic balloon dilatation has been described for symptomatic airway stenoses when alternative options, such as laser therapy or stent implantation, are not indicated or inappropriate, and treatment of stenoses that have caused inflammatory poststenotic complications or atelectases.5 Balloon dilatation may be performed to restore airway lumen followed by endoluminal irradiation or stent placement to maintain an open airway.5 The only major complication reported is fatal hemoptysis in one patient, attributed to a lacerated tumor-infiltrated pulmonary artery where the authors assume that the balloon catheter came to lie within the tumor tissue and not within the former bronchial lumen.5 Hence, adequate intraluminal position of the balloon catheter needs to be ensured prior to inflation. Following stent implantation, balloon dilatation may be performed when the stent does not expand sufficiently or the stent is compressed by extrinsic tumor growth.
References
This article has been cited by other articles:
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  A. L. St. Amand, D. N. Frank, M. A. De Groote, and N. R. Pace Use of Specific rRNA Oligonucleotide Probes for Microscopic Detection of Mycobacterium avium Complex Organisms in Tissue J. Clin. Microbiol., April 1, 2005; 43(4): 1505 - 1514. [Abstract] [Full Text] [PDF]
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