(Chest. 2004;126:634-637.)
© 2004
American College of Chest Physicians
Successful Bronchoscopic Balloon Dilation of Nonmalignant Tracheobronchial Obstruction Without Fluoroscopy*
Martin L. Mayse, MD;
Jennifer Greenheck, APRN;
Mitchell Friedman, MD, FCCP and
Kevin L. Kovitz, MD, MBA, FCCP
* From the Washington University School of Medicine (Dr. Mayse), St. Louis, MO; Tulane University Health Sciences Center (Drs. Friedman and Kovitz), and Tulane University Hospital and Clinics (Ms. Greenheck), New Orleans, LA.
Correspondence to: Martin L. Mayse, MD, Assistant Professor of Medicine, Director of Interventional Pulmonology, Division of Pulmonary and Critical Care Medicine, 660 S Euclid Ave, Campus Box 8052, St. Louis, MO 63110; e-mail: mmayse{at}im.wustl.edu
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Abstract
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Objective: To evaluate the safety and efficacy of bronchoscopic balloon dilation (BBD) without fluoroscopy for relief of tracheobronchial obstruction.
Methods: We performed a retrospective study of all adult patients who underwent BBD without fluoroscopy at the Tulane University Hospital and Clinic between July 1, 1997, and June 30, 2002.
Results: Twenty-four patients (mean [± SD] age, 58 ± 14 years; 80% men) underwent 59 BBD procedures without fluoroscopy for the following conditions: iatrogenic tracheal stenosis (80%); saber-sheath trachea (4%); bronchial stenosis resulting from lung transplantation (4%); sarcoidosis (4%); Wegener granulomatosis (4%); and idiopathic stenosis (4%). All BBD procedures were performed via a rigid bronchoscope (61%) or a flexible bronchoscope (39%) without fluoroscopy. BBD was often combined with mechanical debridement (64%), stent placement (47%), or laser photoresection (19%), although in 26% of cases BBD was the only intervention. During the 59 procedures, 71 different balloon catheters were deployed a total of 112 times (deployment was defined as any use of balloon dilation in a different location, for a different purpose, or to a different inflation diameter). These 112 deployments were performed for primary dilation (49%), dilation prior to stent placement (28%), and stent seating (22%). Improvement in stenosis was achieved immediately postprocedure in all 59 procedures (100%). One balloon ruptured during inflation without clinically significant effect, and no other complications occurred.
Conclusion: BBD without fluoroscopy for the relief of nonmalignant tracheobronchial obstruction can be safely performed through a rigid or flexible bronchoscope. It can be used alone or as an adjunct to other therapeutic modalities. In this series, 100% of airway obstructions were improved, and there were no clinically significant complications. BBD of a tracheobronchial obstruction without fluoroscopy is safe, efficacious, and cost-effective.
Key Words: airway obstruction • balloon dilation • bronchoplasty • bronchoscopy • fluoroscopy • stenosis
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Introduction
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Bronchoscopic balloon dilation (BBD), also referred to as balloon bronchoplasty, is useful for the management of both benign and malignant tracheobronchial obstruction.1234 The prototypical technique involves the use of a balloon catheter passed over a guidewire and positioned within the obstruction with the aid of fluoroscopy.15 The standard accepted methodology is as follows. Bronchoscopy is first performed to localize the airway obstruction. Bronchography then may be used to outline the obstruction, and radiopaque markers are placed on the surface of the skin to identify the proximal and distal limits of the obstruction. A guidewire then is inserted through the working channel of the bronchoscope and is passed through the obstruction. With the guidewire held in place, the bronchoscope is withdrawn and reinserted next to the guidewire such that the obstruction is again visualized. Under fluoroscopic guidance, an appropriately sized balloon catheter is then advanced over the guidewire and positioned within the obstruction. The balloon is then inflated, and the results are observed via both fluoroscopy and bronchoscopy. If necessary, the balloon catheter then can be repositioned or replaced by a larger sized balloon catheter, and the procedure repeated until the desired effect is obtained.
Fluoroscopy is invaluable when direct visualization of an intraluminal obstruction is not possible, as is the case with percutaneous transluminal angioplasty. Fluoroscopy can be used to determine the extent of a luminal obstruction, to properly position the balloon within the obstruction, and to monitor the effect of balloon dilation. However, when the intraluminal obstruction can be completely visualized, as is the case with BBD of tracheobronchial obstructions, the benefit of fluoroscopy is less clear. Fluoroscopy requires specialized equipment and staff, exposes the patient and staff to radiation, and increases the time and cost of the procedure. We hypothesize that when the proximal and distal extent of a tracheobronchial obstruction can be visualized, BBD of the obstruction can be performed safely and efficiently without fluoroscopy. The specific objective of this study was to evaluate the safety and efficacy of BBD of a tracheobronchial obstruction that was performed without fluoroscopy.
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Materials and Methods
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Following approval by the Committee on Use of Human Subjects at Tulane University, we performed a retrospective study of all patients over the age of 18 years who underwent BBD without fluoroscopy by interventional pulmonology at the Tulane University Hospital and Clinic between July 1, 1997, and June 30, 2002. Medical records and operative notes were reviewed in order to extract the following information: patient age; gender; etiology of tracheobronchial obstruction; location of airway obstruction; and indication for procedure. Also noted were the following: bronchoscopic approach; use of other interventions including mechanical debridement, laser photoresection, and stent placement; specific use of balloon; and procedure-related complications such as bleeding, prolonged hypoxia, airway perforation, pneumothorax, respiratory failure, and mortality.
All therapeutic bronchoscopies were performed in the bronchoscopy suite under conscious sedation, or in the operating room under monitored anesthesia care or general anesthesia. Bronchoscopy was performed with a diagnostic flexible fiberoptic bronchoscope (model IT-200; Olympus America Inc; Melville, NY) or a therapeutic flexible fiberoptic bronchoscope (model BF-XT40; Olympus America Inc) using standard techniques prior to the therapeutic intervention in order to best evaluate the airway and plan the best approach. When possible, the entire procedure was performed using one of the two flexible bronchoscopes. When necessary, the patient was intubated with a rigid bronchoscope (Dumon-Harrell type; Bryan Corp; Woburn, MA) using standard techniques. Mechanical debridement was possible using forceps or the beveled tip of the rigid bronchoscope. Laser photoresection was performed using an Nd-YAG laser (Dornier MedTech America; Kennesaw, GA) or a diode laser operating at a wavelength of 980 nm (Ceralas D 25; Ceramoptec; East Longmeadow, MA). When indicated, silicon stents (Bryan Corp) or self-expanding wire mesh stents (Ultraflex stents or Wallstents; Microvasive/Boston Scientific Corp; Natick, MA) were inserted. After the procedure, and depending on baseline medical condition and patient monitoring needs, patients were transferred directly to the ICU or to an outpatient monitored setting prior to discharge home.
BBD was performed using one of several controlled radial expansion balloon catheters (CRE Esophageal Balloon; Microvasive/Boston Scientific). These catheters are available in variety of size ranges, and the balloon is constructed of such material that the nominal diameter of the balloon is proportional to the inflation pressure. With the balloon deflated, the catheter can pass through the 2.6-mm working channel of the diagnostic flexible bronchoscope, the 3.2-mm working channel of the therapeutic flexible bronchoscope, or through the bore of the rigid bronchoscope.
The technique of BBD used in this study was as follows. Bronchoscopic localization of the obstruction was first performed with a flexible fiberoptic bronchoscope. The length of the obstruction was estimated by passing the bronchoscope through the obstruction and noting the distance between the proximal and distal limits of the obstruction. If necessary, the flexible bronchoscope was removed, and the patient was intubated with the rigid bronchoscope. Under direct bronchoscopic visualization, an appropriately sized balloon catheter then was inserted directly into position within the obstruction without the use of a guidewire and without fluoroscopy (Fig 1
, top left, A, and bottom left, C). The balloon was inflated to the desired pressure using a balloon inflation device (Alliance Integrated Inflation System; Microvasive/Boston Scientific) and was held at this pressure for a predetermined time (Fig 1, top right, B, and bottom right, D). The balloon then was deflated, and the results were observed. If the desired airway diameter was not attained, the balloon catheter could then be reinflated to a higher pressure, repositioned, or replaced by a catheter with a larger nominal size and the procedure repeated until the desired effect was obtained. In this study, balloon dilation was performed for one of the following three reasons: principal dilation; dilation prior to stent placement; and assisting with stent deployment. When used principally for dilation prior to stent placement, the balloon was positioned within the obstruction, inflated to the desired pressure, and maintained at that pressure for a period of 1 min. Inflation was performed a total of one to three times. When used to assist with stent deployment, the balloon was positioned within the stent, inflated to the desired pressure, and maintained at that pressure for a few seconds, thus helping the stent to fully expand and properly seat within the airway.
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Figure 1.. BBD without fluoroscopic guidance can be performed with a flexible or a rigid bronchoscope. Using a flexible bronchoscope, the balloon catheter is inserted through the working channel and positioned within the narrowed area of the airway under bronchoscopic visualization (top left, A), and the balloon is then inflated (top right, B) in order to dilate the airway. Using a rigid bronchoscope, the balloon catheter is inserted through the hollow bore of the bronchoscope tube and positioned within the narrowed area of the airway under direct visualization or telescopic visualization (bottom left, C), and the balloon is then inflated (bottom right, D) in order to dilate the airway.
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Patient Characteristics
Twenty-four patients underwent 59 procedures involving BBD of a tracheobronchial obstruction without fluoroscopy during the 5-year period of study between July 1, 1997, and June 30, 2002. Nineteen patients (80%) were women, and 5 patients (20%) were men. Ages ranged from 18 to 80 years, with a mean (± SD) age of 58 ± 14 years. Obstruction was isolated to the trachea in 20 of these patients (84%) and was the result of iatrogenic tracheal stenosis (either prolonged intubation or tracheostomy) in 19 patients (80%). Although the study was not limited to nonmalignant tracheobronchial obstruction, none of the patients who underwent BBD during the study period had malignant tracheobronchial obstructions. Table 1
provides further details about the patient demographics.
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Results
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Balloon Dilation Procedures
Of the 59 procedures involving balloon dilation, 55 (93%) were performed for the relief of a symptomatic airway obstruction, and the remaining 4 procedures (7%) were performed preemptively for treatment of an asymptomatic obstruction discovered during reevaluation. The balloon catheter was deployed though a rigid bronchoscope during 36 of these procedures (61%) and directly through the working channel of a flexible bronchoscope during the remaining 23 procedures (39%). Fifty-four balloon dilation procedures (92%) were limited to the trachea, while the remaining 5 procedures (8%) were limited to the distal bronchi.
Typically, BBD was part of a multimodal approach to the management of tracheobronchial obstruction that utilized mechanical debridement (64%), stent placement (47%), and laser photoresction (19%). However, balloon dilation was the only mode of therapy used in 21 of the 59 procedures (26%). The immediate results of balloon dilation, when used alone or as part of a multimodal therapeutic approach, were satisfactory in all 59 procedures (100%). Table 2 provides further details about the BBD procedures.
Balloon Deployments
During the 59 procedures involving balloon dilation, 71 individual balloon catheters were deployed a total of 112 times (a new deployment was defined as any use of the balloon catheter in a different location for a different purpose, or if a balloon was inflated to a different size). The main use of the balloon during these 112 deployments was principal dilation in 55 deployments (49%), dilation of an obstruction prior to placement of a stent in 31 deployments (28%), and assistance with stent positioning in 25 deployments (22%). Table 3
provides further details about these deployments
Complications
Anticipated complications included significant bleeding, prolonged hypoxia, airway perforation, pneumothorax, respiratory failure, and death. None of these anticipated complications occurred during any of the 112 balloon deployments during the 59 balloon dilation procedures. The only reported complication was the rupture of a single balloon catheter when inflated to 7 atm of pressure (which was within the operational range provided by the manufacturer). No clinically significant adverse events were related to the rupture of this balloon in this patient.
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Discussion
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Balloon dilation procedures traditionally involve the use of balloon catheters passed over a guidewire and positioned within the luminal obstruction with the aid of fluoroscopy. While fluoroscopic guidance is necessary when direct visualization is not possible, as is the case with balloon angioplasty, its utility is unclear when an obstruction can be directly visualized, as is the case with BBD. A similar argument was made by Herth et al,6 who demonstrated that certain self-expanding wire-mesh stents (Ultraflex; Microvasive/Boston Scientific Corp) can be safely deployed without the use of fluoroscopy.
The current study demonstrates that BBD of a nonmalignant tracheobronchial obstruction performed without the use of a guidewire, and without fluoroscopy, is safe and efficacious. No clinically significant adverse events occurred as a result of balloon dilation during any of the 112 balloon deployments that were performed during the 59 interventional procedures. The immediate results of balloon dilation, when used alone or as part of a multimodal therapeutic approach, were satisfactory in all 59 procedures (100%). While the majority of cases in the current study involved BBD of tracheal obstructions, the technique is equally valid for more peripheral airway obstructions, provided that the proximal and distal limits of the obstruction can be visualized bronchoscopically. By avoiding unnecessary fluoroscopy during stent placement as well as BBD, radiation exposure is avoided and significant financial savings are possible.
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Footnotes
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Abbreviation: BBD = bronchoscopic balloon dilation
Received for publication October 29, 2003.
Accepted for publication February 19, 2004.
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References
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- Hautmann, H, Gamarra, F, Pfeifer, KJ, et al (2001) Fiberoptic bronchoscopic balloon dilation in malignant tracheobronchial disease: indications and results. Chest 120,43-49[Abstract/Free Full Text]
- Chhajed, PN, Malouf, MA, Glanville, AR Bronchoscopic dilation in the management of benign (non-transplant) tracheobronchial disease. Intern Med J 2001;31,512-516[Medline]
- Sheski, FD, Mathur, PN Long-term results of fiberoptic bronchoscopic balloon dilation in the management of benign tracheobronchial stenosis. Chest 1998;114,796-800[Abstract/Free Full Text]
- Kovitz, KL, Conforti, JF Balloon bronchoplasty: when and how. Pulm Perspect 1999;16,1-3
- Mehrishi, S, Raoof, S, Metha, AC Therapeutic flexible bronchoscopy. Chest Surg Clin N Am 2001;11,657-690[Medline]
- Herth, F, Becker, HD, LoCiero, J, et al Successful bronchoscopic placement of tracheobronchial stents without fluoroscopy. Chest 2001;119,1910-1912[Abstract/Free Full Text]
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Abstract
Introduction
