In highly selected patient populations, flexible and rigid endoscopic (endobronchial) management offers effective treatment options for benign major airway disease (e.g., stenosis and malacia). These treatments are associated with less morbidity than traditional open surgical interventions. Selection criteria focus primarily on candidacy for more definitive surgical therapy, as patients can be deemed inappropriate candidates for classic resection/reconstruction for a variety of reasons: etiology, extent of disease, failed prior operation, confounding medical comorbidities, and patient preference. Lack of technical expertise at a given institution also may be a factor. Since each institution carries its own bias with respect to these parameters, a patient determined inoperable at one center, in fact, may be considered a reasonable candidate at another.
Clearly, some individuals will benefit greatly from less invasive management of their airway disease. Only rarely is acute life-threatening airway compromise (≥75% luminal compromise) encountered in clinical practice. Moreover, as an alternative to tracheostomy, immediate endoscopic palliation of a high-grade stenosis may be part of a treatment strategy that ultimately incorporates an elective staged resection.
Symptomatic subglottic and tracheal stenoses and tracheomalacias are indications for endoscopic therapy in benign upper airway disease. These etiologies are listed in Table 56-1. Whether used as the primary therapy or as an adjunct to definitive surgery, the goal of endobronchial intervention is to restore airway patency and to provide a durable response, while limiting morbidity. Procedures often involve collaboration between surgeons and interventional bronchoscopists. Critical elements of endoscopic treatments are appropriate patient selection, choice of a specific endobronchial intervention based on indication, focused postoperative care (often including steroid therapy and mucolytics), and anticipation of possible repeated interventions.
Table 56-1ETIOLOGY OF AIRWAY STENOSIS/MALACIA ||Download (.pdf) Table 56-1 ETIOLOGY OF AIRWAY STENOSIS/MALACIA
|LOCATION ||TYPE ||DISEASE |
|Subglottic ||Congenital ||Closed first ring |
| ||Acquired ||External trauma |
|Tracheal ||Congenital ||Membranous web |
| ||Acquired ||External trauma |
Systemic illness Infection
Prior airway intervention
The goal of the endoscopic approach is to preserve the respiratory epithelium while minimizing radial thermal and mechanical injury to the airway. Many procedures can be performed through an adult flexible bronchoscope (video or fiberoptic), although because of the frequent requirement for rigid bronchoscopy, skill with rigid instrumentation is mandatory and must be actively maintained. General anesthesia is generally indicated, although it is possible to perform limited interventions in a bronchoscopy suite with conscious sedation and topical analgesia. Availability of a suitable procedure room (interventional bronchoscopy suite) or an operative room to perform interventions is essential. The suite should contain several high-resolution monitors, endobronchial ultrasound (EBUS) capability, mobile flexible bronchoscopy towers, and fluoroscopic capability.
BENIGN SUBGLOTTIC STENOSIS
The subglottis lies between the vocal cords and the proximal trachea. Congenital subglottic stenosis generally presents early in life and is characterized by an ...