In highly selected patient populations, endoscopic and endobronchial management offers effective treatment options for benign major airway disease (e.g., stenosis and malacia). These options are associated with less morbidity than other surgical treatments. Selection criteria focus primarily on the surgical candidacy of each individual patient. Patients can be deemed inappropriate candidates for resection 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 institute 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 patients benefit from less invasive management of their airway disease. Only rarely do patients present with life-threatening airway compromise (≥50% luminal compromise) requiring urgent endoscopic treatment. To this end, immediate endoscopic palliation of a high-grade stenosis may be part of a treatment strategy incorporating an elective staged resection.
Symptomatic subglottic and tracheal stenoses and tracheomalacias are indications for endoscopic therapy. These etiologies are listed in Table 46-1. 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 careful patient selection, choice of an appropriate intervention based on indication, excellent postoperative care, and often, anticipation for serial procedures.
Table 46-1. Etiology of Airway Stenosis/Malacia |Favorite Table|Download (.pdf)
Table 46-1. Etiology of Airway Stenosis/Malacia
Closed first ring
Prior airway intervention
Modern endoscopic approaches are aimed at respiratory epithelial preservation while minimizing radial thermal and mechanical injury of the airway. Multimodality approaches are used often to affect these goals. Many procedures can be performed through an adult flexible bronchoscope (video or fiberoptic), whereas some require rigid instrumentation. General anesthesia is preferred for most procedures, although it is possible to perform some interventions in a bronchoscopy suite with conscious sedation and topical analgesia.
The subglottis lies between the vocal cords and the proximal trachea. Congenital causes generally present early in life and are characterized by an audible biphasic stridor or a persistent or recurrent croup-type cough. Historically, congenital subglottic stenosis required tracheotomy in over 40% of patients as an early palliative maneuver.1
Acquired subglottic stenosis is commonly associated with antecedent trauma, either externally (e.g., blunt-force injury to the anterior neck) or, more frequently, internally. There is little doubt that this represents an important, often delayed morbidity of laryngotracheal intubation. Airway injury can occur as a result of direct mucosal trauma sustained during intubation, ...