Therapeutic Bronchoscopy Etiology - Benign Stenosis Post - intubation Trauma Post - operative Inflammatory Idiopathic

Endobronchial Palliation of Airway Disease Douglas E. Wood, MD Professor and Chief Division of Cardiothoracic Surgery Vice-Chair, Department of Surgery Endowed Chair in Lung Cancer Research University of Washington

Therapeutic Bronchoscopy Etiology - Benign Stenosis Post - intubation Trauma Post - operative Inflammatory Idiopathic

Therapeutic Bronchoscopy Etiology - Malignant Primary Adenoid cystic Squamous Metastatic Renal cell/breast Local extension Lung Esophageal Thyroid Mediastinal tumor Carcinoid Mucoepidermoid

Therapeutic Bronchoscopy Primary Management Benign - resection and reconstruction Malignant Primary - resection and reconstruction Metastatic - radiation +/- chemotherapy Local extension - radiation +/- chemo

Therapeutic Bronchoscopy Indications Symptomatic stenosis Dyspnea, stridor, obstructive pneumonia Unresectable Extent of airway involvement Metastatic disease Unresectable local invasion Excessive risk of resection

Therapeutic Bronchoscopy Anesthesia Nursing Techniques Close airway collaboration and planning Maintain spontaneous ventilation Standard ventilation Extubate at completion of procedure Familiarity with equipment and routines Preparation for variety of interventions Prepared to assist with emergency airway management

THERAPEUTIC BRONCHOSCOPY Advantages Ventilation anesthesia Direct manipulation Larger instrumentation Larger suction Techniques Rigid Bronchoscopy Ability to place solid stents Disadvantages General Poor distal view Need to intubate

Therapeutic Bronchoscopy Modalities Dilation Core - out Laser Stent Brachytherapy Photodynamic therapy Cryotherapy

Therapeutic Bronchoscopy Indications Dilatation Benign stenosis Techniques Esophageal bougies (8-26 F) Rigid bronchoscope (3.5-10 mm) Hydrostatic balloon (5-18 mm)

Therapeutic Bronchoscopy Core - out Indications Endobronchial tumor Endobronchial granulations Techniques Tips of bronchoscope Biopsy forceps

Therapeutic Bronchoscopy Indications Laser Endobronchial tumor Endobronchial granulations Bleeding or irregular tumor bed Lumen not approachable by rigid bronchoscope Techniques Nd:YAG 2 CO 2 KTP

Therapeutic Bronchoscopy Brachytherapy Indications Small volume endobronchial tumor Maximized external beam radiation Effect maximal for 1-2 cm diameter Technique Single vs multiple catheters Catheter stabilization Dose

Therapeutic Bronchoscopy Indications Stents Recurrent endobronchial tumor Recalcitrant benign stenosis Extrinsic compression Techniques Rigid bronchoscopy Flexible bronchoscopy with fluoroscopy Customization Balloon dilatation

AIRWAY STENTING Anatomic Indications Stent as principal therapy Intrinsic tracheobronchial pathology Amyloid, relapsing polychondritis, malacia Extrinsic compression Stent as adjunct to other endoscopic procedures Endoluminal tumor Recalcitrant stricture

Therapeutic Bronchoscopy Stents Silicone T and T-Y tubes Endoluminal stents Y-stents Expandable Wallstent Permalume Gianturco Palmaz Ultraflex Polyflex Aero

Therapeutic Bronchoscopy Silicone Stents Advantages Adjustable Removable No ingrowth Unreactive Controlled expansion Inexpensive Disadvantages Rigid bronchoscopy Difficult placement Dislodgment inner diameter Distortion

Therapeutic Bronchoscopy Expandable Stents Advantages Flexible bronchoscopy Easy delivery Stable placement Conformation Epithelialization Ventilation through interstices Disadvantages Permanent Difficult adjustment Fluoroscopy Granulations Tumor ingrowth Erosion Expensive

AIRWAY STENTING Tracheobronchial Malacia

AIRWAY STENTING Malacia with 3 stents

AIRWAY STENTING NSCLC Right Mainstem

AIRWAY STENTING NSCLC after Core-Out and Laser

AIRWAY STENTING Right Mainstem Stent Modification of distal stent to prevent obstruction of upper lobe

AIRWAY STENTING NSCLC with Tracheal and Bilateral Obstruction

AIRWAY STENTING Carinal Y-stent

AIRWAY STENTING Bilateral Obstruction from NSCLC

AIRWAY STENTING Bilateral Stents for NSCLC

AIRWAY STENTING Metastatic Sarcoma

AIRWAY STENTING Permalume Tracheal Stent

AIRWAY STENTING Metastatic Sarcoma with Tracheal Compression

AIRWAY STENTING Tracheal Wallstent

Therapeutic Bronchoscopy Treatment Algorithm Symptomatic Obstruction Resectable Airway Resection Benign Dilatation Repeated Recurrence Stent Recurrence Unresectable Malignant Endobronchial Tumor Core-out Laser Brachy Recurrence Extrinsic Compression Stent

Therapeutic Bronchoscopy University of Washington June 1992 to January 2002 Includes dilatation, core-out, out, laser, stent, brachytherapy, PDT 92-02 99-02 Patients 327 162 Procedures 631 306 Stent procedures 223 123 2002-20122012 approximately 200 procedures/yr

Therapeutic Bronchoscopy Outcomes Successful airway palliation Mortality Patients 158/165 (95.8%) Procedures 318/325 (97.8%) Operative or procedure related 0% Hospital and 30 day 2/165 (1.2%) Complications - 22 in 19 patients (11%) Bleeding 3 Stent migration 9 Perforation 2 Stent occlusion 7

Therapeutic Bronchoscopy Conclusions Excellent airway palliation Improves symptoms, function, quality of life, survival May require multiple interventions Does not replace resection for operable lesions