Journal of Bronchology & Interventional Pulmonology:
Marshall University Joan C. Edwards School of Medicine, Huntington, WV
Reprints: Shadi Obeidat, MD, Marshall University Joan C. Edwards School of Medicine, 1249 15th Street, Huntington, WV 25701 (e-mail: email@example.com).
Received for publication November 9, 2009; accepted January 19, 2010
Source of support: None.
There is no conflict of interest.
Dynamic Y stents are used in tracheobronchial obstruction, tracheal stenosis, and tracheomalacia. Placement may be difficult and is usually accomplished using a rigid grasping forceps (under fluoroscopic guidance) or a rigid bronchoscope. We report using a new stent placement technique on an elderly patient with a central tracheobronchial tumor. It included using a flexible bronchoscope, video laryngoscope, and laryngeal mask airway. The new technique we used has the advantages of continuous direct endoscopic visualization during stent advancement and manipulation, and securing the airways with a laryngeal mask airway at the same time. This technique eliminates the need for intraoperative fluoroscopy.
Dynamic Y stents (bifurcated tracheobronchial stents) are indicated for tracheobronchial obstruction, tracheal stenosis, and tracheomalacia. Placement is usually accomplished blindly using a rigid grasping forceps under fluoroscopic guidance. An alternative approach is stent insertion using a rigid bronchoscope. Either way, the stent can be difficult to insert through the vocal cords, and placement using a rigid grasping forceps under fluoroscopy lacks direct visualization while manipulating the stent in the trachea. Furthermore, prolonged manipulation may compromise the patient's airways and oxygenation. We report a case in which we used a new technique for the dynamic Y stent placement.
The patient was a 72-year-old man with stage 4 nonsmall cell lung carcinoma, status after radiation and chemotherapy, who developed an endobronchial lesion partially obstructing the lower trachea and the right main bronchus (Fig. 1).
He initially underwent argon plasma coagulation and debridement of the lesions. Three days later, he had a repeat bronchoscopy for the consideration of a stent placement. Measurements of the needed stent were confirmed using computed tomography guidance and flexible bronchoscopy, and it was decided to use a dynamic Y stent (Boston Scientific, Natick, MA), 1.3 cm in diameter and 5 cm in length above the carina. The vocal cords were anesthetized using topical lidocaine before the introduction of the stent. A video laryngoscope was introduced to visualize the vocal cords. When the patient was still under moderate conscious sedation and was spontaneously breathing oxygen through the nasal cannula, the lubricated stent was introduced using a 17″ alligator forceps and advanced completely through the vocal cords in a vertical manner under direct visualization on the video laryngoscope screen. Once inside the trachea it was oriented horizontally. The stent was then released and the forceps was retracted and removed. The patient was preoxygenated with 100% oxygen before a size 5 laryngeal mask airway (LMA) was placed, gas anesthesia was subsequently started and the patient was ventilated through the LMA. A therapeutic flexible bronchoscope was then introduced through the LMA and advanced through the vocal cords. A flexible grasping forceps (FG-4L-1 Olympus, used in endoscopy for foreign body retrieval) was introduced through the bronchoscope to grasp the stent at the bifurcation. The stent was pushed using the bronchoscope to the appropriate position with gradual release of the forceps until the bifurcation saddled exactly on the carina (Fig. 2). The stent was then completely released from the forceps before the bronchoscope was removed. Appropriate positioning of the stent was confirmed with fluoroscopy and later with a 3-dimensional computed tomographic scan (Fig. 3). Of note, an ENT specialist was available for back-up to perform rigid bronchoscopy or emergent tracheostomy in case the patient became hypoxic or the stent was malpositioned.
Dynamic Y stent is most commonly used in patients with malignant central airway disease. Other indications include tracheomalacia, tracheal stenosis, tracheoesophageal fistula, or stenosis secondary to lung transplantation. Stent placement can be technically difficult1 and airways may be compromised if prolonged manipulation is required. There has been no consensus on a single technique for stent placement, but the most widely used approaches use rigid bronchoscope2–4 or rigid forceps/introducer under fluoroscopic guidance. Rigid bronchoscopy requires significant exposure to general anesthesia and might not be suitable for all patients. Fluoroscopic mapping technique may involve excessive exposure of patients and staff to radiation. In addition, vocal cords may be obscured when trying to introduce the stent. Many other techniques have been suggested to avoid these difficulties. Heitz and Bolliger5 reported a modified technique in which a guidewire was used with assistance of bronchoscopy for direct observation of the passage through the larynx. Strausz et al6 modified the original insertion technique, replacing the rigid bronchoscope with a flexible bronchoscope. Other techniques have also been tried to eliminate fluoroscopy.7
The new technique we used has the advantage of continuous direct endoscopic visualization during stent advancement and manipulation. Using a video laryngoscope helps to prevent vocal cord injury when introducing the stent, and LMA helps to secure the airways and avoid hypoxia, especially if the procedure requires prolonged manipulation. This technique eliminates the need for intraoperative fluoroscopy, thus saving patients and staff from excessive radiation exposure; it also decreases the use of general anesthesia.
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