Airway Stents for Excessive Central Airway Collapse: A Randomized Controlled Open-label Trial.

BACKGROUND: Short-term airway stent placement (stent evaluation) has been employed to evaluate whether patients with excessive central airway collapse (ECAC) will benefit from tracheobronchoplasty. Although retrospective studies have explored the impact of stent placement on ECAC, prospective randomized controlled trials are absent. METHODS: This was a randomized open-label trial comparing patients receiving airway stent placement and standard medical treatment (intervention group) versus standard medical treatment alone (control group) for ECAC. At baseline, patients' respiratory symptoms, self-reported measures, and functional capabilities were assessed. Follow-up evaluations occurred 7 to 14 days postintervention, with an option for the control group to crossover to stent placement. Follow-up evaluations were repeated in the crossover patients. RESULTS: The study enrolled 17 patients in the control group [medical management (MM)] and 14 patients in the intervention group. At follow-up, 15 patients in the MM crossed over to the stent group, resulting in a total of 29 patients in the combined stent group (CSG). Subjectively (shortness of breath and cough), 45% of the CSG exhibited improvement with the intervention compared with just 12% in the MM. The modified St. George Respiratory Questionnaire score in the CSG improved significantly from 61.2 at baseline to 52.5 after stent placement (-8.7, P = 0.04). With intervention, the 6-minute walk test in CSG improved significantly from 364 meters to 398 meters (34 m, P < 0.01). The MM did not show a significant change in the St. George Respiratory Questionnaire score or 6-minute walk test distance. CONCLUSION: Short-term airway stent placement in patients with ECAC significantly improves respiratory symptoms, quality of life, and exercise capacity.

Preoperative Workup of Patients With Excessive Central Airway Collapse: Does Stent Evaluation Serve a Role?

BACKGROUND: Tracheobronchoplasty (TBP) is a definitive anatomic intervention for patients with severe symptomatic expiratory central airway collapse. Although stent evaluations have been described for surgical workup, current literature does not address if improvement during stent evaluation is sustained after TBP. We compared health-related quality of life (HRQOL) and functional status responses after airway stenting to those post-TBP. METHODS: A retrospective review was performed in patients with severe expiratory central airway collapse who underwent stent evaluation followed by TBP from January 2004 to December 2019. Baseline, poststent, 3- and 12-month postoperative HRQOL scores, and functional status were analyzed with statistical tests as appropriate. RESULTS: One hundred twenty patients underwent a stent evaluation and TBP. Baseline and stent evaluation measurements were compared with statistically and clinically significant differences in the Cough Quality-of-life Questionnaire (CQLQ) (55 vs. 68, P <0.01), Modified Medical Research Council (mMRC) 0 to 2 (90% vs. 47%, P <0.01), 6-minute walk test (6MWT) (1301 ft vs. 1138 ft, P <0.01). Improvements in the HRQOL and functional status were maintained from stent evaluation to 3 months postoperatively [CQLQ 55 vs. 54, P =0.63; mMRC 0 to 2 (87% vs. 84%), P =0.39; 6MWT 1350 ft vs. 1314 ft, P =0.33], and 12 months postoperatively [CQLQ 54 vs. 54, P =0.91; mMRC 0 to 2 (95% vs. 86%), P =0.74; 6MWT 1409 ft vs. 1328 ft, P =0.13]. The magnitude of change between the data was not significantly different between the stent evaluation, 3-, and 12 months postoperative. Predicted forced expiratory volume in 1-second measurements at baseline, after stent placement, 3 months, and 12 months post-TBP were 74%, 79%, 73%, and 73%, respectively, and not clinically significant. CONCLUSIONS: Improvement after stent evaluation and the magnitude of improvement may be predictive of postoperative outcomes up to 1 year after surgery.

Tracheobronchoplasty yields long-term anatomy, function, and quality of life improvement for patients with severe excessive central airway collapse.

OBJECTIVES: This study examines the long-term anatomic and clinical effects of tracheobronchoplasty in severe excessive central airway collapse. METHODS: Included patients underwent tracheobronchoplasty for excessive central airway collapse (2002-2016). The cross-sectional area of main airways on dynamic airway computed tomography was measured before and after tracheobronchoplasty. Expiratory collapse was calculated as the difference between inspiratory and expiratory cross-sectional area divided by inspiratory cross-sectional area ×100. The primary outcome was improvement in the percentage of expiratory collapse in years 1, 2, and 5 post-tracheobronchoplasty. Secondary outcomes included mean response profile for the 6-minute walk test, Cough-Specific Quality of Life Questionnaire, Karnofsky Performance Status score, and St George Respiratory Questionnaire. Repeated-measures analysis of variance was used for statistical analyses. RESULTS: The cohort included 61 patients with complete radiological follow-up at years 1, 2, and 5 post-tracheobronchoplasty. A significant linear decrease in the percentage of expiratory collapsibility of the central airways after tracheobronchoplasty was present. Anatomic repair durability was preserved 5 years after tracheobronchoplasty, with decrease in percentage of expiratory airway collapse up to 40% and 30% at years 1 and 2, respectively. The St George Respiratory Questionnaire (74.7 vs 41.8%, P < .001) and Cough-Specific Quality of Life Questionnaire (78 vs 47, P < .001) demonstrated significant improvement at year 5 compared with baseline. Similar results were observed in the 6-minute walk test (1079 vs 1268 ft, P < .001) and Karnofsky score (57 vs 82, P < .001). CONCLUSIONS: Tracheobronchoplasty has durable effects on airway anatomy, functional status, and quality of life in carefully selected patients with severe excessive central airway collapse.

Obese Patients Undergoing Tracheobronchoplasty Have Excellent Outcomes.

BACKGROUND: Tracheobronchoplasty (TBP) is the gold-standard treatment for severe symptomatic excessive central airway collapse; however outcomes among obese patients are unknown. METHODS: A retrospective, single-center analysis was conducted on consecutive patients undergoing TBP for severe symptomatic excessive central airway collapse from 2003 to 2020. Demographics, comorbidities, functional status, and perioperative complications were collected. Functional status was assessed with a 6-minute walk test (6MWT). Health-related quality of life (HRQOL) was assessed with the St George's Respiratory Questionnaire (SGRQ), Cough-specific Quality of Life Questionnaire, and modified Medical Research Council dyspnea scale (mMRC) at baseline and postoperatively. Wilcoxon rank-sum and χ2 tests were used to compare outcomes between groups. A mixed-effects regression model compared 6MWT and HRQOL over time. RESULTS: One hundred three patients underwent TBP with complete follow-up data. Thirty-four patients (33%) were obese (body mass index ≥ 35 kg/m2). Baseline demographics were similar between obese and nonobese groups, but obese patients had worse preoperative SGRQ and mMRC scores. Overall complication rates were similar (52.9% vs 43.5%, P = .36). At 3 months there was no significant difference in SGRQ, Cough-specific Quality of Life Questionnaire, or 6MWT scores; however mMRC scores were higher in obese patients (P = .04). At 12 months there was no significant difference in SGRQ, Cough-specific Quality of Life Questionnaire, mMRC, or 6MWT scores. Correcting for age, sex, and Charlson Comorbidity Index a mixed-effects regression model demonstrated obesity was not an independent predictor for lower 6MWT scores or HRQOL. CONCLUSIONS: Obese patients achieve similar improvement in HRQOL and functional capacity with comparable morbidity after TBP as nonobese patients. Obesity should not preclude patients with severe symptomatic excessive central airway collapse from TBP.

Argon Plasma Coagulation (APC) for the Treatment of Excessive Dynamic Airway Collapse (EDAC): An Animal Pilot Study.

BACKGROUND: Surgical stabilization of the airway through tracheobronchoplasty (TBP) is the current treatment modality for patients with severe symptomatic excessive dynamic airway collapse. However, TBP is associated with increased morbidity and mortality. Bronchoscopic treatment of the posterior membrane using argon plasma coagulation (APC) may be a safer alternative to TBP in highly selected patients. This study aimed to evaluate the effect of APC in the tracheobronchial tree of a sheep animal model. PATIENTS AND METHODS: Two adult sheep were used for this study. Under flexible bronchoscopy, the posterior tracheal membrane was treated with precise APC using different power settings. Chest computed tomography was done at 2 days and bronchoscopy was performed at 30 days following initial procedure, before euthanasia. The airways were assessed for the presence of treatment-related histopathologic changes along with expression of genes associated with fibrosis. RESULTS: There was no perioperative or postoperative morbidity or mortality. Chest computed tomography showed no signs of pneumomediastinum or pneumothorax. Flexible bronchoscopy showed adequate tracheobronchial tissue healing process, independent of the power settings used. Histologic changes demonstrated an increased extent of fibroblastic collagen deposition in the treated posterior membrane when higher power settings were used. In a similar manner, APC treatment managed to activate fibrosis-associated gene transcription factors, with higher settings achieving a higher level of expression. CONCLUSION: APC at high-power settings achieved higher levels of fibroblast collagen deposition at the posterior membrane and higher expression of fibrosis-associated gene transcription factors, when compared with lower settings.

Sensitivity and Safety of Electromagnetic Navigation Bronchoscopy for Lung Cancer Diagnosis: Systematic Review and Meta-analysis.

BACKGROUND: Bronchoscopy is a useful tool for the diagnosis of lesions near central airways; however, the diagnostic accuracy of these procedures for peripheral pulmonary lesions (PPLs) is a matter of ongoing debate. In this setting, electromagnetic navigation bronchoscopy (ENB) is a technique used to navigate and obtain samples from these lesions. This systematic review and meta-analysis aims to explore the sensitivity of ENB in patients with PPLs suspected of lung cancer. RESEARCH QUESTION: In patients with peripheral pulmonary lesion suspected of lung cancer, what is the sensitivity and safety of electromagnetic navigation bronchoscopy compared to surgery or longitudinal follow up? STUDY DESIGN AND METHODS: A comprehensive search of several databases was performed. Extracted data included sensitivity of ENB for malignancy, adequacy of the tissue sample, and complications. The study quality was assessed using the QUADAS-2 tool, and the combined data were meta-analyzed using a bivariate method model. A summary receiver operatic characteristic curve (sROC) was created. Finally, the quality of evidence was rated using the Grading of Recommendations Assessment, Development and Evaluation approach. RESULTS: Forty studies with a total of 3,342 participants were included in our analysis. ENB reported a pooled sensitivity of 77% (95% CI, 72%-82%; I2 = 80.6%) and a specificity of 100% (95% CI, 99%-100%; I2 = 0%) for malignancy. The sROC showed an area under the curve of 0.955 (P = .03). ENB achieved a sufficient sample for ancillary tests in 90.9% (95% CI, 84.8%-96.9%; I2 = 80.7%). Risk of pneumothorax was 2.0% (95% CI, 1.0-3.0; I2 = 45.2%). We found subgroup differences according to the risk of bias and the number of sampling techniques. Meta-regression showed an association between sensitivity and the mean distance of the sensor tip to the center of the nodule, the number of tissue sampling techniques, and the cancer prevalence in the study. INTERPRETATION: ENB is very safe with good sensitivity for diagnosing malignancy in patients with PPLs. The applicability of our findings is limited because most studies were done with the superDimension navigation system and heterogeneity was high. TRIAL REGISTRY: PROSPERO; No.: CRD42019109449; URL: https://www.crd.york.ac.uk/prospero/.

Safety and Efficacy of the Tracheobronchial Bonastent: A Single-Center Case Series.

BACKGROUND: Tracheobronchial stents are widely used devices in interventional pulmonology; however, the current literature on the effectiveness and complication rates of the different types of stents is limited. OBJECTIVE: We report the largest case series of airway Bonastent placement and describe the efficacy and early (<30 days) and late (≥30 days) complication rates. METHODS: We performed a retrospective review of our prospectively collected database of patients who underwent therapeutic bronchoscopy with stent placement. All adult patients who had a tracheal/bronchial Bona-stent placed between July 1, 2017, and July 30, 2019, for any indication at our institution were included. The efficacy as well as intraoperative and short- and long-term complications of Bonastent placement were evaluated. RESULTS: Sixty Bonastents were placed in 50 patients. The etiology was malignant in 90% of the cases, while 2 patients had a tracheoesophageal fistula. All procedures were performed via rigid bronchoscopy. The most common location for stent placement was the bronchus intermedius, followed by the trachea, in 32 and 30% of the cases, respectively. Seventy percent of the patients (35/50) had improvement of respiratory symptoms within 30 days. Twenty-eight stents (48%) were removed at a mean of 74 days. Seventeen patients (34%) died within 30 days of stent placement. The overall complication rate was 54% (27/50 patients) at a mean follow-up of 111 days. The stent-related complication rate was 23.3% (14/60 cases) within <30 days and 53% (18/34 cases) at ≥30 days. CONCLUSIONS: The tracheobronchial Bonastent is effective for the treatment of patients with central airway obstruction and tracheoesophageal fistulae with an acceptable safety profile.

Deep Brain Stimulation Surgery for Status Dystonicus: A Single-Center Experience and Literature Review.

BACKGROUND: Status dystonicus (SD) is a life-threatening complication in which episodes of dystonic movements become increasingly frequent and severe, requiring urgent hospital admission, and can lead to respiratory, metabolic, and bulbar complications. Pharmacologic treatment has been the mainstay management for this complication; however, many refractory patients will still require further treatment. Deep brain stimulation (DBS) is an established therapeutic strategy that has been used for dystonia, and now it has been proposed to be used for SD. METHODS: In this case series, we describe our experience with early DBS placement in 5 patients with SD to control symptoms that are refractory to pharmacologic therapy. In addition, we present a literature review of this therapy in the treatment of SD. RESULTS: Before discharge, symptomatic relief (decrease of dystonic movements and resolution of abnormal postures) was evidenced in all patients with a median of 3 days (interquartile range, 1-7) after surgery was performed. A follow-up Unified Dystonia Rating Scale score and Burke-Fahn-Marsden rating scale motor subscale score, at 6 months after hospital discharge with values being inferior to 20 and 30, respectively, for all cases. None of the patients had a recurrence of SD in the last follow-up period. CONCLUSIONS: DBS surgery is a suitable, versatile, reversible and adequate therapy in the treatment of SD that is refractory to initial pharmacologic treatment.

Caracterización del realce meníngeo intracraneal / Intracranial Meningeal Enhancement Characterization

Objetivo: Describir las características del realce meníngeo intracraneal (RMI) como hallazgo en resonancia magnética y su comportamiento según las diferentes patologías asociadas descritas en la literatura científica. Materiales y métodos: Estudio descriptivo de corte transversal realizado con información recolectada de 89 estudios, entre enero y diciembre de 2011, en los cuales se encontró realce meníngeo como hallazgo positivo en la lectura original. Cada estudio fue sometido a nueva revisión por un neurorradiólogo para la caracterización morfológica del realce meníngeo. Resultados: Las causas más frecuentes de RMI fueron enfermedad metastásica (21,3 %), etiología infecciosa (21,3 %), antecedente de cirugía intracraneal (20,2 %) y neoplasias primarias (13,5 %). Del total de las infecciones del sistema nervioso central (19 casos) se documentó infección por VIH en 12 pacientes (70,6 %). El paciente con antecedente quirúrgico de mayor antigüedad fue sometido a craneotomía 17 años antes de la toma de la resonancia magnética incluida en el estudio, en la cual persiste el realce aunque no se han definido signos de recidiva por imagen o por clínica hasta 2015. El tipo de realce más frecuente fue el leptomeníngeo (46,1 %), seguido del mixto (43,8 %) y el paquimeníngeo (10,1 %). En el subgrupo de realce leptomeníngeo, las etiologías más frecuentes fueron infecciosa (31,7 %), enfermedad metastásica (19,5 %) y neoplasias primarias (17,1 %), persistiendo esta tendencia en el subgrupo de realce paquimeníngeo. En el subgrupo de realce mixto, la etiología posquirúrgica fue la primera causa (35,9 %), seguida de la enfermedad metastásica (23,1 %) y las infecciones (18 %). En los casos de etiología infecciosa se encontró un predominio del patrón de realce leptomeníngeo, nodular y difuso, sin realce paquimeníngeo, como único tipo de realce. Conclusión: Aunque un patrón de realce meníngeo determinado no es indicativo de una patología específica, el estudio detallado de sus características puede aportar información que permite plantear grupos diagnósticos, particularmente en casos de etiología neoplásica o infecciosa, aporte de relevancia en casos en que el realce meníngeo anormal es la única alteración evidente en una resonancia magnética.

Objective: To describe the characteristics of intracranial meningeal enhancement (IME) as magnetic resonance imaging findings and their behavior under different associated conditions as described in the scientific literature. Materials and methods: Descriptive cross-sectional study with data collected from the images archive between January and December of 2011, obtaining 89 eligible studies in which it was determined, in the original reading, presence of IME as positive finding. Each study was subjected to further review by a neuroradiologist of the institution for morphological characterization of the IME. Results: The most common causes of IME were: metastatic disease (21.3%), infectious etiology (21.3%), history of intracranial surgery (20.2%) and primary neoplasms (13.5%). Of total CNS infections (19 cases), HIV infection was documented in 12 patients (70.6%). The patient with the oldest surgical history underwent craniotomy 17 years before performing the MRI included in the study, with persistance of IME with no signs of recurrence defined by image or clinical manifestations up to 2015. The most frequent IME type was leptomeningeal (LME) (46.1%), followed by mixed (MME) (43.8%) and pachymeningeal (PME) (10.1%) enhancements. In the subgroup of LME, the most common etiologies were: infectious (31.7%), metastatic disease (19.5%) and primary neoplasms (17.1%). This trend persisted in the subgroup of PME. In the subgroup of MME, post-surgical etiology was the leading cause (35.9%), followed by metastatic disease (23.1%) and infections etiologies (18%). Conclusion: Although a particular pattern of meningeal enhancement is not indicative of a specific pathology, detailed study of its features can provide information that allow the proposal of diagnostic groups, particularly in cases of neoplastic or infectious etiology, relevant contribution in cases where the abnormal meningeal enhancement is the only anormality in MRI.