Endobronchial Obstruction: The Impact of Interventional Pulmonology on Morbidity & Mortality

 The Case: 

  • 64 yo M veteran smoker w PMH severe COPD on 4L O2 by NC, pAfib on AC, admitted in December for progressive dyspnea over weeks, found to have a bronchus intermedius obstruction due to extrinsic compression from a NSCLC mass near the right hilum.  

Portable CXR on admission

Portable CXR 3 days later

  • Basic Statistics on Morbidity & Mortality in NSCLC
    • 5 yr Survival NSCLC (w Rx):
      • Stage I: 60-80%
      • Stage II: 40-50%
      • Stage III: 10-20%
      • Stage IV: <<10%
    • 40-85% of NSCLC patients will have symptoms related to the primary tumor.
      • Cough, dyspnea, wheeze, hemoptysis
    • QoL is influenced by:
      • Tumor itself
      • Metastases
      • Treatment
      • Paraneoplastic syndromes
  • Indications for airway stenting are:
    • Extrinsic stenosis of central airways with or without intraluminal components due to malignant or benign disorders
    • Complex, inoperable tracheobronchial strictures
    • Tracheobronchial malacia
    • Palliation of recurrent intraluminal tumor growth
    • Central airway fistulae (esophagus, mediastinum, pleura)
  • Contraindications
    • Nonviable lung is present beyond the obstruction
    • Extrinsic compression of an airway by a vessel
  • Stent related complications
    • Displacement
    • Mucus impaction
    • Granuloma formation at stent ends
    • Re-obstruction by tumor
    • Halitosis
    • Infection
    • Perforation of airway walls
    • Hemoptysis
    • Pain
    • Cough
    • Fire (during laser resection)

NOTE:  No prospective, randomized trials exist on the utility of palliative stenting for proximal airways obstruction for obvious ethical reasons.  The following conclusions were drawn from single-center prospective cohort / observational studies published in the literature about their centers’ experience with these patients and their centers’ available interventions.

Conclusions

  • Interventional Pulmonology procedures (such as stenting) should be considered for palliation of large airway obstruction in malignant disease
  • Patients can anticipate an improvement in dyspnea and spirometric measures, but overall QoL is not as clear
  • Complications are not rare, but most patients demonstrate overall benefit from intervention.
  • With achieved airway patency, mortality approximates that of patients without previous obstruction.  However, no center to date has evaluated the impact of large airway stenting versus not-stenting on mortality from malignant endotracheal or endobronchial obstruction.  One can imagine the challenging ethical issues regarding this.

žReferences

  1. —Bollinger et al.  ERS/ATS statement on interventional pulmonology.  Eur Respir J 2002; 19: 356-373
  2. —Chhajed PN, Baty F, Pless M, et al. Outcome of treated advance non-small cell lung cancer with and without airway obstruction. Chest 2006;130:1803–7.
  3. —Ferrell et al. Palliative Care in Lung Cancer.  Surg Clin North Am. 2011 April ; 91(2): 403–ix.
  4. —Amjadi et al. Impact of Interventional Bronchoscopy on Quality of Life in Malignant Airway Obstruction.  Respiration 2008; 76: 421-428.

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