In Reply to: Case 0300_04 -- Tracheobronchial Stent Placement in a Patient with Compromised Airway due to Radiation-induced Fibrosis posted by Editor on March 07, 19100 at 10:58:25:
Thanks for sharing this interesting case. I do not have experience with tracheobronchial stents and therefore learned alot from your case.
I think we are all reluctant to place stents in patients with benign disease when the longterm results have not been determined. I assume a multi-disciplinary team concluded that no other techniques were available to restore and maintain bronchial patency in this young lady with radiation fibrosis. The only thing I can think of is some form of positive pressure ventilation (CPAP).
I dont know whether I would have stented left mainstem bronchus at initial setting. However, I do believe that the right bronchial Wallstent partially covering the left mainstem bronchus may have contributed to the problems on the left. While we routinely get away with this in the arteries, in the lung this likely prevents clearance of mucous and secretions from the "jailed out" airways. Then when the left mainstem bronchus was stented, the adjacent lip of the right Wallstent had nowhere to go except across the right sided lumen - preventing clearance of secretions etc on the right.
Regarding pleural collection - I strongly agree with early and liberal use of fibrinolytics to enhance drainage. We have been using 2 mg TPA in 30-60 ccs of saline. There is little to lose except for the cost of the agent. Although not proven, I suspect the accelerated drainage and perhaps a better ultimate result more than compensate for the expense of the TPA.
Again, thanks for sharing this interesting case. We often learn the most from cases which do not have the most appealing longterm outcomes.