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

doi:10.1016/j.jtcvs.2022.05.037

The Journal of Thoracic and Cardiovascular Surgery

Volume 165, Issue 2, February 2023, Pages 518-525

https://doi.org/10.1016/j.jtcvs.2022.05.037 Get rights and content

Abstract

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.

Graphical abstract

Section snippets

Study Design and Cohort

This is a longitudinal study of sequential repeated measurements of airway collapsibility in patients who underwent TBP for severe ECAC. The study was approved on July 2005 by the Beth Israel Deaconess Medical Center Institutional Review Board (Protocol No. 2005P-000112). Written informed consent was obtained from all patients before any study interventions.

The study cohort included patients 18 years and older diagnosed with severe symptomatic ECAC who underwent TBP from 2002 to 2016. Severe

Results

Between January 2002 and December 2016, our cohort consisted of 162 patients. A total of 75 patients (46.29%) had postoperative complications, with 38 (23.45%) having severe complications (Clavien Dindo Score >3a). Of these, only 3 patients died of complications related to surgery. Only 7 patients underwent re-do TBP during the study period. Of the remaining 152 patients (excluding the 3 who died and the 7 with re-do TBP), 61 with severe ECAC who had undergone TBP with consecutive repeated

Discussion

Our study shows that patients with severe ECAC undergoing central airway stabilization with TBP demonstrate mid-term and long-term clinical benefit with regard to airway anatomy, respiratory symptoms, QOL, functional status, and exercise capacity in patients with severe ECAC. The anatomic improvement was greatest at years 1 and 2, with a marked decrease (improvement) in the degree of expiratory airway collapse up to 40% and 30%, respectively. In general, the repair durability persisted at

Conclusions

In this largest longitudinal study reported to date, we have shown that TBP has beneficial midterm and long-term effects on airway anatomy, respiratory symptoms, functional status, QOL, and exercise capacity outcome measures in a carefully selected cohort of patients with severe symptomatic ECAC. We believe that despite the limitations of this study, the results in our study are innovative and compelling, and further justify this aggressive surgical approach for these patients with significant

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Cited by (1)

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2023, Revue des Maladies Respiratoires
Le collapsus trachéobronchique expiratoire regroupe la trachéobronchomalacie, maladie des anneaux cartilagineux et le collapsus dynamique excessif des voies aériennes, bombement majeur de la membraneuse au niveau la paroi postérieure. La symptomatologie repose sur des signes respiratoires peu spécifiques comme la dyspnée, la toux ou les difficultés d’expectoration. Le diagnostic est obtenu lors d’épreuves dynamiques, par l’endoscopie bronchique et/ou le scanner. La trachéobronchomalacie peut être primaire (génétique, idiopathique) ou secondaire liée à un traumatisme, une trachéotomie, une intubation, une intervention chirurgicale, une transplantation, un emphysème, une infection, une inflammation, une bronchite chronique, une compression extrinsèque ou à des anneaux vasculaires non diagnostiqués dans l’enfance. Certains algorithmes décisionnels thérapeutiques ont été proposés, mais aucune recommandation précise n’a été établie. Le traitement, d’abord médical (prise en charge de la pathologie sous-jacente, parfois associée à la ventilation non invasive), est réservé aux malades symptomatiques, après évaluation du retentissement de la maladie (statut fonctionnel et perfomance status du malade, évaluation des symptômes et de la qualité de vie par différents scores). Si les symptômes persistent, d’autres traitements sont discutés. Au sein de l’arsenal thérapeutique, la bronchoscopie interventionnelle permet : (1) la sélection des malades pouvant bénéficier du traitement chirurgical de référence, avec la mise en place d’une endoprothèse comme test thérapeutique avant trachéobronchoplastie ; (2) la pose d’endoprothèses dans les voies aériennes chez les malades non chirurgicaux, dans le but d'obtenir une amélioration des symptômes et de la qualité de vie, au prix d’effets secondaires majeurs liés aux endoprothèses ; (3) la prise en charge de la majorité des complications associées aux endoprothèses (obstruction, granulomes, migration fracture) ; (4) des alternatives thérapeutiques avec la possibilité de techniques thermo-ablatives. Enfin, le développement de nouvelles endoprothèses pourrait permettre de diminuer le taux de complications. Ces différentes options restent encore très discutées à l’heure actuelle.
Tracheobronchomalacia is usually characterized by more than 50% expiratory narrowing in diameter of the trachea and the bronchi. The expiratory collapse includes two entities: (1) the TBM related to the weakness of the cartilaginous rings, and (2) the Excessive Dynamic Airway Collapse (EDAC) due to the excessive bulging of the posterior membrane. Patients have nonspecific respiratory symptoms like dyspnea and cough. Diagnosis is confirmed by dynamic tests: flexible bronchoscopy and/or computed tomographic scan of the chest. There are different forms of tracheobronchomalacia in adults: primary (genetic, idiopathic) or secondary to trauma, tracheotomy, intubation, surgery, transplantation, emphysema, infection, inflammation, chronic bronchitis, extrinsic compression; or undiagnosed in childhood vascular rings. Some management algorithms have been proposed, but no specific recommendation was established. Only symptomatic patients should be treated. Medical treatments and noninvasive positive pressure ventilation should be the first line therapy, after evaluation of various quality measures (functional status, performance status, dyspnea and quality of life scores). If symptoms persist, therapeutic bronchoscopy permits: (1) patient's selection by stent trial to determine whether patient benefit for surgical airway stabilization; (2) malacic airways stenting in patients who are not surgical candidates, improving QOL despite a high complication rate; (3) the management of stent-related complication (obstruction, plugging, migration granuloma); (4) alternative therapeutics like thermo-ablative solution. Lasty, the development of new types of stents would reduce the complication rates. These different options remained discussed.

: Beth Israel Deaconess Medical Center Institutional Review Board (Protocol No. 2005P-000112), approved July 2005.

: Presented at the 2019 Annual Meeting of the American College of Chest Physicians, New Orleans, Louisiana.

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

Abstract

Objectives

Methods

Results

Conclusions

Graphical abstract

Section snippets

Study Design and Cohort

Results

Discussion

Conclusions

Clin Chest Med

Arch Bronconeumol

Ann Thorac Surg

J Thorac Cardiovasc Surg

Chest

Radiol Clin North Am

Respir Med

Chest

J Clin Epidemiol

Ann Thorac Surg

Ann Thorac Surg

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