Palliative intubation of the trachea and main bronchi

J THORAC CARDIOVASC SURG 80:736-741, 1980

Palliative intubation of the trachea and main bronchi A method is presented for the endoscopic intubation of malignant tumors of the trachea and main bronchi with a Souttar tube. This is appropriate when urgent relief (~t' respiratory obstruction is necessary and when the tumor is unsuitable for resection. Eight patients have been so treated, with relief of symptoms for up to 70 weeks in seven, The method fed led in one patient, There were no operative deaths.

David B. Clarke, M.B., F.R.C.S.,* Birmingham, England

W

hen malignant tumors of the trachea intrude upon the lumen to the extent that respiratory obstruction with distressing stridor results, urgent measures to restore the airway are demanded. Events cannot wait upon the careful preoperative planning and complicated techniques required for resection of the trachea, carina, or the origins of the main bronchi. A method of palliative intubation of the major air passages with Souttar tubes designed for the esophagus is presented. This has succeeded in securing immediate relief of symptoms in seven of eight patients treated. The tube is well tolerated and the patients usually are not aware of its presence. The technique is appropriate when surgical excision is contraindicated by excessive length of the tumor or mediastinal spread. However, in the cases to be described, urgent relief of respiratory obstruction was the prime objective. Once this had been achieved consideration was given to the feasibility of tracheal resection. In no case was this appropriate, because of the length of trachea and main bronchi involved by tumor, an unfavorable cell type, evidence of involvement of the esophagus, the age and debility of the patient, or the presence of other malignant lesions in the larynx or lung. Operative procedure

The clinical presentation and the penetrative chest radiograph give reasonably accurate localization of the site of airway obstruction. If the condition of the patient From Queen Elizabeth Hospital, Birmingham, England. Received for publication Dec. II, 1979. Accepted for publication April 14, 1980. 'Consultant Cardiothoracic Surgeon.

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is not critical, additional information may be obtained from a tracheogram or tracheal tomogram. A Negus bronchoscope, with provision for Venturi ventilation, is passed under general anesthesia after preliminary oxygenation with a face mask. The site and severity of the obstruction are immediately apparent. It is usually possible to shoulder the tip of the bronchoscope past the tumor into the air passages beyond and, after aspirating secretions, to ensure adequate relief of hypoxia by a further period of ventilation. Rarely it will be necessary to force a passage through the tumor with the tip of the bronchoscope and biopsy forceps. Bleeding is seldom troublesome and can be controlled by diathermy coagulation by means of biopsy forceps insulated with a length of rubber tubing (Fig. I). Diathermy coagulation will also shrivel the tumor and further enlarge the airway. The surgeon and his nurse assistant must wear rubber gloves to protect themselves from painful diathermy burns, and care must be taken to ensure that the rubber tube insulation prevents the metal biopsy forceps from touching the bronchoscope or the patient will sustain burns of the lip and tongue. The method of intubation is determined by the fact that a Souttar tube cannot be passed through a bronchoscope. A Souttar tube is selected of a diameter determined by the surgeon's appraisal of the size of the trachea. A tube with an outer diameter of 8 mm usually is satisfactory, but a larger tube may be employed on occasion. It is cut to an appropriate length and the coils are pulled apart at the distal end (Fig. 2). This ensures that if the tip of the tube rests on the carina, the origins of the two main bronchi are not obstructed, and if the tube is passed into the right main bronchus, air can pass between the expanded coils into the upper lobe of the right lung.

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Fig. I. Diathermy fulgeration of the tumor with insulated biopsy forcep s.

Fig. 3. Bougie passed through the tumor.

eMS Fig. 2. Souttar tube prepared by distracting the distal coils of the spring .

The following steps must be performed with speed as, for a time. the airway will be completely obstructed: A gum elastic bougie is passed down the bronchoscope and through the obstruction into the right main bronchus (Fig. 3). The bronchoscope is removed and a laryngoscope is used to obtain a view of the larynx. The Souttar tube is threaded over the bougie and advanced into the trachea with McGill angled forcep s (Fig . 4) . The bronchoscope is now reintroduced by sliding it over the bougie. Its tip engages the upper end of the Souttar tube, and firm pressure is used to drive the tube through the site of obstruction until its lower end is in either the lower trachea or the right main bronchus (Fig . 5) . The bougie is now removed and patenc y of the tube is confirmed by passing a suction catheter through it. Any fragments of tumor which may have been displaced into the lumen of the tube or the distal bronchial tree are removed with biopsy forceps or suction.

Fig. 4. Souttar tube advan ced over bougie .

Difficulty may be experienced in intubat ing a left main bronchus obstructed by a fungating tumor . As the tube negotiates the sharp angle into the lumen of the bronchus, its inferior margin will tend to plough up a sliver of tumor which obstructs the tube (Fig . 6) . Thi s complication led to failure in one patient. Extrinsic compression of the bronchus does not present this problem. Both main bronchi can be intubated when a tumor at the carina produces bilateral airway obstruction.

Results Eight patients have been treated by emergency intubation of the trachea or main bronchi, with immediate symptomatic relief in seven . The anatomic sites of obstruction are indicated in Fig . 7. All presented with

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Fig. 5. Bronchoscope used to impact the Souttar tube in the tumor.

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Fig. 6. Difficulty experienced in intubating the left main bronchus. The Souttar tube ploughs into the tumor. acute respiratory distress and stridor. Age and sex of the patients, tumor cell type, site of intubation, and length of survival are detailed in Table I. In the patient in whom technical difficulties prevented the intubation of the left main bronchus, temporary relief was afforded by fulgerating a passage through the tumor with diathermy. Patients were unaware of the presence of the tube and none complained of the irritating cough which might have been expected to be produced by a metallic object in contact with the carina. Further procedures have been necessary in three patients. In one, the first patient in the series to be treated, intubation was required after repeated fulgeration of a squamous carcinoma of the trachea. The patient's age and poor general

Thoracic and Cardiovascular Surgery

health were considered to be contraindications to surgical excision or radiotherapy. Dyspnea was relieved and he remained well until stridor recurred 2 months later. At repeat bronchoscopy tumor was found to be extending over the orifice of the tube. This was removed by diathermy fulgeration, to reveal further obstruction caused by tumor growing between the coils of the spring. The tube was grasped with insulated forceps and a coagulating diathermy current was passed until the tumor shriveled and turned black. The fragments were then removed from the lumen without difficulty. Six months later dysphagia developed because of extension of the tumor into the esophagus. This was palliated with an esophageal Souttar tube. In the second patient to require a repeat procedure, a recurrent adenocarcinoma of the esophagus developed 21 months after esophagectomy. This invaded the trachea and led to his urgent admission to the hospital with respiratory obstruction. Effective palliation was achieved by intubation until 2 months later, when he again presented with stridor and profuse hemoptysis. At bronchoscopy the tumor was observed to have extended proximally and to be obstructing the Souttar tube. This was removed and replaced by a longer tube. Profuse bleeding into the trachea followed this procedure, but this ceased spontaneously and he left the hospital breathing without difficulty. He had no further episodes of hemoptysis. Further extension of the tumor necessitated resiting the tube 3 months later. Multiple intubations were required in a 70-year-old man with a carinal tumor obstructing both main bronchi. Tubes were inserted into the right and left main bronchi (Fig. 8) with relief of symptoms until 16 weeks later, when he presented with dysphagia caused by extension of the tumor into the esophagus. A third Souttar tube was inserted but he died 2 days later. Megavoltage radiotherapy was used in five of the eight patients. It was contraindicated in two because of previous irradiation and debility. One patient died before treatment could be commenced. The quality of life was greatly improved. No patient complained of an irritating cough attributable to the tube and only one was aware of the sensation of a foreign body in the trachea. This sensation was not distressing. In patients successfully intubated, survival has been from 4 to 70 weeks and all have been capable of light activities. The patient who survived longest, a man of 79, died quietly shortly after cleaning his car. The tube became displaced in one case when, following a course of radiotherapy, it passed from the trachea into the right main bronchus. A nonmalignant stricture subsequently developed with recurrence of stridor. This

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(

Fig. 7. Sites of malignant obstruction in eight patients. Table I. Palliative intubation of trachea and bronchi Age (yrj

Sex

Type

Sites intubated

Palliated for:

Remarks

79 72 70 49 56 70 56 58

M M M M F M M M

Squamous Squamous Squamous Squamous Squamous Oat cell Squamous Adenocarcinoma

Trachea Trachea Right and left main bronchi Failed-left main bronchus Right main bronchus Right main bronchus Trachea Trachea

70 wk 4 wk 16 wk Died 3 days 50 wk Alive 16 wk Alive 20 wk Alive 28 wk

Diathermy four times before intubation Lung and larynx carcinoma Plus esophageal Souttar tube and radiotherapy

stricture was dilated and the tube was replaced in the trachea in order to maintain patency. Discussion

Few surgeons have been able to acquire an experience with malignant tumors of the trachea as wide as that reported by Grillo." He concluded that resection with reconstruction of the trachea offers the best palliation and chance for cure in squamous cell carcinoma and adenoid cystic carcinoma, but 23 of the 63 patients in his series were not suitable for operation. A mortality rate of 15% was incurred; it was not possible to predict survival from the rather small number of patients studied. The method of palliative intubation presented here is appropriate when surgical excision is contraindicated

Radiotherapy Radiotherapy Revised once, radiotherapy Revised twice, radiotherapy

by excessive length of the tumor or mediastinal spread or when there is need for urgent relief of respiratory obstruction. Intraluminal stents for the relief of benign trachea stenosis have been reported by Harkins," who used a metal alloy tube, by Montgomery," who devised a silicone T-tube that was inserted through a tracheostomy, and by Duvall and Bauer, ~ who modified the Montgomery tube so that it could be inserted at bronchoscopy. Pagliero and Shepherd" used a stainless steel wire coil to stent a stricture that resulted from the dehiscence of a tracheal anastomosis. The use of a metal rather than a plastic tube when radiotherapy is to be employed has no disadvantage. Indeed, there are theoretical reasons to expect a margi-

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The Journal of Thoracic and Cardiovascular Surgery

Fig. 8. A, Preoperative radiograph showing complete obstruction of the left main bronchus. Band C, Postoperative radiographs after intubation of right and left main bronchi. The left lung has partially re-expanded. D, Tomograph showing positions of Souttar tubes. nal improvement in the efficacy of therapy because of local scatter of the irradiation in the region of the metal coil. Palliation of malignant obstruction of the trachea has been achieved by repeated endoscopic resection. In two cases of carcinoid and adenoid cystic carcinomas reported by Nakratzas and his colleagues," survival for 9 and 3 years, respectively, was attained, but less satisfactory results are obtained with more malignant tumors, and repeated endoscopy is necessary." Endoscopic resection of the tumor followed by radiotherapy gives worthwhile relief of respiratory obstruction, but the danger of hemorrhage during resection of extensive or vascular tumors is a disadvantage of this method. Bleeding has not been a serious problem in patients treated by intubation. A small number of patients treated by bronchoscopic resection with a laser beam have been described. 8

Cryotherapy has been employed successfully in the management of papillomas of the trachea, but as yet there is little reported experience with its use in malignant tumors. Karja and his colleagues? treated five patients without achieving long-term palliation; Holden and McKelvie!" described the successful treatment of two patients with recurrent tumor in the tracheostome following laryngectomy for carcinoma. Repeated applications of the cryoprobe were needed. The use of a Souttar tube for this purpose does not appear to have been described previously. The value of palliative intubation of the esophagus is widely appreciated; the average survival period is 156 days. II When used in the trachea, the Souttar tube achieves results which equal these if not bettering them, and the quality of life enjoyed by the patients approaches normality. The hazard of embarking on a course of radiotherapy

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when the lumen of the trachea is critically narrowed by tumor is avoided. The principal advantage of the method is that distressing symptoms are alleviated immediately and the patient is discharged from the hospital shortly thereafter. This contrasts favorably with palliation achieved at the expense of a major operation with a prolonged period of convalescence in a patient with a short life expectancy. More than 40 years' experience has confirmed the value of the Souttar tube in the management of inoperable carcinoma of the esophagus." It is possible to achieve equally gratifying relief of distressing symptoms by using the technique in the management of malignant lesions involving the major air passages. REFERENCES Grillo H: Tracheal tumors. Surgical management. Ann Thorac Surg 26:112-125, 1978 2 Harkins WB: An endotracheal metallic prosthesis in the treatment of stenosis of the trachea. Ann Otol Rhinol Laryngol 61:663-675, 1952 3 Montgomery WW: Silicone tracheal T-tube. Ann Otol Rhinol Laryngol 83:71-75, 1974

4 Duvall AJ, Bauer W: An endoscopically introducible T-tube for tracheal stenosis. Laryngoscope 87:20312037, 1977 5 Pagliero KM, Shepherd MP: Use of stainless steel wire coil prosthesis in treatment of anastomotic dehiscence after cervical tracheal resection. J THORAC CARDIOVASC SURG 67:932-935, 1974 6 Nakratzas G, Wagenaar JPN, Reintjes M, Scheffer E, Swierenga J: Repeated partial endoscopic resections as treatment for two patients with inoperable tracheal tumours. Thorax 29:125-131, 1974 7 Houston HE, Payne WS, Harrison EO, Olsen AM: Primary cancers of the trachea. Arch Surg 99: 132-139, 1969 8 Laforet EG, Berger RL, Vaughan CW: Carcinoma obstructing the trachea. Treatment by laser resection. N Engl J Med 294:941-943, 1976 9 Karja J, Jokinen K, Paiva A: Experiences with cryotherapy in otolaryngological practice. J Laryngol Otol 89:519-526, 1975 10 Holden HB, McKelvie P: Cryosurgery in the treatment of head and neck neoplasia. Br J Surg 59:709-712, 1972 II Ammann MD, Collis JL: Palliative intubation of the esophagus. J Thorac Cardiovasc Surg 61:863-869, 1971 12 Souttar HS: Cancer of the esophagus. Br Med J 2:797, 1934