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THE CORRELATION OF METHACHOLINE BRONCHIAL PROVOCATION TEST AND QUESTIONNAIRE
October 2009, Vol 136, No. 4_MeetingAbstracts Abstract: Case Reports | October 2009
DISINTEGRATION OF POSTERIOR WALL OF RUSCH Y DYNAMIC TRACHEAL STENT: A NEW COMPLICATION Kalpesh P. Patel, MD*; Shaheen Islam, MD; Nitin Bhatt, MD University of Maryland, Baltimore, MD Chest. 2009;136(4_MeetingAbstracts):3S. doi:10.1378/chest.08-2354
Abstract INTRODUCTION: Tracheostenosis is a relatively uncommon complication of many benign and malignant conditions. Airway stents are often used in benign central airway obstruction. As these patients outlive the expected stent life, previously unseen stent related complications are now rising. Silicone stents are preferable in benign condition as it can be removed easily. We report the first case of a new complication of Rüsch Y stent where the posterior wall was disintegrated. During our extensive search we did not find any similar report in the literature. CASE PRESENTATION: In August 2005, 45 year old male developed severe angioedema requiring intubation followed by tracheostomy due to prolonged airway compromise. A month later, he was admitted with severe dyspnea and stridor. Bronchoscopic examination revealed 90% tracheostenosis, about 6 mm in diameter and 2.5 cm from carina. He was treated with Argon plasma coagulation (APC) resection of stenotic area. In the following months he required several APC resections, cryotherapy and balloon dilation to relieve symptoms. Because of the recurrent nature, we decided to place a Dumon silicone stent in February 2006. Although he was decanulated immediately after stent placement, later it migrated 3 times requiring bronchoscopic repositioning and eventual stent removal within a month. We decided to place a Y stent to prevent migration. Dynamic Rüsch Y stent was chosen because it mimics normal trachea and has improved secretion clearance. Patient improved clinically and remained symptom free for 3 years. He underwent 7 follow-up bronchoscopies between April, 2006 and February 2009. Except some granulation tissue at proximal end of the stent no other difficulties were encountered. During last bronchoscopy in February 2009, a defect was found on the posterior wall of the stent with protrusion of tracheal wall during respiration. This was not seen during previous bronchoscopy on February 2008. Because of compromised integrity of the stent and to avoid any ongoing tracheal injury, the stent was removed with rigid bronchoscopy. The stent had foul smell and had a 1.5 cm × 2.0 cm area of posterior wall disintegration.
DISCUSSIONS: In July 2005, Food and Drug Administration (FDA) issued notification against the use of metallic stent in benign conditions. Common complications include stent migration, granulation tissue formation, mucus plugging, infection or stent fracture. Silicone stents are an appropriate choice in benign tracheostenosis. Hour-glass shaped stents or Y stents are less likely to migrate. Rüsch Y stent was chosen as we expected the stent to be in place for a prolonged duration. Because of the difficulty and expertise required for Rüsch Y stent placement, it is not used in most centers, hence long term experience with this stent is limited. Review on 135 cases with Rüsch Y stent from 1997 did not report any similar complication. Possible etiology for this unusual complication could be: 1) Any damage to the stent during placement with Freitag forceps that might have increased in size over time: no such injury was found during immediate post-placement and 7 follow-up bronchoscopies over two years; 2) Chronic cough or even normal breathing causing repeated shear stress to the pliable posterior wall: possible in our case; 3) Infection weakening the stent wall: possible in our case as stent was foul smelling; 4) Chronic Acid reflux: there were no clinical or bronchoscopic evidence such as arytenoid or tracheal inflammation seen in our patient; 5) Smoking related damage to the stent: our patient is non-smoker. CONCLUSION: Disintegration of Rüsch Y Stent is an unusual complication. Although Rüsch Y stent helps with secretion clearance, it may not be an ideal choice in benign cases with an expected duration of more than two years. DISCLOSURE: Kalpesh Patel, No Financial Disclosure Information; No Product/Research Disclosure Information Monday, November 2, 2009 4:30 PM - 6:00 PM
DISINTEGRATION OF POSTERIOR WALL OF RUSCH Y DYNAMIC TRACHEAL STENT: A NEW COMPLICATION Kalpesh P. Patel, MD*; Shaheen Islam, MD; Nitin Bhatt, MD University of Maryland, Baltimore, MD Chest. 2009;136(4_MeetingAbstracts):3S. doi:10.1378/chest.08-2354
Abstract INTRODUCTION: Tracheostenosis is a relatively uncommon complication of many benign and malignant conditions. Airway stents are often used in benign central airway obstruction. As these patients outlive the expected stent life, previously unseen stent related complications are now rising. Silicone stents are preferable in benign condition as it can be removed easily. We report the first case of a new complication of Rüsch Y stent where the posterior wall was disintegrated. During our extensive search we did not find any similar report in the literature. CASE PRESENTATION: In August 2005, 45 year old male developed severe angioedema requiring intubation followed by tracheostomy due to prolonged airway compromise. A month later, he was admitted with severe dyspnea and stridor. Bronchoscopic examination revealed 90% tracheostenosis, about 6 mm in diameter and 2.5 cm from carina. He was treated with Argon plasma coagulation (APC) resection of stenotic area. In the following months he required several APC resections, cryotherapy and balloon dilation to relieve symptoms. Because of the recurrent nature, we decided to place a Dumon silicone stent in February 2006. Although he was decanulated immediately after stent placement, later it migrated 3 times requiring bronchoscopic repositioning and eventual stent removal within a month. We decided to place a Y stent to prevent migration. Dynamic Rüsch Y stent was chosen because it mimics normal trachea and has improved secretion clearance. Patient improved clinically and remained symptom free for 3 years. He underwent 7 follow-up bronchoscopies between April, 2006 and February 2009. Except some granulation tissue at proximal end of the stent no other difficulties were encountered. During last bronchoscopy in February 2009, a defect was found on the posterior wall of the stent with protrusion of tracheal wall during respiration. This was not seen during previous bronchoscopy on February 2008. Because of compromised integrity of the stent and to avoid any ongoing tracheal injury, the stent was removed with rigid bronchoscopy. The stent had foul smell and had a 1.5 cm × 2.0 cm area of posterior wall disintegration.
DISCUSSIONS: In July 2005, Food and Drug Administration (FDA) issued notification against the use of metallic stent in benign conditions. Common complications include stent migration, granulation tissue formation, mucus plugging, infection or stent fracture. Silicone stents are an appropriate choice in benign tracheostenosis. Hour-glass shaped stents or Y stents are less likely to migrate. Rüsch Y stent was chosen as we expected the stent to be in place for a prolonged duration. Because of the difficulty and expertise required for Rüsch Y stent placement, it is not used in most centers, hence long term experience with this stent is limited. Review on 135 cases with Rüsch Y stent from 1997 did not report any similar complication. Possible etiology for this unusual complication could be: 1) Any damage to the stent during placement with Freitag forceps that might have increased in size over time: no such injury was found during immediate post-placement and 7 follow-up bronchoscopies over two years; 2) Chronic cough or even normal breathing causing repeated shear stress to the pliable posterior wall: possible in our case; 3) Infection weakening the stent wall: possible in our case as stent was foul smelling; 4) Chronic Acid reflux: there were no clinical or bronchoscopic evidence such as arytenoid or tracheal inflammation seen in our patient; 5) Smoking related damage to the stent: our patient is non-smoker. CONCLUSION: Disintegration of Rüsch Y Stent is an unusual complication. Although Rüsch Y stent helps with secretion clearance, it may not be an ideal choice in benign cases with an expected duration of more than two years. DISCLOSURE: Kalpesh Patel, No Financial Disclosure Information; No Product/Research Disclosure Information Monday, November 2, 2009 4:30 PM - 6:00 PM