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Multilevel dilatation of tracheal and bronchial stenosis using a non-occlusive tracheal dilatation balloon in a patient with sclerosing airway disease

      Introduction

      A 33-year-old female presented with acute upper airway obstruction secondary to laryngeal stenosis, for which she initially received a tracheotomy, then a laryngectomy. She suffers a progressive inflammatory process involving her entire respiratory tract, that has resulted in stenosis of the nasal passages, trachea distal to the tracheotomy site, and bilateral bronchi. At presentation, her condition was critical, requiring serial multilevel dilatations of the airway to maintain patency. Sequential dilatation with solid bougies was undesirable because of concerns for airway trauma, and the fact that her laryngectomy and anatomy precluded the use of a rigid bronchoscope. The patient was considered for surgery under cardiopulmonary bypass or extra-corporeal membrane oxygenation, but was declined as a candidate for either therapy due to the very low likelihood of success of definitive reconstructive surgery.

      Method

      We elected to use a novel, non-occlusive tracheal dilatation balloon currently under investigation at our facility. Ethical approval and informed consent for compassionate use were prospectively obtained. Anaesthesia with spontaneous ventilation was provided with a balanced technique using nebulised lignocaine, intravenous dexmedetomidine infusion and sevoflurane in oxygen. Flexible fibreoptic endoscopy using a paediatric bronchoscope via the tracheostomy demonstrated tracheal, left and right main bronchus stenosis (4.7, 3.0 and 6.0 mm respectively). Endoscopy was performed through a catheter mount with bronchoscopy adaptor to allow continuous ventilation. By passing the tracheal dilatation balloon parallel to the tracheostomy tube, the trachea was dilated with continuous spontaneous ventilation. To dilate the left main bronchus (LMB), a guide-wire was passed through the bronchoscope into the bronchus, the bronchoscope withdrawn and then placed parallel to the tracheostomy tube, and the balloon passed over the guide-wire into the LMB. Ventilation of both lungs during dilatation was confirmed clinically. It was elected to allow these two sites a chance to heal, and a second dilation procedure was subsequently performed in the same fashion after 14 days.

      Results

      Dilatation at each site with the non-occlusive balloon was performed for 3 minutes without interruption of spontaneous breathing, oxygenation or ventilation, as confirmed by pulse oximetry and waveform capnography. The patient’s respiratory compromise improved rapidly with each procedure, and there were no complications other than minor transient mucosal bleeding at the dilation sites.

      Discussion

      This case documents the first use of a non-occlusive tracheal dilatation balloon for multilevel endoscopic dilation of the trachea and bronchi. Importantly, this technique allows dilatation of intrathoracic stenosis in patients with difficult airway anatomy and/or limited physiological reserve. Prospective evaluation of the device in a series of adult patients is currently underway.