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Our Experience of Placement of Airway Sems in
Three Different Scenarios of Lung and
Esophageal Malignancy
Sarath Chandra Kadur Srikanta Rao1Nandakishore Baikunje1Chandramouli Mandya Thimmaiah1
Rajesh Venkataram2Giridhar Belur Hosmane1
1Department of Pulmonary Medicine, KS Hegde Medical Academy,
Mangaluru, Karnataka, India
2Department of Pulmonary Medicine, Yenepoya Medical College,
Mangalore, Karnataka, India
J Health Allied Sci
NU
2024;14:66–70.
Address for correspondence Giridhar B. H., MD, PhD, Department of
Pulmonary Medicine, KS Hegde Medical Academy, Deralakatte,
Mangaluru 575018, Karnataka, India
(e-mail: giridhar.belur@gmail.com).
Background
Central airway obstruction can be of benign or malignant
etiology, of which malignancy is the more common cause.
Malignant central airway obstruct ion occurs in 20 to 30% of
patients with lung cancer and is usually associated with poor
prognosis. Timely therapeutic intervention, endobronchial
debulking and tracheobrochial stenting give immediate re-
lief to the patient by improving the airway lumen and hence a
better quality of life.
Tracheoesophageal fistula (TEF) is a pathological communi-
cation of the trachea and the esophagus. It can be congenital or
acquired. It can be further classified as benign etiology or
malignant etiology. Thoracic malignancy such as carcinoma
lung or esophagus can lead to TEF by direct extension of the
tumor, as a result of surgery, chemotherapy, radiotherapy or
pre-existing stent erosion into the adjacent structures. Due to
the advanced stage of malignancy, most patients will be eligible
only for palliative proceduressuch as endobronchial stenting as
compared with surgery. Hereby, we present three such scenari-
os of tracheobronchial stenting for palliative purpose.
Case Presentation
Case 1
A woman in her late 40s presented with a diagnosis of carcinoma
middle one-third of the esophagus with systemic hypertension
presented with a history of cough, expectoration, and exertional
dyspnea since 4 weeks. Expectoration was mucoid in consistency,
nonfoul smelling, and not blood-stained. There were no com-
plaints of fever, chest pain, orthopnea, or paroxysmal dyspnea.
She also had complaints of dysphagia, generalized weakness, and
loss of weight. Her dysphagia was more to solids than liquids. She
Keywords
►central airway
obstruction
►endobronchial
stenting
►tracheoesophageal
fistula
►SEMS
Abstract Malignant central airway obstruction refers to the obstruction of the trachea, and right
or left main bronchus due to neoplastic growth. The airway is generally compromised
by 50% at presentation when the patient develops symptoms. Diagnosis is done by
flexible bronchoscopy and imaging. However, treatment is challenging due to recur-
rence, and increased vascularity of tumors, owing to dreaded complications of
bleeding and airway compromise. Tracheoesophageal fistula is an abnormal commu-
nication of the trachea with the esophagus. It occurs in advanced stages of esophageal
and lung malignancy. Bronchoscopy and airway stenting is the palliative treatment
option due to the advanced stage of the disease. We present three different case
scenarios of thoracic malignancies who underwent airway stenting.
article published online
November 8, 2023
DOI https://doi.org/
10.1055/s-0042-1758037.
ISSN 2582-4287.
© 2023. The Author(s).
This is an open access article published by Thieme under the terms of the
Creative Commons Attribution License, permitting unrestricted use,
distribution, and reproduction so long as the original work is properly cited.
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Original Article
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Article published online: 2023-11-08
was diagnosed with squamous cell carcinoma esophagus 1 year
ago for which she had received radiotherapy and chemotherapy.
On examination, she had a saturation of 90% in room air, a heart
rate of 100 bpm, a respiratory rate of 25 breathsper min, biphasic
stridor, and respiratory distress. She had made multiple hospital
visits for recurrent respiratory infections and was under follow-
up with her oncologist for regular chemotherapy and radiation
therapy. She underwent a diagnostic bronchoscopy in her local
hospital that revealed the central airway obstruction secondary to
the extension of the esophageal growth into the trachea. She was
referred to our center for further management of the endotra-
cheal obstruction.
All relevant investigations were done. A blood workup
showed leukocytosis. Liver and renal function tests were
within normal limits. CECT showed soft tissue density-
enhancing mass lesion measuring 20 2327 m m in the
upper thoracic esophagus at D1 and D2 levels. Anteriorly, it is
seen infiltrating the tracheal lumen causing luminal stenosis
The patient was started on oxygen via nasal cannula at 2
L/min, antibiotics, steroids and bronchodilator nebulization.
Oxygen taperedto room air gradually.Repeat CT thorax and 3D
reconstruction of the central airways were done to find out the
extent of the lesion. The lesion was located at a distance of
52.9 mm from the subglottis and the extent of the lesion was
17.2 mm. The lesion caused a near-total occlusion of the
trachea leaving behind a narrow opening of 2.4 mm for venti-
lation (►Figs. 1–2)Aflexible self-expanding metallic stent of
6 cm in length was chosen to have a margin of 2 cm on either
side of the lesion. The patient was intubated with the rigid
tracheoscope under general anesthesia in the operating room.
Under direct vision with the telescope, the guidewire was
passed through the narrowlumen beyond the lesionand a self-
expanding stent was deployed. (►Fig. 3) The patient was
extubated on the table, she tolerated the procedure well.
Post-procedure repeat CT thorax was done to assess the stent
expansion and placement. Tracheal lumen patency was re-
established.The patient’s respiratory distress reduced and was
discharged the next day on steroids, antibiotics, and antihy-
pertensives. She was advised to follow up on her chemothera-
py and radiotherapy course.
The patient presented after 5 months of tracheal stent
placement wi th complaints of cough and expec toration since
4 weeks. On examination, saturation was 95% in room air
with bilateral equal air entry, and normal vesicular breath
sounds. Repeat chest X-ray and repeat bronchoscopy were
done, which confirmed the position of the stent. She was
treated symptomatically and is undergoing regular
chemotherapy.
Fig. 1 Pre procedure airway measurements –Distance of the stenosis
from subglot tis - 52.9 mm. Length of stenosis –17.2 mm. The patent
lumen at the stenosed part –2.4 mm.
Fig. 2 Bronchoscopic view of the intraluminal growth in the trachea
causing near-total obstruction.
Fig. 3 Post procedure –post endotracheal stenting CT thorax view of
the stenosed part.
Journal of Health and Allied Sciences
NU
Vol. 14 No. 1/2024 © 2023. The Author(s).
Airway Sems Placement in Lung and Esophageal Malignancy Rao et al. 67
Case 2
The second case is about a female patient in her late 50s
who presented with a history of cough, expectoration since
4 months. She had gradually progressive breathlessness
since 2 months. She also had an evening rise in temperature
and loss of weight. However, there was no dysphagia,
hoarseness of voice, or abdominal complaints. On examina-
tion, oxygen saturation was 98% in room air, pulse rate was
90 bpm, blood pressure was 120/80 mmHg, respiratory rate
was 20 breaths per min. Respiratory system examination
revealed bilateral equal air entry, no added sounds. Patient
had undergone flexible bronchoscopy in another hospital
which diagnosed an intraluminal growth in the lower end of
the trachea causing luminal narrowing histopathologically
diagnosed as nonsmall cell lung cancer –squamous cell
carcinoma. CT thorax and image 3D reconstruction of the
central airways was performed to confirm the obstruction,
examine for distal airway patency, and find the extent of the
lesion. The intraluminal lesion was located in the lower end
of the trachea arising from the right later wall of the
trachea. The lesion extended for 22.4 mm with the narrow-
est part of the lumen measur ing 1.3 mm. Under general
anesthesia, rigid bronchoscopic intubation was done, a
flexible bronchoscope was used to pass the guidewire
beyond the lesion. Self-expanding metallic stent deployed
under fluoroscopic guidance. It is worth noting the difficul-
ty while deploying the stent that the stent was getting
deployed much proximally as expected. The stent had to be
withdrawn out through the rigid bronchoscope to be
reloaded and redeployed much distally to the expected
stent placement location. The stent position was confirmed
by a flexible bronchoscope and chest X-ray. Tracheal lumen
re-established thereby immediately relieving the patient’s
symptoms (►Fig. 4). The patient was referred to a medical
oncologist for further management.
Case 3
The third case was a male patient in his sixth decade presented
with a cough since 1 month, vomiting since 1 month, fever
episodes on, and off since 1 week. The patient also had a history
of weight loss and loss of appetite. On examination, he had an
oxygen saturation at 96% in room air, pulse rate was 95 beats
per min, and respiratory rate was 18 breaths per min. Respira-
tory system examination revealed equal air entry bilaterally and
crepitations in infra scapular and mammary areas. Upper
gastrointestinal scopy was done with a biopsy from the mid-
dle-third of the esophagus, which turned out to be squamous
cell carcinoma. The patient was referred to look for a trachea
esophageal fistula. Flexible bronchoscopy was done, which
showed a fistulous opening connecting the trachea and esoph-
agus at the lower end of the trachea just above the carina
(►Figs. 5 and 6). Rigid bronchoscopy was done under general
anesthesia. The challenge during the stent placement was that
after deployment of the stent, the polyvinyl bead at the distal
end of the stent deployer dislodged and remained behind in the
airway. The polyvinyl bead of the stent deployer had to be
removed. Because the conical part was difficult to grasp with
rigid forceps, fogarty balloon was passed distal to it and slowly
withdrawn. The stent was reloaded and deployed under fluoro-
scopic guidance(►Fig. 7). The rent in the air way was covered by
the stent. The patient’s presenting symptoms reduced.
Fig. 5 Tr ach eo esop hagea l fistula in the lower end of the trachea.
Fig. 4 Re-established lumen after endotracheal stenting.
Journal of Health and Allied Sciences
NU
Vol. 14 No. 1/2024 © 2023. The Author(s).
Airway Sems Placement in Lung and Esophageal Malignancy Rao et al.68
Discussion
Malignant central airway obstruction refers to a neoplastic
narrowing of the trachea, right and left main bronchus. Obstruc-
tive lesions are classified into intraluminal (intrinsic), extra-
luminal (extrinsic), or a combination of both. The neoplastic
etiology can be a primary lung tumor or adjacent tumors such as
esophageal, laryngeal, mediastinal tumors, or lymphoma.
Symptoms are dyspnea, cough, hemoptysis, wheezing, or post
obstruction pneumonia. Our patient had cough, wheezing,
exertional dyspnea along with swallowing difficulty.
Diagnosis is by flexible bronchoscopic examination and
visualization of the trachea bronchial obstruction. Once
diagnosed, treatment is challenging due to the following
reasons a) difficult to debulk the tumor with a flexible
bronchoscope owing to bleeding and the need for rigid
bronchoscopy and b) the risk of airway compromise and
need for a pre-decided plan of hemostasis such as electro-
cautery and APC.1The aim of treatment in malignant central
airway obstruction is to re-establish the patency of the
airway lumen. In case of an intrinsic obstruction, this can
be achieved by tumor debulking by cryoprobe, multiple
biopsies, and coring the tumor with the beveled edge of
the tracheobronchoscope. To maintain patency and prevent
the lumen to be compromised, a tracheobronchial stent may
be placed. In case of an extrinsic compression causing airway
luminal narrowing, the patient benefits by the placement of
an airway stent along with treating the cause.2In our case,
the patient underwent a check bronchoscopy with flexible
bronchoscope, followed by rigid bronchoscopy and tracheal
stenting with a self-expanding metallic stent.
A rigid tracheo-bronchoscope is the instrument of choice
in case of airway manipulation due to its larger lumen and
ability to use varied instruments along with ventilation.2
Because the lesion of interest in our case was in the mid-part
of the trachea, a rigid tracheoscope was used.
Airway stents have an important role in rapid and effec-
tive symptom-relieving in central airway obstruction. Stents
can be silicone, metallic, or hybrid material. Further metallic
stents are classified into uncovered, covered, and partially
covered stents. The choice of stent depends on the patient’s
pathology.3Metallic stents are difficult to remove as com-
pared with silicone stents due to the ingrowth of granuloma
and tumor tissue around the stent. The general consensus is
that metallic stents are used in malignant obstruction as the
stent will be left in place for the rest of the patient’s lifetime,
whereas silicone stents can be removed easily in the benign
condition once the cause is treated. The US FDA recommends
against using metallic stents in benign conditions.4The
commonest type of stent being used around the world is
the covered self-expandable metal stents (SEMS). Covered
SEMS mean use was 44%, followed by the silicone stents
(37%), Y stents (15%), uncovered SEMS (12%), and Montgom-
ery T tube (5%).5
TEF often occurs with tracheal and esophageal malignan-
cies. Approximately 5 to 15% of patients develop TEF due to
esophageal malignancy, while 1% are caused by bronchogen-
ic carcinoma.6Patients usually present with cough while
having food or fluids, purulent bronchitis, and pneumonia. In
view of advanced disease in malignancy patients, surger y is
often not possible. Such patients are ideal for tracheal
stenting with or without esophageal stenting.
Learning Points/Take Home Messages
•Malignant central airway obstruction is a common
occurrence.
•SEMS placement provides immediate symptom relief in
lung malignancy with central airway obstruction and
tracheoesophageal fistula on palliative care.
•It establishes airway patency and improves the quality of
life.
Conflict of Interest
None declared.
Fig. 6 Conicaldistalendpieceofthestentdeployer.
Fig. 7 Endo luminal view of Y stent after deployment.
Journal of Health and Allied Sciences
NU
Vol. 14 No. 1/2024 © 2023. The Author(s).
Airway Sems Placement in Lung and Esophageal Malignancy Rao et al. 69
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NU
Vol. 14 No. 1/2024 © 2023. The Author(s).
Airway Sems Placement in Lung and Esophageal Malignancy Rao et al.70
