Treatment of bronchial airway obstruction using a rotating tip microdebrider: a case report
© Kennedy et al; licensee BioMed Central Ltd. 2007
Received: 21 November 2006
Accepted: 26 March 2007
Published: 26 March 2007
Central airway obstruction is a common complication of lung cancer. The microdebrider is a new device available for treatment of central airway obstruction.
We report a case a 59-yr-old male with T3N2M1 non-small cell lung cancer with malignant distal left mainstem obstruction treated successfully with a novel elongated rotating tip microdebrider via rigid bronchoscopy with sufficient length to reach distal bronchial lesions.
Discussion and Conclusion
The microdebrider is an excellent addition to the spectrum of interventions available for the management of central airway obstruction with advantages including accuracy and immediate removal of debris without a need for separate suctioning or limitation in oxygenation.
The microdebrider is a recent addition to the armeratarium available to the interventional bronchoscopist for central airway occlusion, following the successful application of laryngeal microdebriders for over a decade [1–3]. However, limitations of the microdebrider include maneuverability and length (37 cms) which limits use to the trachea and proximal main-stem bronchi. We report a case of malignant distal left main-stem obstruction treated with a new elongated rotating tip microdebrider (45 cms) via rigid bronchoscopy with sufficient length to reach distal bronchial lesions.
A 53-yr-old male with T3N2M1 non-small cell left upper lobe lung cancer with bilateral brain metastases diagnosed one-month prior was referred for management of dyspnea and hemoptysis. The patient had noted a dramatic increase in dyspnea over the prior 3 days. Past medical history was unremarkable and he had a negative smoking history.
Discussion and Evaluation
Approximately 20–30% of patients with lung cancer will develop airway obstruction and therefore the management of airway obstruction is a vital component of the services provided by an interventional pulmonology program . Many modalities are currently available, the majority of which rely on thermal injury to the targeted area. These techniques include electrocautery, argon plasma coagulation, cryotherapy, laser therapy, brachytherapy and photodynamic therapy, each with their own advantages and disadvantages . Disadvantages of thermal modalities as a group include uncontrolled thermal injury to normal tissue with complications such as perforation and fistula, limitation of inspired oxygen concentration because of the risk of endobronchial fire and the need for separate suction devices, which requires intermittent removal of the thermal device from the bronchoscope with prolongation of the procedure.
Microdebriders accomplish debridement using a powered rotating blade coupled with suction allowing rapid removal of debris. To date, microdebriders have been used primarily in sinus surgery and advantages include rapid accurate debridement with maintenance of vision because of instantaneous removal of blood and debris through integrated suction . Subsequently, microdebriders were designed for the management of laryngotracheal carcinoma with successful debridement and avoidance of tracheotomy . Tracheal blades were subsequently designed up to 37 cm in length and allowed access to tracheal lumen and proximal mainstem and a retrospective analysis of 23 patients highlighted successful treatment of tracheal granulation tissue, idiopathic subglottic stenosis and malignant disease . The novel device used in this case report has a number of advantages over prior microdebrider devices. The added length (8 cm) allows access to distal bronchial lesions. The rotating tip allows better maneuverability and precision, reducing the possibility of debriding normal tissue.
It is unclear presently what modality is superior for the treatment of central airway obstruction. Approaches depend on the lesion involved and operator preference and experience. We agree with other authors that microdebridement is useful when precision is essential; especially where high flow oxygen is required . A comparison of microdebrider bronchoscopy to thermal modalities to identify the best strategy for the management of central airway obstruction will be difficult, because of the difficulty of designing blinded randomized controlled trials in this critically ill population. In fact, this case highlights the benefit of using multiple modalities to treat central airway obstruction. The limitations of one modality (bleeding and damage of tissue for pathological inspection with microdebridement) can often be overcome by combining various therapeutic options.
In conclusion, this case report details the successful management of a distal left mainstem obstructing malignant lesion with a combination of therapies including a novel elongated microdebrider with rotating tip. Prospective trials are required to identify specific indications for this therapy along with long-term outcomes in the management of central airway obstruction.
Competing or Financial interests
The author(s) declare that they have no competing interests.
= computed tomography
The authors wish to acknowledge that the microdebrider device and image was supplied by Medtronic, Jacksonville, Florida.
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