What are the current guidelines for the management of tracheal stenosis?

Management of Tracheal Stenosis: Current Guidelines

For patients with tracheal stenosis, both therapeutic bronchoscopy and surgical resection are recommended treatment options, with the choice depending on the type of stenosis, patient factors, and available expertise. 1

Initial Assessment and Diagnosis

• A comprehensive evaluation should include respiratory-focused history, physical examination, chest CT scan, and appropriate laboratory investigations to determine the etiology and extent of tracheal stenosis 1
• Tracheal stenosis is defined as part of central airway obstruction (CAO), characterized by 50% or greater occlusion of the trachea 1

Treatment Approach Based on Stenosis Type

For Benign Tracheal Stenosis:

• Simple stenosis (web-like):

  • First-line: Bronchoscopic treatment with airway dilation alone or combined with other modalities 1, 2
  • Success rates for simple stenosis with bronchoscopic treatment approach 100% 2

• Complex stenosis:

  • Consider either open surgical resection or therapeutic bronchoscopy based on stenosis characteristics 1, 3
  • For recurrent stenosis after multiple interventions, silicone stenting may provide effective management 3

Therapeutic Bronchoscopy Options:

1. Rigid bronchoscopy is preferred over flexible bronchoscopy for therapeutic interventions 1

   • General anesthesia/deep sedation is recommended over moderate sedation 1
   • Either jet ventilation or controlled/spontaneous assisted ventilation can be used 1

2. Specific bronchoscopic techniques:

   • For stenosis: Airway dilation (alone or combined with other modalities) 1, 4
   • For endobronchial disease: Tissue excision and/or ablation 1
   • Local therapy options include:
     • Mitomycin C application (75% success rate at 4 months) 1
     • Laser resection 5, 4
     • Balloon dilation 2, 4

3. Stent placement:

   • Reserved for cases where other bronchoscopic and systemic treatments have failed 1
   • Silicone stents are preferred for benign stenosis as they are removable and resistant to microbial colonization 3
   • After stent placement, either routine surveillance bronchoscopy or symptom-driven bronchoscopy is acceptable 1

Surgical Options:

• For benign post-intubation tracheal stenosis, surgical reconstruction remains the gold standard for definitive treatment in suitable candidates 3, 5
• For complex stenosis with failed bronchoscopic management, surgical approach is recommended 1, 2
• Tracheostomy may be considered in select patients who are not surgical candidates 1

Algorithm for Management

1. Initial classification of stenosis as simple or complex 2

   • Simple: Web-like, short segment
   • Complex: Long segment, involving multiple structures, inflammatory

2. For simple stenosis:

   • Begin with bronchoscopic treatment (dilation ± laser) 5, 2
   • If unsuccessful after up to three sessions, consider surgical sleeve resection 5

3. For complex stenosis:

   • Initial bronchoscopic treatment with temporary stent placement 5
   • Assess operability after 6 months 5
   • If operable and stenosis recurs after stent removal, proceed to surgery 5
   • If inoperable, consider permanent palliative stenting 5

Special Considerations

• For patients with tracheobronchomalacia, noninvasive ventilation may be considered as primary intervention 1
• For severe tracheobronchomalacia refractory to noninvasive ventilation, a stent trial followed by tracheobronchoplasty may be considered 1
• In elderly patients with comorbidities, flexible bronchoscopic treatment modalities have shown 87% success rates over long-term follow-up 4

Complications and Follow-up

• Most common complication is granulation tissue formation 3, 4
• High-dose rate endobronchial brachytherapy may be used for refractory stent-related granulation tissue 4
• Long-term surveillance is necessary, particularly for patients with stents 1

Caution

• All current recommendations are based on very low certainty of evidence 1
• Treatment decisions should be made by a multidisciplinary team with expertise in airway management 1
• Mortality remains high for patients with complex stenosis, particularly those with associated cardiac malformations 6