Technique of Dilation

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The instruments that should be available include rigid bronchoscopes, ranging as follows: 3.5, 4, 5, 6, 7, 8, and 9 mm sizes (Figure 19-1). Jackson bronchoscopes with a ventilating sidearm are preferred. These bronchoscopes have the advantage of a somewhat rounded character to their bevelled tip. This contrasts with the rather sharp, spade-like lip of Storz bronchoscopes (see Figure 5-3 in Chapter 5, "Diagnostic Endoscopy"). The latter, in pediatric sizes, are superb for diagnostic examination in infants and children but are less advantageous for dilation of tight stenoses. Small-sized Jackson-Pilling esophageal bougies should be available. These may be difficult to obtain. Standard bronchoscopic biopsy forceps, both straight and angled, should also be available. A wide suction cannula is essential. A zero degree Hopkins telescope is used.

The lesion is visualized through an adult bronchoscope and secretions are cleared. Dilation is commenced with successively larger bougies. The full length of the bougie is not passed, to avoid distal injury of the membranous wall. At this point, it is sometimes possible to advance the adult bronchoscope over a larger bougie, with a firm but gentle corkscrewing motion, after engaging the bronchoscope's tip in the stenotic orifice. Excessive force should not be used, nor should this be done blindly. The stricture may be far firmer than normal tracheal tissue. If excessive force is used prior to adequate dilation, the broncho-scope could perforate the softer membranous wall just above the stricture. For the same reason, an endo-tracheal tube must not be forced through a stenosis over a stylet. If there is firm resistance, or if it appears nonfeasible, then the patient should be ventilated briefly, with the proximal end of the bronchoscope occluded either with the thumb or an occlusive window. At any point during these maneuvers, should the anesthetist request that manipulations cease in order to ventilate the patient through the undilated stricture, the surgeon must comply immediately.

Jackson pediatric bronchoscopes are used next. The starting size is chosen after visualizing the stenosis. The smaller pediatric bronchoscopes (3.5 to 5 mm) are passed through the vocal cords with a laryngoscope. A Jackson laryngoscope with a removable slide is ideal for this purpose (Figure 19-2). Other laryngoscopes

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figure 19-1 Instruments for tracheal dilations. From top to bottom: adult Jackson ventilating bronchoscope (7, 8, and 9 mm); range of small diameter semirigid plastic esophageal bougies which will pass through a 7 mm bronchoscope; 9 mm by 25 cm ventilating bronchoscope, useful but not essential for treating subglottic stenosis; pediatric ventilating Jackson bronchoscopes (3.5, 4, 5, and 6 mm).

figure 19-1 Instruments for tracheal dilations. From top to bottom: adult Jackson ventilating bronchoscope (7, 8, and 9 mm); range of small diameter semirigid plastic esophageal bougies which will pass through a 7 mm bronchoscope; 9 mm by 25 cm ventilating bronchoscope, useful but not essential for treating subglottic stenosis; pediatric ventilating Jackson bronchoscopes (3.5, 4, 5, and 6 mm).

may be used, with a straight Miller blade being preferred. The slide must be removed from the Jackson intubating laryngoscope so that the laryngoscope can be removed after a short bronchoscope has been inserted. The bronchoscope is introduced through the stenosis with a firm but gentle, slightly rotary movement. Secretions are aspirated as necessary. The patient is immediately ventilated vigorously, with the proximal end of the bronchoscope occluded. With even a 3.5 mm bronchoscope, it is possible to attain entirely satisfactory levels of oxygenation and CO2 removal. When the anesthesiologist agrees that it is safe to proceed, the next sized bronchoscope is passed. Serial dilations continue until adult-sized bronchoscopes are passed. The surgeon must decide how large a bronchoscope to pass without danger of splitting the trachea. It is almost always possible in adults to carry dilation through a 7 or 8 mm bronchoscope, effectively a 9 to 10 mm diameter. After the airway has been thoroughly cleansed, and the patient is well oxygenated and stable, the last bronchoscope is withdrawn and the patient awakened.

A stenosis, particularly when inflamed, may be divulsed by dilation. Bits of granulation tissue and torn fragments of scar that remain on the tracheal wall are removed patiently and conservatively with biopsy forceps before withdrawing the bronchoscope. I have never encountered excessive bleeding with these maneuvers. Minimal bleeding from biopsy can be easily tamponaded with the bronchoscope, and soon stops. If spontaneous ventilation has been used, it is usually unnecessary to intubate the patient following the procedure. If undue secretions figure 19-2 Jackson laryngoscope to facilitate rigid bronchoscopy. The slide attached to the blade is removed prior to the introduction of a pediatric bronchoscope, since the latter is too short to allow the slide (and hence the bronchoscope) to be removed after passing the bronchoscope. Because of the small diameter of a 3.5 or 4 mm broncho-scope, the intubating laryngoscope greatly facilitates their passage.

figure 19-2 Jackson laryngoscope to facilitate rigid bronchoscopy. The slide attached to the blade is removed prior to the introduction of a pediatric bronchoscope, since the latter is too short to allow the slide (and hence the bronchoscope) to be removed after passing the bronchoscope. Because of the small diameter of a 3.5 or 4 mm broncho-scope, the intubating laryngoscope greatly facilitates their passage.

or blood are present or if the patient breathes poorly, an endotracheal tube is passed through the dilated area for adequate toilet until the patient is fully awake. Ventilation is seldom necessary.

Dilation performed precisely in this stepwise fashion has been completely safe in our hands, in hundreds of patients. Deviations or loss of control could easily lead to neurologic damage or death. The airway that is attained may remain satisfactory in caliber for days to months (Figure 19-3). The length of palliation is highly unpredictable. Subsequent management depends on the therapeutic plan for the basic disease. If patients are expected to need frequent dilations, require a long wait before definitive surgery, will be returning to uncertain medical supervision, or are unsuitable for repair and hence require permanent splinting, then a T tube should be considered.

Stenosis due to postintubation cuff injury responds well in the short term to dilation since the pathology consists principally of a circumferential cicatrix. In contrast, stomal stenosis is the result of contraction of an anterior defect, which pulls the tracheal walls together. The dilating bronchoscope is therefore easily passed through a stomal stenosis, but the walls of the trachea snap back together again as soon as the dilating instrument is withdrawn. The bronchoscope will remove granulomas that may be present on the anterior scar, producing some immediate relief.

A laser can be used to trim part of a stenosis adjacent to the tracheal lumen. Granulations can also be removed. Laser excision to any depth risks perforation of an hourglass stenosis into the mediastinum, esophagus, or brachiocephalic artery. In stomal stenosis, lasering to any depth will destroy the contracted tracheal wall. Radial laser incisions followed by dilation have been recommended. There is little to indicate that the laser improves upon direct bronchoscopic dilation for acute obstruction. Repeated laser treatment produces more scarring and can lengthen a previously short lesion. It is not very satisfactorily curative. Experienced practitioners hence advise use of laser definitively only in thin, "web-like" benign stenosis.1,2 Such lesions are vanishingly rare and also respond to simple dilation urgently and to surgical resection definitively (see Chapter 37 "Laser Therapy for Tracheobronchial Lesions"). Institution of a tracheostomy below a stenotic lesion to permit repeated laser treatments is to be deplored, since it compounds the lesion by damaging a greater length of trachea (see Figure 10-2A in Chapter 10, "Tracheostomy: Users, Varieties, Complications").

Tracheostomy should generally not be used to manage acute obstruction. Dilation, performed as described, is preferred, since it does not injure more trachea, which makes future resection more complicated. If tracheostomy must be used, either acutely or to temporize after initial dilation, it should ideally be placed through the stenotic segment if this is accessible in the neck. Future resection will remove both stenosis and stoma without loss of more trachea. If the stenosis is below the sternal notch, and tracheostomy is necessary for some reason, it should be placed at the level of the second ring, the distal stenosis dilated, and a tube introduced that is long enough to pass through the dilated stricture.

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  • yonas
    How do bronchi and trachea dilated?
    3 years ago

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