Endoscopic management of patients with excessive central airway collapse: a narrative review

Abstract

To provide a narrative review of the novel endoscopic approaches available in the literature for the treatment of excessive central airway collapse (ECAC). ECAC is characterized by excessive expiratory collapse of the central airway which can lead to dyspnea, cough, difficulty clearing secretions and recurrent respiratory infections. Surgical stabilization of the airway via tracheobronchoplasty (TBP) has been considered the standard of care for patients who have severe symptomatic ECAC despite optimal medical management. However, a significant proportion of patients are not adequate candidates for surgery. We performed a systematic search of MEDLINE/PubMed and ClinicalTrials.gov databases, then narrative reviews of identified reports, focusing on those published in the last 10 years. Of 129 references to ECAC from a MEDLINE/PubMed search, 54 were from the last 10 years and 30 were the focus of this review.Further cross reference was made to ClinicalTrials.gov for 1 study, however the results have not yet been published and the study is currently underway. Endoscopic thermo-ablative techniques such as argon plasma coagulation (APC) has been evaluated in ex-vivo as well as in-vivo models, showing promising results; However human studies are underway. Laser TBP and custom designed stents are currently under development, although the evidence is limited to case reports and case series. Novel endoscopic treatments are promising for the treatment of ECAC. However, more studies are needed to prove efficacy.

Long‐term pneumatic stenting with positive expiratory pressure therapy for severe expiratory central airway collapse

“…( 2 , 9 ). In select patients who are not surgical candidates, CPAP may be a feasible alternative for long‐term management or adjunctive to TBP for those with residual symptoms ( 10 ). Nonetheless, the long‐term efficacy of NIPPV has not been unequivocally established ( 2 , 7 , 9 , 10 ).…”

“…In select patients who are not surgical candidates, CPAP may be a feasible alternative for long‐term management or adjunctive to TBP for those with residual symptoms ( 10 ). Nonetheless, the long‐term efficacy of NIPPV has not been unequivocally established ( 2 , 7 , 9 , 10 ). The mechanism behind NIPPV is pneumatic stenting, which is defined by increased transmural pressure in the central airway due to increased intraluminal pressure on the trachea from NIPPV, expanding the cross‐sectional area of the airway lumen ( 11 ).…”

Airway Stents for Excessive Central Airway Collapse

“…8 The benefit of USEMAS over silicone stents in this context is attributed to their capacity to preserve the airway's innate mucociliary clearance and superior inner diameter-to-wall thickness ratio. 25 This improved functionality allows the stent evaluation to serve as a better predictor of response to TBP. By reducing complications, USEMAS can ensure that the benefits of airway stabilization are not confounded, making them a valuable choice for stent evaluations in ECAC.…”

Pneumatic stenting in the surgical candidacy assessment for cough variant expiratory central airway collapse

“…On the contrary, short-term stenting is the preferred predictor for potential improvement after TBP due to its immediate central airway stabilization [ 9 ]. Significant objective improvement following stent trial has been reported in 65–75% of patients [ 10 , 11 ]. However, some patients may be unsuitable for this invasive trial and present related complications such as granulation tissue formation, intractable cough, valve migration, mucus plugs, or impaction, that could lead to the narrowing of the lumen or worsening symptoms, especially in cough phenotypes.…”