Between March 1987 and March 1989, 66 patients (45 men and 21 women) were intubated. The ages of these patients varied from 8 to 83 years (mean age: 54 years). Of these 66 patients, 21 had squamous cell carcinoma; two, oat cell carcinoma; seven, adenocarcinoma; three, adenoid cystic carcinoma; one, carcinoid tumor; one, Ilodgkin’s tumor; one, lymphoma; one, leiomyosarcoma; and one, mediastinal tumor. The remaining cases included two of amyloidosis, 23 of tracheal stenosis, and three of bronchial stenosis (one after bilateral lung transplant). Surgery had either already been performed or was contraindicated due to the involvement of the trachea, main stem bronchi and parenchyma, or esophagus, and/or due to age or debility.
Our first cases were performed using a Montgomery T-tube which had been modified by removing its “leg” and adding a flange on lx>th ends to prevent migration. Encouraged by the success of these first attempts and in collaboration with Genie Biologique Medical, ANVAR and ARTEMIS, we designed and had manufactured a tube expressly for tracheobronchial intubation (Cometh, Marseille, France, and Bryan Corp, Woburn, MA). This prosthesis is made of molded silicone. Its outside surface bears regularly placed studs with pitted ends specially designed to prevent the tube from sliding or turning and carefully polished to remove all sharp edges. A complete set of prostheses includes several diameters and lengths including one long tube with two diameters and a side hole for simultaneous tracheal and bronchial intubation (Fig 1 and 2).
Figure 1. Set of silicone prostheses; the outside surface bears regularly placed studs. Bronchial and tracheal prostheses.
Insertion requires rigid bronchoscopy with the patient under general anesthesia. The most appropriate system is the Dumon- Harrell Universal Bronchoscope (Efer, la Ciotat, France, and Bryan Corp, Woburn, MA). This system features a series of interchangeable tubes of various sizes. These tul>es can l>e used to calibrate and dilate the stenosis. Calibration is especially important to the choice of a snug-fitting stent. Also because these tul)es telescope over each other, they can be used as introducers for prostheses of all sizes.
FIGURE 2. Tracheobronchial prostheses.
Two insertion techniques can l>e used. In the first the prosthesis is placed over the open tube and then pushed off with a prosthesis pusher. In the second, it is placed inside the open tube and then pushed out. The second technique is the safest because it eliminates the risk of snagging a vocal cord with the studs of the prosthesis. This is especially important with the larger-diameter stents used in the trachea. To facilitate insertion of the prosthesis into the open tube, a funnel-like accessory has been designed (Fig 3). Regardless of the insertion technique, final adjustments can be made using foreign body forceps. Removing the dedicated prosthesis is very simple. Since it is made of a very flexible material, the prosthesis can be collapsed by rolling it up around a pair of forceps attached to any point on the upper rim. The collapsed prosthesis can then be easily jammed against the tip of the rigid open tube and withdrawn.
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FIGURE 3. 1, Under visual control with a telescope (A), an open tube (В) is introduced until the tip reaches a point beyond the stenosis (C). 2, Using the vacuum connection a prosthesis (F) is rolled and aspirated into the prosthesis introducer tul>e (D) through a hockey-puck-shaped funnel loader (E). 3, After withdrawing the telescope (A), the introducer tube (D) is passed down the open tube (В). 4, A prosthesis pusher (G) is used to push the prosthesis (F) out into the stenosed segment (C).
The manufacturer of the Dumon Harrell universal bronchoscope now offers a dedicated prosthesis introducer. This accessory consists of an introducer, a funnel for loading the stent into the introducer and a plunger for pushing the stent out of the introducer. The placement technique with the dedicated introducer which comes in three sizes is illustrated in Figure 3.
Prior to intubation, the laser should be used to resect intraluminal growth and reestablish patency. Our technique of laser resection has been described elsewhere. Briefly, it consists of coagulation of the tissue followed by mechanical removal using the tip of the bronchoscope. Hypoxia or bleeding, or both, the main potential complications, are easily controlled using a rigid bronchoscope system and one or two suction catheters. With regard to hypoxia, the patient should always be thoroughly oxygenated before undertaking insertion. Indeed, since the prosthesis is rolled inside the tube the air flow is low during placement. Also to prevent hypoxia, insertion should be achieved as rapidly as possible remembering that adjustments can be made using alligator forceps.