J Thorac Cardiovasc Surg 2006;131:253-254
© 2006 The American Association for Thoracic Surgery
Management of pediatric airway obstruction
C.S. Pramesh, MS, FRCS,
Rajesh C. Mistry, MS
Division of Thoracic Surgery, Tata Memorial Hospital, Mumbai, India
To the Editor:
We read with interest Vinograd and colleagues' article
on the management of airway obstruction in children by using self-expandable metal stents (SEMS). We commend the authors on a thorough and detailed description of the difficulties encountered in treating children with this complex problem. The options available to treat pediatric airway obstruction include surgical resection and anastomosis (including slide tracheoplasty), silicone (eg, Dumon) stents, Montgomery T-tubes, and SEMS. Recently, there has been a disturbing trend of using SEMS as the first option in treating benign tracheobronchial pathology, primarily because of the ease of deployment and the dramatic relief of obstruction in the short term.
We feel that it needs to be reiterated strongly that SEMS should remain the last resort in patients with benign stenosis or those with a surgically correctable airway obstruction. SEMS have a number of complications that are difficult to treat long-term. The ideal indication for SEMS is a patient with terminal malignancy with airway obstruction in whom the expected low survival from the primary malignancy precludes the occurrence of stent-related complications. SEMS cause intense granulation tissue, which often causes the same symptoms for which the stent was deployed; subsequent attempts to alleviate this problem with laser, electrocautery, and so on usually have disappointing results. Moreover, contrary to the authors' views, removal of these stents is difficult and fraught with danger. Single and short-segment tracheal stenosis should be treated by primary surgery in centers experienced in pediatric tracheal surgery. Stenting should be reserved for patients in an acute situation (where silicone stents may be deployed as a temporary measure) before referral to a center specializing in tracheal surgery.
Although not practical in infants and very small children, Dumon stents and Montgomery T-tubes are invaluable in stenting lesions that are too long for safe reconstruction.
More often than not, the stent stabilizes the airway, and decannulation is possible in most cases.
Moreover, the ease with which silicon stents can be removed if definitive surgery is being considered makes it an attractive option to tide over an acute situation. The pediatrician, pulmonologist, or thoracic surgeon involved in managing complex airway problems needs to be aware of the basic underlying pathology and intelligently apply the right solution to a specific problem.
- Vinograd I, Keidar S, Weinberg M, Silbiger A. Treatment of airway obstruction by metallic stents in infants and children. J Thorac Cardiovasc Surg 2005;130:146-150.[Abstract/Free Full Text]
- Wood DE, Liu YH, Vallieres E, Karmy-Jones R, Mulligan MS. Airway stenting for malignant and benign tracheobronchial stenosis. Ann Thorac Surg 2003;76:167-174.[Abstract/Free Full Text]
- Grillo HC. Stents and sense. Ann Thorac Surg 2000;70:1142.[Free Full Text]
- Pereszlenyi A, Igaz M, Majer I, Harustiak S. Role of endotracheal stenting in tracheal reconstruction surgeryretrospective analysis. Eur J Cardiothorac Surg 2004;25:1059-1064.[Abstract/Free Full Text]