In the first of this 6-part series, Gaetane C. Michaud, MD, chief of interventional pulmonary medicine at New York University (NYU) Langone Medical Center and associate professor of medicine, speaks with Pulmonology Advisor about the clinical utility of airway stenting for central airway obstruction.
I am Gaetane Michaud, MD, chief of interventional pulmonary medicine at New York University (NYU) Langone Medical Center. I am an associate professor of medicine, and I work in the Program for Oncology Research at NYU.
One of the first things we are going to talk about today is the rule of airway stenting for central airway obstruction. I’ve been involved in interventional pulmonary medicine for almost 17 years, and I have broad experience using airway stents in both malignant and benign disease.
The rule has evolved over time. Initially, we used airway stenting mainly for palliation in malignancy. We have a growing program here at NYU for benign disease, things such as tracheobronchomalacia and tracheal stenosis. The exact rule is really dependent. So, when we think about airway obstruction, we think about whether it is intrinsic or extrinsic. This means, is it within the airway itself solely and can be just sheared off the airway wall without requiring any stenting, and is there an ultimate treatment that will actually be curative? The other thing we consider is whether or it is actually all pushing from the outside. We put a hollow metal tube called a rigid bronchoscope into the airway, and we work through that, but once we take that rigid bronchoscope out, is the airway going to collapse? If that is the case, then we usually like to put a piece of metal in there.
A stent is either metal or a piece of plastic that actually looks a little bit like a chain-link fence and holds the tumor back to allow the airway to remain open. Generally what we say is an approximately 50% reduction of the normal size of an airway will lead to symptoms. That said, it doesn’t take very much to take somebody from 50%, or even less than 50%, to more than that if they get a little bleeding or if they get a little bit of airway secretions or some swelling. So, there is definitely a rule for stenting, even in people who have lesser degrees of obstruction, if they are at risk for ongoing worsening, of if they don’t have a lot of options for treatment.
There are some golden rules when we are thinking about airway stenting. For benign disease, we say that an airway stent is a stent for life. So you need to make sure that you are selecting your patients very well. A very big part of airway stenting and the decision to do an airway stent is to select the right stent for the right patient. It is important to know that there are a lot of different stents on the market. There is not a “one size fits all” answer, so you need to be tailoring your decision-making with respect to stenting to the patient and to the patient’s conditions and not tailoring it to your abilities.
Click here to view part 2.