In the third 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 potential side effects of airway stenting.
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When addressing the discussion about airway stenting and about the long-term effects of airway stenting, [we must remember that] stents are not meant to be in the airway. Patients will often cough a lot, and as they cough, the stent can move a little bit, especially the silicone ones. You can also get granulation tissue with the metallic stents. Many things have been tried to minimize the amount of granulation tissue that is formed, and a well-fitted stent actually is better. You have to have a good plan for how you can manage that. It is no different having a stent fill up with granulation tissue than to have tumor grow back through. So we just need to make sure we know what we are doing.
There are a lot of things that we can do for granulation tissue. We can use cryotherapy, but you have to remember that with a lot of the thermal modalities that we can use (argon plasma coagulation, laser, etc), injury begets injury. So if you injure the airway, it is going to scar and you are going to get more injury. We use a lot of cryotherapy here. The airway is actually relatively cryo-insensitive, so it allows us to take down that granulation tissue pretty safely.
Other things that that can happen is you can get back your overgrowth in stents, and that happens particularly with the silicone stents. If you think about the stent being silicone coated, it is like a piece of plastic. It is warm and wet, which is a perfect environment for microbes to grow. In fact, a lot of these patients actually are chronically colonized. So, we are very careful about maintaining stent hydration. We have people who use nebulizers, and we try to minimize the secretions that get stuck to the stent because they can build up and can also occlude the airway.
Our stent migration rate is actually extremely low. I think it has a lot to do with how many stents have you placed, have you measured your airway well, and have you made sure that you have the most appropriate stent for your patient?
When I was at Harvard many years ago, we started externally fixing certain silicone stents that were high up in the trachea. I still do that, and I will put a stitch through to the outside to hold that stent in place if I am concerned that it is going to migrate.
Click here to view part 4.