WABIP Newsletter 2022, Issue 2

Volume 10

Issue 02

MAY 2022

Inside This Issue

Editorial, 2-4

Technology Corner, 5-6

Tips from the Experts, 7-9

Humanitarian News, 10-11

Best Image Contest, 12

WABIP News, 13

Research, 14-15

Links, 16

Patients with Complex Tracheal Disease Benefit from a

Multidisciplinary Airway Team

WABIP Newsletter

M A Y 2 0 2 2 V O L U M E 1 0 , I S S U E 2

EXECUTIVE BOARD

Hideo Saka, MD

Japan, Chair

Stefano Gasparini,

Italy, Vice-Chair

Silvia Quadrelli, MD

Argenna, Immediate

Past-Chair

David Fielding MD

Australia, Treasurer

Naofumi Shinagawa,

Japan,

Secretary General

Philippe Astoul, MD

France, President

WCBIP 2022

Menaldi Rasmin, MD

Indonesia, President

WCBIP 2024

STAFF

Michael Mendoza

General Manager

Judy McConnell

Administrator

Kazuhiro Yasufuku

Newsleer Editor-in-

chief

P A G E 2

Not uncommonly paents who present with dysp-

nea, wheezing, cough, or other respiratory symp-

toms are inially diagnosed as having asthma or

COPD, but ulmately found to have tracheal steno-

sis. This can be secondary to a number of condions

including but not limited to mechanical injury (e.g.

post intubaon, post tracheostomy) as well as con-

necve ssue disease, inhalaonal injury, radiaon,

and infecons (post tuberculosis, viral or tracheis

from Klebsiella rhinoscleromas or other organ-

isms). These tracheal abnormalies are found in

paents with varying comorbidies and many mes

present in the form of rm broc cicatrix, which

vary in degree of obstrucon, length, morphology,

and locaon, specically the distance from the cri-

coid carlage. As such, collaboraon within a mul-

disciplinary team of physicians with experse in

dierent techniques involving otolaryngologists,

thoracic surgeons, and intervenonal pul-

monologists ensures the most opmal management

for individual paents. In muldisciplinary airway

team meengs and clinics, the teams consider dier-

ent methods for management of tracheal diseases

including medical management alone, endoscopic

incisions and dilaon, stenng, or open surgical re-

secon (Figure 1).

Muldisciplinary management of complex airway

cases includes regular conferences to discuss these

paents and review their CT scans, laryngoscopy and

bronchoscopy videos. This is oen followed by

shared clinics for further evaluaon and joint proce-

dures in the operang room. Like other centers

across the world, at the University of Chicago we

have developed a formal Complex Airway Disease

Center, where paents are evaluated by our mul-

disciplinary team of physicians including interven-

onal pulmonology, ENT, and thoracic surgery. Cas-

es are reviewed at a monthly conference for shared deci-

sion-making and planning purposes. Notably, collaborave

management in the operang room is also frequently u-

lized for both airway assessment and therapeuc manage-

ment. In some cases, airway patency has to be restore

emergently via rigid bronchoscopy but an evaluaon by a

surgeon can be performed simultaneously, especially for

paents who are known to have complex stenosis and are

otherwise surgical candidates (Figure 2). Other mes, oto-

laryngology manages the subgloc laryngeal disease or

performed suspension laryngoscopy with jet venlaon,

while IP manages the tracheal component, especially in

inoperable paents with extensive, mulfocal disease or

those with acute necrozing tracheis casing airway com-

promise (Figure 3). Addionally, monthly meengs are held

with long-term acute care hospital partners to ensure op-

mal follow up for paents who may get transferred to such

a facility (especially post tracheostomy paents). We have

recently proposed an algorithm of muldisciplinary care

which is ulized by the members of our team (Figure 1) (1).

Another important service of the muldisciplinary complex

airway care team is to manage paents who develop short

or long-term tracheostomy-related adverse events. These

paents require careful management to ensure opmal

management of any tracheostomy-related issues including

but not limited to stomal strictures, subgloc stenosis,

stenosis/granulaon distal to the tracheostomy and trachea

-esophageal stulas. For inpaents, allied healthcare pro-

viders (nurses, physician assistants, or respiratory thera-

pists) with specialized training in tracheostomy manage-

ment should be involved for a consistent follow up and ear-

ly detecon of any tracheostomy-related issues and to as-

sure an opmal post procedure management (downsizing

the tracheostomy tube, capping trials, decannulaon). Ad-

dionally, speech and language pathologists are integral

members helping paents to resume speech funcon. Stud-

ies have described the approach to implementaon of tra-

Ajay Wagh

, Brandon Baird

, Maria Lucia Madariaga

, Elizabeth Blair

, Sepmiu Murgu

Secon of Pulmonary and Crical Care Medicine/Intervenonal Pulmonology, Department of Medicine, The University of

Chicago, Chicago, IL, USA

Secon of Otolaryngology, Department of Surgery, The University of Chicago, Chicago, IL, USA

Division of Thoracic Surgery, Department of Surgery, The University of Chicago, Chicago, IL, USA

Correspondence to: Ajay Wagh. Division of Intervenonal Pulmonology, The University of Chicago, 5841 S Maryland Ave,

Chicago, IL 60637, USA. Email: awagh@medicine.bsd.uchicago.edu.

W A B I P N E W S L E T T E R

P A G E 3

References:

1. Agrawal A et al. Respir Med. 2021;187:106582.

2. Crosbie R et al. J Laryngol Otol. 2014;128(2):171-3.

3. Norwood MG et al.. Postgrad Med J. 2004;80(946):478-80.

4. Meister KD et al. Otolaryngol Head Neck Surg. 2021;164(5):984-

1000.

5. Lamb CR et al. Chest. 2020 Oct;158(4):1499-1514.

cheostomy specialists and have demonstrated im-

proved outcomes with fewer complicaons and

crical incidents. Tracheostomy specialists can also

help to educate other sta members in tracheosto-

my management (2, 3). Since the beginning of

COVID-19 pandemic, there has been even more of

a need for careful tracheostomy management from

specialized care teams as described (4, 5).

Like in other areas of medicine, such as thoracic

oncology, engaging a muldisciplinary team of pro-

fessionals with dierent educaonal backgrounds

and skillsets can help oer opmal management

for complex airway paents. The group can also

collaborate and provide long term follow up care

required to ensure airway stability, evaluate for

recurrence in seng of malignancy resecon, and

to help migate any potenal complicaons.

Figure 1. Muldisciplinary Benign tracheal stricture management per Agrawal et al (1). Used with permission from Elsevier.

W A B I P N E W S L E T T E R

P A G E 4

A Mul-disciplinary Management Algorithm in Paents with Benign Airway Strictures Mechanical Dilaon: LAMD (Laser As-

sisted Mechanical Dilaon) or Cold Knife Assisted Mechanical Dilaon. ERM'T: Endoscopic resecon (+/- Wedge Approach)

with adjuvant medical therapy (PPI, ICS and TMP/SMX). ED: Endoscopic Dilaon, ENT: Ear, Nose & Throat Surgery, IP: Inter-

venonal Pulmonology, TS: Thoracic Surgery. *This algorithm applies only to idiopathic subgloc stenosis (iSGS). For paents

with connecve ssue disorders, rst treatment opon will be endoscopic management due to high recurrence rate post-

surgical resecon. ** Endoscopic management depending on severity of symptoms. Paent will undergo radial incision with

or without mechanical dilaon. ~ Outpaent follow up with ENT including outpaent laryngoscopy and in-oce injecon of

intralesional steroids. % Failure dened as paents requiring more than 3 intervenons over 2-3 years with symptomac re-

currence and >50% stenoc index, despite oce-based intralesional corcosteroid injecon. + Consider use of oce based

intralesional steroid injecon to maintain patency and reduce me to re-intervenon. *# Complex: Longer> 1 cm, with or

without chondris. # Simple: Less than 1 cm in size, without chondris. @ Factors aecng surgical candidacy include mulple

comorbidies, prolonged steroid use, stricture locaon, or long vercal extent (>4-6 cm). § Failure dened as repeated proce-

dures including recurrent stent migraon, followed by symptomac recurrence of stenosis. All paents with airway stent will

follow the stent protocol dened below. Stent Follow-up Protocol: Flexible Bronchoscopy with moderate sedaon 4-6 weeks

post stent placement. Follow up bronchoscopy every 2-3 months or based on clinical symptoms. 0.9% Normal saline nebulizer

5-10 ml TID. Stent card & Stent educaon.

Figure 2. Severe PITS in a paent with respiratory distress seen

during rigid bronchoscopy (top le). Laser assisted mechanical

dilaon restored airway patency (top right). At the me of recur-

rence, the paent underwent surgical resecon. The le boom

le panel shows the marked proximal and distal aspects of the

stenosis. The excised tracheal stenosis segment of ~ 3 cm is seen

on the boom right panel.

Figure 3. Top panel. Severe tracheal stenosis developed distal to the p of a tracheostomy tube (picture A taken aer the

tracheostomy tube was removed). Post dilaon, a mucosal tear caused bleeding from the posterior tracheal wall which was

successfully coagulated using electrosurgery via tracheal stoma by the ENT surgeon (B and C). Then a T tube was inserted and

via rigid bronchoscopy using rigid forceps, the bronchoscopist assist in opening up the infra-stomal arm of the T tube (D).

Boom panel: E. severe symptomac pseudomembranous tracheal stenosis immediately post extubaon seen during exible

bronchoscopy. F. Suspension micro-laryngoscopy was performed by the ENT surgeon with Jet venlaon. G. Rigid broncho-

scopic debridement of the pseudo-membranes is performed. H. Then the stricture is dilated and airway patency is restored.

W A B I P N E W S L E T T E R

P A G E 5

Technology Corner

3D Prinng for Surgical Planning for Subgloc Airway Stenosis

Introducon

The surgical treatment of subgloc cicatricial stenosis remains one of the most challenging elds in airway surgery. In addi-

on to the esmated resecon length, the proximity of the stenosis to the vocal folds is the main characterisc dictang

the appropriate surgical technique. Not only a complete resecon of the cicatricial ssue, but also preservaon and resto-

raon of the funconal capacies of the larynx should be achieved. In general, the pre-operave work-up in paents with

airway stenosis should at least consist of a computed tomography (CT) and bronchoscopy. However, even for experienced

surgeons the pre-operave judgement of the exact extent of the stenosis and the required surgical repair remains demand-

ing, especially in subgloc pathologies.

Background

Addive manufacturing and three-dimensional (3D) prinng is nowadays broadly available. Consequently, a growing num-

ber of possible medical applicaons has been described. Especially in the diagnosis and treatment of airway pathologies, a

variety of possible applicaons were described by various instuons world-wide (1-4). Beyond manufacturing customized,

paent-specic implants such as airway prosthesis (4), the transion of two-dimensional CT images into 3D-printed, hap-

cally percepble models changed the possibilies of teaching and planning complex surgical procedures (5). For instance,

3D-printed models of centrally located lung cancer can be used to teach surgical residents the principles of bronchial sleeve

resecons (6). Using materials with similar rigidity and elascity as the human airways, bronchial sleeve resecons were

even simulated in a simplied, but anatomically correct way during dry lab trainings. Similarly, 3D printed models can also

be used to plan complex resecon at the laryngotracheal juncon.

Dependent on the extent of subgloc stenosis in relaon to the anatomical structures, various surgical techniques have

been described. Cricotracheal resecon including a paral resecon of the cricoid arch and the rst tracheal rings is consid-

ered the basic technique to address a stenosis, which is limited to the anterior poron of the cricoid. A dorsal mucosectomy

at the cricoid plate has to be added to the procedure, as soon as the scaricaon of the mucosa or submucosa is present at

the dorsolateral poron of the cricoid. This involvement is rather typical in paents suering from an idiopathic subgloc

stenosis. The most complex type of subgloc stenosis reaches the vocal fold and is therefore described as gloo-subgloc

stenosis. If a complete resecon by means of a cricotracheal resecon with a very extended dorsal mucosectomy is not

resulng in a sucient subgloc lumen, the larynx has to be enlarged by the interposion of carlage anteriorly and/or

posteriorly.(7) Although the ulmate decision which of these techniques has to be made during the surgical procedure,

experienced airway surgeons will be able to predict the necessary surgical technique with a very high accuracy. However,

students, residents and surgeons not experienced in airway surgery usually exhibit dicules in merging bronchoscopic

ndings with the corresponding CT images. Subsequently, the incorrect classicaon of the airway stenosis negavely

aects planning the appropriate surgical procedure.

Thomas Schweiger, MD, PhD,

Kazuhiro Yasufuku, MD, PhD,

Konrad Hoetzenecker, MD, PhD

1 Department of Thoracic Surgery, Medical University of

Vienna, Austria.

2 Division of Thoracic Surgery, Toronto General Hospital,

University Health Network, Toronto, Ontario, Canada

W A B I P N E W S L E T T E R

P A G E 6

Clinical Applicaon

We could previously demonstrate the value of 3D-printed models over convenonal CT images or bronchoscopy in paents

with subgloc stenosis. (8) In this work, the study parcipants were divided into subgroups dependent on the level of ex-

perience in airway surgery (residents vs. fellows or non-airway surgeons vs. dedicated airway surgeons). Parcipants were

provided with bronchoscopy videos, convenonal CT scans or 3D-models of 19 paents with subgloc stenosis and asked

to classify the stenosis and to choose the appropriate surgical technique for resecon. Residents and fellows/non-airway

surgeons beneted most from the 3D models which signicantly improved their diagnosc accuracy. Interesngly, the

group of experienced airway surgeons achieved almost a similar high accuracy by sole evaluaon of bronchoscopy videos.

Two-dimensional axial CT images were of least value throughout all study groups. This study illustrated the potenal bene-

ts of 3D models when treang paents with subgloc stenosis. Moreover, these models might be of value in paent edu-

caon and when obtaining informed consent for laryngotracheal resecons. 3D models could be used to illustrate specic

surgical procedures and possible funconal implicaons aer surgery to the paent. However, there also several issues

liming the clinical applicaons of these 3D printed models. First, processing of the raw imaging data to delineate the ste-

nosis from the individual anatomical structures and mul-color prinng requires a degree of knowledge and resources,

which are not available at every instuon. Moreover, manufacturing a 3D model for each individual paent referred for

surgery would most likely exceed these capacies even if present and established. The me needed from imaging acquisi-

on to the producon of a model is rather weeks than days, dependent on the available infrastructure and personnel. Last,

the diagnosc benet decreases with growing experience of the surgeon. Thus, prinng a 3D model of each paent receiv-

ing laryngotracheal surgery might not be feasible, and also not necessary.

In summary, a set of 3D models of typical and also exceponal cases can contribute to a deeper understanding of complex

airway stenoses. 3D models should be considered an addional way to visualize a surgical problem in a comprehensive

manner.

Conclusions

3D printed airway models are a tool which can increase the diagnosc accuracy of subgloc stenosis and improve surgical

planning of a resecon. The broad availability of 3D prinng and the relavely easy access will foster the use of these mod-

els in training and in clinical pracce.

References:

1. Tsai A et al. JTCVS Tech 2021;ahead of print.

2. Les AS et al. Laryngoscope 2019;129:1763-71.

3. Kamran A et al. JTCVS Tech 2021;8:160-9.

4. Schweiger T et al. J Thorac Cardiovasc Surg 2018;156:2019-21.

5. Leung G et al. S Int J Pediatr Otorhinolaryngol 2022;155:111083.

6. Hashimoto K et al. JTCVS Techniques 2022;online, ahead of print.

7. Schweiger T et al. J Thorac Cardiovasc Surg 2022;163:313-22 e3.

8. Hoetzenecker K et al. Ann Thorac Surg 2019;107:1860-5.

Tips from the Experts

P A G E 7 V O L U M E 1 0 , I S S U E 2

Introducon:

Tracheal or laryngotracheal stenosis may result from a broad spectrum of underlying eologies including gastroesophageal reux disease,

systemic disorders such as scleroderma or sarcoid, infecon, malignancy, or radiaon injury. At mes, the cause of the stenosis cannot be

specied, and is termed idiopathic. However, internal trauma due to endotracheal intubaon or tracheostomy is the most common cause of

acquired stenosis.

The dramac rise in mechanical venlaon due to the COVID-19 pandemic further solidies this as a causave frontrun-

ner.

While endoscopic intervenons are oen rst-line therapy for symptom palliaon, recurrence is common. Surgical resecon and air-

way reconstrucon oers denive treatment with high rates of success.

3,4

Paent Evaluaon and Indicaons:

Paents with acquired tracheal stenosis typically present with a history of dyspnea exacerbated by exeron which may progress to wheez-

ing or stridor in the seng of advanced disease. Symptoms severe enough to rise to medical aenon typically occur when stenosis has

reached at least 50% of the airway diameter and inial misdiagnosis with more common respiratory ailments is common.

5,6

Workup includes

pulmonary funcon tests, serologic evaluaon for anneutrophil cytoplasmic anbodies, and computerized tomography (CT) of the neck

and chest. Dynamic CT may facilitate idencaon of tracheomalacia which may accompany tracheal stenosis in select paents. Grading

systems include the Myer-Coon system which is based on stenoc severity and the McCarey system which categorizes based on locaon

and length of stenosis.

7,8

Bronchoscopy is the gold standard diagnosc technique and remains essenal to evaluang surgical candidacy. While rigid bronchoscopy

has been promoted in paents with more severe symptoms,

we have found exible bronchoscopy to be sucient in the majority of pa-

ents. We typically perform this with the paent under general anesthesia but without paralycs in order to evaluate vocal cord funcon

and the degree of airway collapse due to associated tracheomalacia. The procedure is performed with a laryngeal mask airway in place and

temporary removal of the tracheostomy tube, if present, to allow thorough evaluaon of the airway. Key components of the exam include

assessment of: (1) type of lesion, (2) locaon of stenosis including involvement of the cricoid carlage, (3) length of stenosis, (4) involvement

of other structures, notably the proximal larynx, (5) gloc aperture, (6) recurrent laryngeal nerve funcon, and (7) length of normal trachea.

In the seng of subgloc stenosis, assessment of the subgloc aperture is crical to successful surgical resecon; this region must be of

sucient diameter and free of inammaon or other mucosal abnormality. (Figure 1)

There is no age threshold that precludes a paent from surgical consideraon and the procedure is generally well tolerated even in older,

frail paents. However, there are several pre-exisng condions that warrant careful consideraon during preoperave evaluaon. While

paents with borderline pulmonary funcon oen tolerate tracheal resecon, surgery should be avoided in those who are likely to require

postoperave mechanical venlatory support, or paents with condions that put them at high risk of requiring intubaon postoperavely,

such as individuals with poorly controlled myasthenia gravis prone to respiratory decompensaon. In addion, paents with pre-exisng

neurologic dysfuncon pose a parcular challenge to successful surgery, as paent cooperaon with airway clearance and tolerance of the

guardian stch to avoid excessive head movement postoperavely is crical. Similarly, any suggeson of aspiraon needs to be thoroughly

invesgated preoperavely. These paents may require tracheostomy permanently or unl neurologic funcon improves. Finally, modia-

ble risk factors including obesity and steroid use should be reced prior to surgery.

Open Surgical Approach to Tracheal Stenosis

John D Mitchell, MD

Davis Endowed Chair in Thoracic Surgery

Professor and Chief, General Thoracic

Surgery

University of Colorado

Lauren Taylor, MD

Chief Resident, Cardiothoracic

Surgery

Tips from the Experts

P A G E 8 V O L U M E 1 0 , I S S U E 2

Procedural Consideraons:

There is rarely an indicaon for emergent tracheal resecon; surgery in this seng may be fraught with complicaons. Paents in extremis

are oen beer served with tracheostomy or endoscopic intervenon such as dilaon to secure the airway with plans for formal surgical re-

secon and reconstrucon aer their condion has temporized. Similarly, it is prudent to delay resecon in the seng of acve infecon

near the operave eld as well as excessive local inammaon due to recent tracheostomy or dilaon.

A key to successful tracheal resecon and primary anastomosis is determinaon of how much trachea may be removed safely. Over the

years, invesgaons performed in animals and human cadavers have measured anastomoc tension with various lengths of resecon in an

aempt to answer this queson.

9-12

Unfortunately at present no reliable means of intraoperave measurement of anastomoc tension exists

and this technique is not rounely used in pracce. While precise limits of tracheal resecon remain elusive, about 50% of the adult trachea

may be safely removed in most cases. It is generally accepted that permissible lengths vary based on paent age, body habitus, and history of

prior neck or chest surgery that may limit tracheal mobility due to scarring. For a stenosis of the proximal airway, neck exion as well as surgi-

cal release maneuvers such as mobilizaon of the pre-tracheal plane or suprahyoid laryngeal release have been shown to decrease anasto-

moc tension and allow surgeons to push the boundaries of resecon; for distal airway stenosis, a hilar release can aord similar advantages.

Resecon of subgloc stenosis is typically performed through a collar incision, with excision of the stoma site if a tracheostomy was present.

Addional upper neck incision, sternotomy, or thoracotomy may be required in some instances depending on locaon of the tracheal lesion

and need for release maneuvers. Neck extension is achieved through careful paent posioning with a pillow between the scapulae and is

crical to ensure adequate exposure of the operave eld. In addion, bronchoscopy may be used intraoperavely to localize the lesion at

the me of tracheal transecon.

Subgloc stenosis poses parcular surgical challenges due to the relavely narrow caliber of the laryngotracheal region and parcular care

must be taken to preserve the vocal cords when cricoid resecon is necessary. The anastomosis is performed in an end-to-end fashion using

interrupted absorbable sutures. We commonly use a strap muscle to buress the anastomosis and prevent stula development. At the me

of primary anastomosis, the paent’s neck is moved to a exed posion to minimize tension. We typically do not place T-tubes but favor

placement of a guardian stch prior to extubaon to limit neck mobility during the rst week aer surgery.

An experienced anesthesia team is essenal and constant communicaon between surgeon and anesthesiologist is needed to ensure surgical

success. A variety of airway management strategies during tracheal resecon have been described. While surgical cross-eld intubaon and

jet venlaon are the most well-established, newer techniques have been proposed including use of supragloc airways, regional anesthe-

sia, and extracorporeal support.

13,14

We favor endotracheal intubaon aer inducon of general anesthesia with a small caliber endotracheal

tube as needed to accommodate the degree of stenosis. Aer tracheal transecon, the surgeon places an armored endotracheal tube distally

in the airway and cross-eld venlaon is used unl the anastomosis is complete.

Postoperave Care and Surveillance:

The majority of paents are extubated in the operang room at the conclusion of surgery. If ongoing mechanical venlaon is necessary, it is

essenal to ensure that the cu of the endotracheal tube is posioned distal to the anastomosis with minimal inaon. Decadron may be

indicated for some paents if signicant laryngeal edema is present. All of our paents are monitored in the intensive care unit and kept nil

per os for the rst 24-48 hours postoperavely unl formal swallow evaluaon is complete. We keep the guardian stch in place unl post-

operave day 7 at which me bronchoscopy is performed. If the anastomosis is healing appropriately, the stch is removed along with surgi-

cal drains and the paent is discharged home.

We rounely follow paents with serial bronchoscopic evaluaons aer hospital discharge. (Figure 2) This facilitates early detecon of anas-

tomoc complicaons and allows for intervenons such as debridement of granulaon ssue or dilaon of anastomoc strictures. In the

seng of tracheal resecon for tumor, bronchoscopy also serves the added role as surveillance of cancer recurrence.

Surgical Complicaons and Outcomes:

Complicaons of tracheal resecon and reconstrucon have been minimized with advances in surgical technique. However, a variety of anas-

tomoc and other complicaons may sll arise. Formaon of granulaon ssue at the anastomosis is one of the more common complicaons

(although less frequent with the use of absorbable suture) and may be addressed by vigilant bronchoscopic follow-up postoperavely. Excess

anastomoc tension or impaired tracheal blood supply due to over-dissecon may lead to necrosis, separaon or stricture that may be rec-

ed with endoscopic techniques or in some instances require re-resecon. Hemorrhage due to innominate artery erosion may occur if care is

not taken to ensure that the artery does not rest in direct contact with the anastomoc sutures. Similarly, vocal cord dysfuncon and subse-

quent aspiraon may result from an error in surgical technique and failure to protect the nerves during tracheal dissecon. A rare but debili-

tang complicaon to consider during paent posioning is quadriplegia due to extreme cervical exion or extension.

Despite known complicaons, contemporary literature reports improved surgical outcomes. A recent retrospecve analysis of 228 consecu-

ve laryngotracheal resecons performed over the last decade demonstrates 0% perioperave mortality rate. The overall complicaon rate

was 9.6%; 7.8% are aributed to airway complicaons with the most common being restenosis. At a mean follow up of 65.5 months, deni-

ve treatment success was achieved in 98.7% of paents.

Similar success was reported by Wang and colleagues in 2015 with 96% of paents

who underwent surgical resecon for idiopathic subgloc stenosis achieving good to excellent postoperave results.

Findings reported by

Tips from the Experts

P A G E 9 V O L U M E 1 0 , I S S U E 2

D’Andrilli et al. echo these results with denive good or excellent results in 94.5% of their cohort and a complicaon rate of 9.2%.

Conclusions:

Surgical resecon and reconstrucon oers denive treatment of tracheal stenosis with recent literature demonstrang encouraging trends

in improved postoperave outcomes. Surgical treatment of this disease is likely to play an increasingly prominent role due to the prevalence

of mechanical venlaon aributed to the COVID-19 pandemic. Adherence to meculous surgical techniques and the parcipaon of experi-

enced teams in high-volume centers is important to ensure surgical success, parcularly in the seng of subgloc stenosis.

References:

1. Aravena C et al. J Thorac Dis. 2020;12(3):1100-1111. doi:10.21037/jtd.2019.11.43

2. Piazza C et al. Eur Arch Otorhinolaryngol. 2021;278(1):1-7. doi:10.1007/s00405-020-06112-6

3. Maurizi G et al. J Thorac Cardiovasc Surg. 2021 Mar;161(3):845-852. doi: 10.1016/j.jtcvs.2020.12.023. Epub 2020 Dec 14. PMID: 33451851.

4. D'Andrilli A et al. Eur J Cardiothorac Surg. 2016 Jul;50(1):105-9. doi: 10.1093/ejcts/ezv471. Epub 2016 Jan 19. PMID: 26792926

5. Maldonado F et al. Orphan Tracheopathies. In: Con V, Cordier JF, Richeldi L, editors. Orphan Lung Diseases. London: Springer London, 73-89.

6. Costanno CL et al. J Thorac Dis 2016;8:S204-9.

7. McCarey TV. Laryngoscope 1992;102:1335-40. 10.1288/00005537-199212000-00004

8. Myer CM et al. Ann Otol Rhinol Laryngol 1994;103:319-23. 10.1177/000348949410300410

9. Cantrell JR et al. J Thorac Cardiovasc Surg 1961;42:589–98.

10. Kotake Y et al. J Thorac Cardiovasc Surg 1976;71:600–4.

11. Michelson E et al. J Thorac Cardiovasc Surg 1961;41:748–59.

12. Grillo HC et al. J Thorac Cardiovasc Surg 1964;48:741–9.

13. Schieren M et al. J Cardiothorac Vasc Anesth. 2017 Aug;31(4):1351-1358. doi: 10.1053/j.jvca.2017.03.020. Epub 2017 Mar 24. PMID: 28800992.

14. Schieren M et al. Anesth Analg. 2018 Apr;126(4):1257-1261. doi: 10.1213/ANE.0000000000002753. PMID: 29293182.

15. Wang H et al. Ann Thorac Surg.2015;100:1804-11.

Figure 1: Preoperave exible bronchoscopy demonstrates signi-

cant subgloc stenosis. This paent was deemed to be a suitable

operave candidate and underwent laryngotracheal resecon.

Figure 2: Postoperave surveillance bronchoscopy in the paent with

subgloc stenosis who underwent laryngotracheal resecon demon-

strates that the anastomosis is healing well without evidence of stric-

ture.

Humanitarian News

W A B I P N E W S L E T T E R P A G E 10

PARAGUAY PROJECT

In November 2021 the World Bronchology Foundaon (WBF) received, from Paraguay, a request for help to treat paents

with post-intubaon tracheal stenosis due to COVID. Concretely, Dr Domingo Regalado Pérez asked the Foundaon for a

rigid bronchoscope and for providing training to deal with this unforeseen diculty of the COVID pandemic. Dr Domingo

Regalado Pérez is the head of the Pneumology Service of the General Luque Hospital, which belongs to the Ministry of Public

Health in Paraguay, and is also a member of the WBF Board. The aim of the Project was to bring a rigid bronchoscope with

opcs, light source, camera and forceps and to conduct a course-workshop on the use of the rigid bronchoscope and thorac-

ic ultrasound. For this project, support and funding was sought from the Asociación Española de Endoscopia Respiratoria y

Neumología Intervencionista (AEER), the Sociedad Española de Neumología y Cirugía Torácica (SEPAR) and help from the

commercial companies Ibersurgical and Suministros Hospitalarios. For this project, the AEER, and SEPAR gave nancial sup-

port, while the companies Ibersurgical and Suministros Hospitaraios gave material”. The culminaon of the project consisted

in a week-long trip to Paraguay which took place the last week of March 2022 where three professionals were awarded to

take part in the trip, Dr. Javier Flandes and Dr. Enrique Cases by AEER and the nurse Susana Alvarez by SEPAR. Prior to the

trip, all the expected material was obtained, as well as various prostheses and dierent endoscopic material, so that the

budget reached for this project was around 25,000 €.

Once in Paraguay, the rst day of the course-workshop was held at the Hospital Central del IPS-Asunción, where a series of

lectures on rigid bronchoscopy and thoracic ultrasound were given. It is worth menoning the presentaon on broncho-

scope reprocessing given by nurse Susana Alvarez, as the lecture aroused a lot of interest among the aending doctors. In

addion, during the second they of the course, nurse Susana had the opportunity to collaborate with the nurses working at

above menoned hospital, as well as with nurses working in other hospitals from Auncion and Luque. Not only she was able

to collaborate but also to conduct presentaons and workshops on reprocessing, sedaon and the handling of endoscopic

samples.

The following days of the Course-Workshop were held at the Hospital General of Luque. Luque is a city of Paraguay located

in the Central Department near to Asunción which is the current capita of Paraguay. In this hospital were addressed topics

related to the rigid bronchoscopy and thoracic ultrasound as well as other issues such as the diagnosc and therapeuc pos-

sibilies of the cryoprobe, thermoplasty, the endoscopic diagnosc possibilies of the pulmonary nodule or pleural patholo-

gy were developed. In this hospital, we had the possibility to parcipate in the treatment of two paents suering from tra-

cheal stenosis. The paents were treated with the new rigid bronchoscope and were placed a Dumon prosthesis and a

Leufen prosthesis donated by Suministros Hospitalarios. Thanks to the opcal and camera equipment donated by Ibersurgi-

cal, the two intervenons were visualised by the young pneumologists. Thoracic ultrasound scans were also performed in

dierent departments of the hospital to familiarise the pneumologists with the dierent pathologies and some specic diag-

noses were made, such as a diaphragmac paralysis in a venlated paent who was dicult to wean.

The course was aended by around twenty-ve young pulmonologists from dierent cies of Paraguay who showed their

enthusiasm for intervenonal pneumology and their eagerness for training in this eld. We would like to thank the Sociedad

Paraguaya de Neumología and its president Dr. José Oviedo for their warm welcome and for the logiscal and technical sup-

port we were given, without which this project would not have been possible. We would also like to thank the pneumolo-

gists Dr Domingo Pérez, soul of the Project in Paraguay, Dr Gilberto Chaparro whose experience in intervenonal bronchos-

copy we consider fundamental for the further development of this Project, the young pneumologists who parcipated t in

the course and the members of the Pneumology Service of the General Hospital of Luque in whose hands lies the future of

intervenonal pneumology in Paraguay, Dr Diego Medina, Dr Avid Aluan, Dr Silvio Benitez, Dr Liza Davalos, Dr Sergio Cárde-

nas, Dr Diego Aguayo and Dr Carlos Pallarolas.

In addion to this Project in Paraguay and the previous Projects developed with AEER and SEPAR Solidaria in Panama, El Sal-

vador and Honduras in 2018, the WBF parcipated in the SEPAR Solidarity Project held in the Sahrawi Refugee Camps in Al-

giers. In this project, a GeneXpert was brought for the diagnosis of tuberculosis and which has been fundamental for the

Humanitarian News

W A B I P N E W S L E T T E R P A G E 11

diagnosis of COVID in this Camp. There is a project underway to bring a bronchoscope to the camp and to provide training to

a digesve endoscopist to work in the refugee camp, because the camp does not have a pulmonologist and there are nearly

200,000 people living there with limited means and depending on external aid.

Best Image Contest 2022 (2 of 3)

Descripon:

Spontanous rupture of Bronchogenic Cyst

A- Axial CT view of the bronchogenic cyst before rupture

B- Axial CT view of the bronchogenic cyst aer rupture

C- Bronchoscopy view of intact bronchogenic cyst in the right upper lobe

D- Bronchoscopic view of ruptured bronchogenic cyst causing breach on the bronchial wall

Submier:

Dr. Roshan Kumar

Best Image Contest

P A G E 12

This image is the 1 of 3 selected among 100+ submissions to our Best Image Contest held in late 2021. Please

stay tuned to the next Image Contest opening later this year. Find the above image and more at the WABIP

Academy Image Library at hps://www.WABIPacademy.com/imagelibrary

P A G E 13

WABIP News

WCBIP 2022 Registraon Discounts Ending Soon

Take advantage of registraon discounts of up to 33% unl July 15, 2022 for WCBIP Marseille

2022. If you register for "remote access" (virtual) rst, you can upgrade to on-site access at any

me, even at the venue. In which case, the price dierence will be invoiced.

WABIP Vice Chair Nominaons

Nominaons for the next WABIP Vice-chair are sll open unl July

1, 2022. If you would like to consider a colleague for the chance to

be the next Vice-chair, you may nominate by downloading and

compleng the following form @ hps://cdn.wabip.com/

downloads/vice-chair/WABIP-Vice-Chair-Nominaon-Form-

2022.pdf

WCBIP 2026 Bids

As the above, the deadline for WCBIP bids applicaons is July 1,

2022. We cordially invite you to submit a bid for organizing our

biennial congress which shall take place 4 years from now. Down-

load and complete the following form to begin @ hps://

www.wabip.com/news/544-wcbip2026bids2

WABIP Awards

Celebrate and give recognion to your outstanding colleague in the

IP community by nominang him or her for a WABIP Award. Nomi-

naons for the Killian Medal, the Dumon Award and the Lifeme

Achievement Award are due by July 1, 2022. You may nominate

yourself for the Becker Award upon subming an abstract for

WCBIP 2022. More details at hps://www.wabip.com/awards

WABIP Board of Regents Meeng in Marseille

We are pleased to announce that the next BOR meeng will be held in Marseille on-site this October 6, 2022 at

1:00 pm CEST. For those who cannot aend on site, Regents may join via Zoom. This meeng will include elecons

for next WABIP Vice-chair and vong for WCBIP 2026 host site, as described above. General members: please be

sure to contact your society representave (Regent) so that he/she may represent your vote.

The Mantra of Medicine

Muldisciplinary Approach and Personalized Therapy

Idiopathic subgloc stenosis (ISGS) is a rare (1:400,000), recurrent, broinammatory disease that results in debilitang and life-threatening air-

way obstrucon. While ISGS is a rare condion, it is well-known to intervenonal pulmonologists, laryngologists, and thoracic surgeons.

Causes of ISGS include congenital, trauma such as intubaon or tracheostomy, inammatory condions, and idiopathic diseases. This disease can

lead to debilitang symptoms such as dyspnea, cough, hoarseness, stridor, and sleep apnea. Oen the management opons are limited, invasive,

or subopmal, with recurrences requiring repeated intervenons. In many cases, quality of life is severely aected. Unfortunately, due to the

young age of paents in most of these cases, the impact of this disease is felt even more.

As intervenonal pulmonologists, we oen ulize rigid bronchoscopic dilaons, endobronchial ablave therapies, injecons of anbroc agents

such as steroid and mitomycin, and airway stenng. Our colleagues in ENT usually perform balloon dilaons and CO2 laser ablaon with or without

anbroc injecon, while thoracic surgeons perform cricotracheal resecon (CTR) and end to end anastomosis of the trachea in select cases when

feasible. The treatment approaches are oen instuon and provider-dependent. As we all have been taught in our training, rare and complex

diseases like ISGS should have a muldisciplinary approach to provide personalized therapy at expert centers. This oers the best chance to give

paents a long-term and denive treatment.

A large study (1) recently tried to answer the quintessenal queson of the best treatment strategy for ISGS. The study prospecvely compared the

outcomes of the three most common approaches for managing ISGS. It recruited ISGS paents with or without previous treatment from mulple

centers across the United States in a prospecve manner. The study's primary endpoint was the me between the inial and second procedures.

Secondary endpoints of the study included quality of life, voice handicap, eang assessment, funconal health, and postoperave complicaons.

Eight hundred and ten paents were enrolled in the study. Inial surgical procedures were endobronchial dilaon (n = 603; 74.4%), endobronchial

Editor-in-Chief: Dr. Kazuhiro Yasufuku

Research

Primary Business Address:

Kazuhiro Yasufuku, Editor-in-Chief WABIP

Newsleer

c/o Judy McConnell

200 Elizabeth St, 9N-957

Toronto, ON M5G 2C4 Canada

E-mail: newsleer@wabip.com

P A G E 14

Associate editor:

Dr. Ali Musani

Associate editor:

Dr. Sepmiu Murgu

Ali I. Musani MD, FCCP

University of Colorado School of Medicine,

Denver

resecon and medical therapy (n = 121; 14.9%), and surgical therapy with CTR (n = 86; 10.6%). Overall, 22.8% of paents had a recurrent

surgical procedure during the 3-year study. However, the recurrence rates diered in three treatment groups, CTR, 1.2%; endobronchial

with medical therapy, 12.4%; and endobronchial dilaon, 28.0%. Among successfully treated paents without recurrence, those treated with

CTR had the best quality of life, the worst voice symptoms, and the most signicant perioperave risk. The most used therapeuc approach,

endoscopic dilaon, was associated with a higher recurrence rate than other procedures. In contrast, endoscopic resecon with medical

therapy (treatment of choice by the intervenonal pulmonologists) was associated with beer disease control than endoscopic dilaon and

had a minimal associaon with vocal funcon.

This study substanates the algorithmic approach of ISGS in a muldisciplinary fashion. In our pracce, every ISGS paent is referred to tho-

racic surgery for CTR if feasible. Unfortunately, most paents do not qualify for CTR due to confounders, including stenosis too close to the

vocal cords, long previous surgeries, and anatomical and medical issues. Our second line of treatment for ISGS is an intervenonal pulmonol-

ogy comprehensive approach with endotracheal resecon/debulking and dilaon with rigid bronchoscopy and endotracheal steroid injec-

ons, with or without stent and ablave therapies such as laser or cautery. Stents and ablave therapies are uncommonly used nowadays.

Our other adjuvant strategies include robust medical and behavioral control of gastroesophageal reux disease, management of hiatal her-

nia if contribung to reux, aggressive treatment of obesity, and workup and treatment of autoimmune diseases.

The answer to the queson as to the best approach for these paents remains, "it depends"! It depends on the locaon of the stenosis,

comorbidies, other confounding issues as menoned above, and perhaps most importantly, the experse of the treang instuons and

physicians. Hence, the mantra of "muldisciplinary approach to oer personalized therapy." Furthermore, as menoned earlier, the key is to

refer these paents to the expert centers once the diagnosis is established and the inial treatment is provided to prevent acute respiratory

compromise. This strategy has been proven to oer paents the best chance of meaningful recovery and the best quality of life.

Reference:

1. Gelbard et al. JAMA Otolaryngol Head Neck Surg. 2020 Jan 1;146(1):20-29.

Research

P A G E 15

P A G E

WABIP ACADEMY- WEBCASTS

The WABIP has started a new educaon project recently: THE WABIP ACADEMY. The WABIP Academy will pro-

vide free online webcasts with new and hot topics that will interest pulmonologists and intervenonalists.

Current webcast topic: Tissue acquision for biomarker directed therapy of NSCLC

You can reach these webcasts by using this link: hp://www.wabipacademy.com/webcast/

www.bronchology.com Home of the Journal of Bronchology

www.bronchoscopy.org Internaonal educaonal website for

bronchoscopy training with u-tube and

facebook interfaces, numerous teachiing

videos, and step by step tesng and assess

ment tools

www.aabronchology.org American Associaon for Bronchology and I

ntervenonal Pulmonology (AABIP)

www.eabip.org European Associaon for Bronchology and

Intervenonal Pulmonology

W A B I P N E W S L E T T E R

Links

www.chestnet.org Intervenonal Chest/Diagnosc Procedures (IC/DP)

NetWork

www.thoracic.org American Thoracic Society

www.ctsnet.org The leading online resource of educaonal and

scienc research informaon for cardiothoracic

surgeons.

www.jrs.or.jp The Japanese Respirology Society

sites.google.com/site/asendoscopiarespiratoria/

Asociación Sudamericana de Endoscopía Respiratoria

P A G E 16