Emergency Treatment of Tracheobronchial Stent Migration

A 25-yr-old man was referred to our intensive care unit for acute respiratory distress related to an airway obstruction. This patient presented with a motor cerebral palsy that was complicated by a history of uncontrolled epilepsy. Several months previously, he had undergone prolonged tracheal intubation for status epilepsy requiring tracheostomy. A tracheal stenosis had complicated this tracheostomy, and a Dumon silicone tracheobronchial stent was placed using a rigid bronchoscope.

This patient presented with a dry cough associated with acute dyspnea during meals, suggesting pulmonary inhalation. The tolerance was so poor that the patient was brought to the hospital in an emergency. At admission in the emergency department, the patient was hemodynamically stable, with an arterial blood pressure of 140/60 mmHg and a heart rate of 105 beats/min, whereas polypnea persisted and was associated with confusion. There was an inspiratory dyspnea complicated by hypoxemia. Arterial blood gas analysis performed while the patient breathed room air showed a pH of 7.49, an arterial oxygen tension of 62 mmHg, and an arterial carbon dioxide tension of 47 mmHg. Results of a clinical examination of the oropharynx were normal. A chest radiograph showed a foreign body in the right main bronchus, which corresponded to the silicon tracheobronchial stent migration. Rigid bronchoscopy, which is the method of choice, was unavailable in this emergency situation. Therefore, diagnostic fiberoptic bronchoscopy was chosen.

Anesthesia was induced with propofol, and muscular relaxation was obtained using succinylcholine. Tracheal intubation was performed using a large (9-mm) endotracheal tube (Portex, Tijuana, Mexico). The fiberoptic bronchoscopy enabled us to observe a nearly complete tracheal obstruction by the endotracheal granuloma and to confirm the migration of the tracheobronchial stent below the endotracheal granuloma in the right main bronchus. Consequently, a nearly complete obstruction of the left main stem bronchus was observed. Because a rapid therapeutic response was needed and because rigid bronchoscopy was not available, we used a new technique to replace the tracheobronchial stent. We placed an arterial embolectomy catheter (Bard, Rancho Santa Margarita, CA) beside the flexible fiberoptic bronchoscope (fig. 1A). The balloon of the catheter was placed distal to the extremity of the tracheobronchial stent and then inflated. Thereafter, we pulled this Fogarty catheter under the fiberoptic bronchoscope control and gently repositioned the tracheobronchial stent (fig. 1B). Then, we aspirated all bronchial secretions accumulated beyond the stent and verified the absence of inhalation of any alimentary debris. The patient was awakened and rapidly extubated. Chest radiography confirmed a good position of the stent. Two days later, rigid bronchoscopy also confirmed the correct position of the stent.

A silicone tracheal stent provides prompt and durable palliation in patients with unresectable central airway obstruction,1although multiple procedures are often necessary to maintain a satisfactory airway.5In nonurgent tracheobronchial stenosis, flexible fiberoptic bronchoscopy is used for silicone stent placement by a modified Seldinger technique followed by balloon dilatation.6,7 

However, silicone stent migrations are a common complication, with an incidence between 9.5% and 24%.1,3,4Silicone stents migrate more than metal stents because of the inherent properties of stents. Moreover, metal stents are expanded with a balloon in the collapse portion so they become as close to a custom fit as possible. In comparison, silicone stents, with numerous studs along the outer surface designed to prevent migration, are usually folded and released in place to expand to their preformed shape.

Although the fiberoptic bronchoscope is now available in nearly every center for difficult tracheal intubation, this is not the case with rigid bronchoscopy. Moreover, mobilization of the stent required dedicated materials that are not widely available in emergency conditions.

In the current case, foreign body inhalation was suspected by clinical history and chest radiography. Because of the respiratory distress, we decided to perform tracheal intubation and fiberoptic bronchoscopy. We performed anesthesia induction using succinylcholine to prevent pulmonary regurgitation in a full-stomach context. The migration of the tracheal stent was obvious only during fiberoptic bronchoscopy, and radiographic evidence of the stent migration was only understood afterward. The respiratory distress could be related to two phenomena: the tracheal obstruction related to the granuloma and the stent migration into the origin of the right main stem bronchus, leading to partial left main stem bronchus obstruction (fig. 1A).

Several points should be discussed to analyze the potential limitations of our technique. First, mobilization of the stent was easy because of the type of stent, which is known to be easy to mobilize. This would not be the case with every type of stent (e.g. , metal stents), and information regarding the type of stent is often lacking in emergency conditions. A card indicating the type and indication of the stent should be provided to each patient. Second, mobilization of the stent should be done carefully to avoid any traumatic lesion of the trachea that could result in hemorrhage or rupture. These complications might be more frequent in cases of tumors. Third, this technique is easy for a distal stent migration but could be more difficult for a proximal stent migration because it is difficult to push the stent with the balloon in this case. Last, the correct replacement of the tracheal stent and the lack of a traumatic lesion should always be confirmed later by a specialized endoscopist using rigid bronchoscopy, as we did here.

In conclusion, in emergency conditions, when rigid bronchoscopy is unavailable, silicon tracheal stent migration can be successfully and rapidly treated under fiberoptic bronchoscopy using a Fogarty catheter. Anesthesiologists and emergency physicians should be aware of this simple technique because it requires materials that are widely available in most operating rooms.