Bronchial stenosis

An important late sequela of mustard inhalation is a tracheal/bronchial stenosis that necessitates bronchoscopy and other procedures (Freitag et al., 1991). Mustard has been reported to create a long-term sensitivity to smoke, dust, and similar arrbome particles, probably as a result of clinically unapparent bronchospasm (Morgenstern et al., 1947 Buscher and Conway, 1994). 

Rare complications as have been reported in literature are aortic and bronchial necrosis [58], bronchial stenosis [59], unilateral diaphragmatic paralysis [60], pulmonary infarction (especially in patients who have suffered pulmonary artery embolism), left main bronchial-esophageal fistula [61], and non-target embolization (colon, coronary and cerebral circulation) [62]. Especially the newer spherical embolic materials (tris-acryl gelatin) can traverse from the bronchial into the pulmonary circulation, and then through unoccluded pulmonary arteriovenous malformations into the systemic circulation [41]. 

Girard P, Baldeyrou P, Lemoine G, Grunewald D (1990) Left main-stem bronchial stenosis complicating bronchial artery embolization. Chest 97 1246-1248... 

The first report on the oldest metal stent used in the tracheobronchial system was pubUshed by Wallace et al. in 1986 (Wallace et al. 1986). Since then, several studies on the use of this stent type have been pub-hshed and the stent became one of the most frequently applied metal stents in tracheobronchial mahgnancy. Wallace and colleagues initially reported on two cancer patients. Gianturco stents were placed in one to dilate a postoperative bronchial stenosis that caused pneumonia, and in the second to support a tracheal graft that collapsed with respiration. Stents were successfully placed and the patients symptoms improved (Wallace et al. 1986). 

Because of its smaller opening diameter, Palmaz stents have been used mainly in children (Filler et al. 1998 Furman et al. 1999) and only occasionally in the adult bronchial tree. Slonim et al. (1998) reported on Palmaz stent insertion in bronchial stenosis of three patients with malignant, inoperable obstructions (Slonim et al. 1998). Two patients had respiratory distress and one atelectasis. Immediately after stent placement, all patients had improvement of the respiratory distress or the atelectasis. The follow-up period ranged from 0.5 to 9.2 months. 

Respiratory tract 1. Bronchiolitis obliterans 2. Bronchial stenosis 3. Neovascularization and tracheal vulnerability 4. Chronic cough with blood sputum 5. Diminished mucociliary clearance 6. Interstitial lung disease 7. Emphysema... 

The most common airway problems are anastomotic dehiscence and bronchial stenosis due to strictures. The reason is mostly a lack of perfusion of the bronchial tree, as the donor airways depend on a retrograde pulmonary-to-bronchial arterial circulation until revascularization of the bronchus wall occurs. Ischaemia is greater on the right main bronchus than on the left, therefore anastomotic healing is better on the left and early stenotic problems or dehiscence occur on the right anastomosis more frequently than on the left side. In the early years of transplantation the en bloc technique was mainly performed with a high incidence of tracheal dehiscence, which prompted the development of bilateral lung transplantation. 

Scheduled bronchoscopies are performed routinely during the first year after transplantation at most transplant centres. Inspection of the anastomotic sutures, control of anastomotic wound healing, BAL with microbiologic cultures and transbronchial biopsies are taken to document lung tissue quality and to diagnose acute or chronic lung rejection, invasive infections and eventually to perform interventional procedures such as dilatation or stenting of bronchial stenosis. 

Respiratory effects can lead to bacterial pneumonia and respiratory failure with death from secondary sepsis. Complications include chronic bronchitis and bronchial stenosis. Mustard gas is also thought... 

Undesired effects. The magnitude of the antihypertensive effect of ACE inhibitors depends on the functional state of the RAA system. When the latter has been activated by loss of electrolytes and water (resulting from treatment with diuretic drugs), cardiac failure, or renal arterial stenosis, administration of ACE inhibitors may initially cause an excessive fall in blood pressure. In renal arterial stenosis, the RAA system may be needed for maintaining renal function and ACE inhibitors may precipitate renal failure. Dry cough is a fairly frequent side effect, possibly caused by reduced inactivation of kinins in the bronchial mucosa. Rarely, disturbances of taste sensation, exanthema, neutropenia, proteinuria, and angioneurotic edema may occur. In most cases, ACE inhibitors are well tolerated and effective. Newer analogues include lisinopril, perindo-pril, ramipril, quinapril, fosinopril, benazepril, cilazapril, and trandolapril. 

Snashall, P.D. and Chung, K.F. (1991). Airway obstruction and bronchial hyperresponsiveness in left ventricular failure and mitral stenosis. Am. Rev. Respir. Dis. 144, 945-956. 

HUMAN HEALTH RISKS Acute risks irritation of eyes, skin and mucous membranes congestion in pharynx and trachea skin burns stenosis of upper respiratory system cornea damage polyps Chronic Risks chronic bronchitis bronchial constriction wheezing chemical pneumonitis pulmonary edema. 

The most important morphological examination prior to insertion of an airway stent is a spiral computed tomography (CT) of the major airways. A CT enables a delineation of the airway obstruction. It further demonstrates the length of stenosis, grade of obstruction, and allows calibrated measurements of the smallest diameter of the obstruction. CT can also differentiate a mucosal obstruction from a submucosal cause of obstruction, and further extra-tracheal or exo-bronchial disease responsible for airway comprise. Another advantage of CT is the possibility to assess the relation of the underlying cause of obstruction to other crucial mediastinal and/or pulmonary structures (e.g., major vessels, esophagus, heart, lymph nodes). 

George and colleagues (1992) treated nine patients with malignant central airway obstruction due to tracheal (n=3) or main bronchial ( =6) stenosis with Gianturco stents. All patients suffered from severe dyspnea or asphyxia (four were emergency treatments). All patients had dramatic and rapid reUef of their symptoms after stent insertion. Two patients with intraluminal tumor growth required additional endobronchial measures to control local tumor progression. Patients survived between 3 weeks and 8 months after the intervention. Causes of death were cachexia or pneumonia. 

Obstructive lung disease has been rarely associated with BD as well as trachea-bronchial ulcerations and stenosis. Ulcerative lesions may be found in the trachea and proximal airways. Mucosal edema may result in irregular narrowing of the airway (21-23). 

Delayed bronchial problems such as stenosis can be suspected when atelectasis occurs weeks or months after transplantation. Diagnosis of stenosis has to be confirmed by bronchoscopy and CT. Reasons for late bronchial stenotic problems are chronic infectious problems due to ischaemia and strictures due to shrinking bronchial walls. 

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