Tracheal stenting for tracheal collapse

Tracheal stenting for tracheal collapse

Jan 01, 2011

Catching a breath: See how interventional radiology helped a Yorkie with increasingly worse breathing problems.
When medical management is no longer adequate, patients with tracheal collapse need more aggressive surgical intervention. See how stent placement helped this struggling Yorkie.

Initial findings

  • Signalment: 12-year-old 9-lb (4.1-kg) spayed female Yorkshire terrier
  • Presenting complaint: Progressively worsening periods of inspiratory dyspnea accompanied by mild coughing
  • Pertinent history: Three-year history of collapsing trachea and mild chronic valvular disease; failed medical management consisting of theophylline ER, butorphanol, diphenhydramine, enrofloxacin and acepromazine
  • Medications: Prescription diet w/d (Hill's Pet Nutrition), hydrocodone (2.5 mg orally every six hours), prednisone (2.5 mg orally every 12 hours)
  • Physical examination findings: Bright, alert and responsive; body condition score 6/9; Grade 2/6 holosystolic heart murmur; intermittent inspiratory dyspnea with mild cyanosis; inducible cough on tracheal palpation; profound increased inspiratory respiratory effort (suggesting upper airway involvement) with moderately increased expiratory effort as well (suggesting intrathoracic tracheal or bronchial involvement)

Diagnostic evaluation

  • Hemoglobin saturation: 94 percent
  • Complete blood count: Mild stress leukogram
  • Serum chemistry profile: ALT 79, AST 39, ALP 420
  • Thoracic and cervical radiographic and fluoroscopic examination: See Figure 1
  • Tracheobronchoscopy: See Figure 2
  • Cardiology consult: Mild chronic valvular disease

Treatment decisions

Figure 1: A lateral thoracic and cervical static fluoroscopic image demonstrating cervical and thoracic inlet tracheal narrowing (black arrows) and open intrathoracic tracheal lumen and carina (white arrows).
This patient had received various medications with little improvement in clinical signs. A historical cardiology consultation reported no need for cardiac medications at that time. At an examination two weeks earlier, a final attempt at medical management included antibiotics, corticosteroids and antitussives. No major improvement in clinical signs led to the consideration of more aggressive interventions.

Figure 2: A tracheoscopy performed before stent placement demonstrating grade 4 (complete) collapse of the trachea at the level of the intrathoracic trachea.
Treatment options discussed with the owner included extraluminal tracheal ring placement and intraluminal stent placement. While the primarily inspiratory clinical signs suggested more severe extrathoracic tracheal collapse, physical examination and fluoroscopic evaluation suggested concurrent intrathoracic tracheal and bronchial collapse. Tracheal stenting was chosen to treat both the extrathoracic and intrathoracic tracheal collapse.

Stent placement

Figure 3: A lateral thoracic and cervical static fluoroscopic image obtained at 20 cm H2O positive pressure ventilation (PPV) demonstrating maximal tracheal diameter. A marker catheter (black arrows) is in place in the esophagus for measurement purposes. The carina is open (white block arrow). Line 3 is 10 mm and used to calibrate the image in order to determine the diameter of the trachea (Line 4).
The patient was anesthetized, and, with fluoroscopic guidance, positive pressure (Figure 3; 20 cm H2O) and negative pressure (Figure 4; -15 cm H2O), ventilation tracheal measurements were made to determine the maximal tracheal diameter and the extent of the tracheal or bronchial collapse. A self-expanding metallic tracheal stent was placed through the endotracheal tube (Figure 5). Tracheoscopy was repeated to confirm precise stent placement (Figure 6). The patient recovered in 40 percent oxygen in the intensive care unit until it was awake and ambulatory.