A 39-year-old female patient was admitted to our hospital on October 13, 2010 because of cough and expectoration for 3 years, chest tightness and shortness of breath for approximately 1 month. On November, 2007, she was ever admitted to a local hospital with complaints of cough, expectoration and white phlegm, but not fatigue, night sweats, fever and chest pain. The local hospital diagnosis was bronchial asthma. She was given anti-inflammatory drugs, but her symptoms persisted.
On admission, physical examinations revealed that she was clear-minded, breath was 26 times per min, pulse was 100 beats per min, and blood pressure was 132/80 mmHg. Chest examination revealed wheeze in the trachea, and rough breath sound with in aspiratory and expiratory wheeze in both lungs. Her abdominal examination was normal. No pathological syndrome was observed. Chest CT scan revealed pulmonary TB on both sides, especially in the middle and lower lobe. Lower tracheal stenosis, right bronchus stenosis and right pleural thickening were also observed (Fig. 3). Sputum smear for acid-fast bacilli was positive. Subsequently she was given combined anti-TB treatment (INH, RFP, EMB and PZA) since December 13, 2010. On December 17, 2010, bronchoscopy was performed under local anesthesia, revealing that as shown in Fig. 4a, the glottis was normal, false diverticula was present in the middle segment of trachea, and stenosis was present in the middle and lower trachea, barely allowing the passage of the bronchoscopy (BF BC-260, Olympus Corporation, Tokyo, Japan). Tracheal mucosal congestion and swelling were present, and the left main bronchus and lobar bronchus on the left side was patent, although with the presence of viscous secretions. However, the right main bronchial stenosis was observed with caseous necrotic material attached to the bronchial orifice and could not permit the passage of the bronchoscopy (BF BC-260, Olympus Corporation, Tokyo, Japan). Our final diagnosis was active secondary pulmonary tuberculosis, tracheal and right main bronchial tuberculosis. On January 12, 2011, the patient was administrated with endotracheal intubation. After a month, the endotracheal catheter was removed and then, the patient was discharged.
On February18, 2011, she was re-admitted to our hospital. The bronchoscopic high-pressure (6 atm) balloon dilatation (MK58880, Boston Scientific Cork Company, Ireland) was performed in the middle and lower trachea for the patient under general anesthesia and electrocardiogram (ECG) monitoring. Mechanical ventilation was applied to assist the patient's breathing. When the oxygen saturation was below 95 %, the balloon stopped dilatation and started empting. The balloon dilatation lasted as long as 1.5 min for each cycle. When the oxygen saturation recovered to be above 99 %, the second balloon dilatation was performed and repeated. The bronchoscopic high-pressure (5 atm) balloon dilatation was also performed under ECG monitoring for the right main bronchial stenosis twice with5 min for each cycle. After the balloon dilatation, the BC-260bronchoscope could pass through the middle and lower trachea stenosis but not the IT-260bronchoscope. For the right main bronchus stenosis, BC-260 bronchoscope could not even pass (Fig. 4b). Her chest tightness, shortness of breath symptoms were improved after the balloon dilatation treatment, but still could not tolerate PFT.
She received balloon dilatation treatment for 5 more times on March 28, April 22, May 6, June 7 and July 18, 2011, respectively. On June 28, 2012, a repeat bronchoscopy showed that the middle and lower trachea stenosis was dilated and patent without the presence of congestion and swelling, allowing the passage of the IT-260 bronchoscope. The orifice of the right main bronchus was still narrowed, could not permit the passage of the bronchoscopy (BC-260), but the caseous necrotic materials disappeared (Fig. 4c). No restenosis occurred in the patient in 1 year outpatient follow-up. Timeline of case 2 was listed in Table 2.
We searched the WANFANG and PubMed database for articles published between 1984 and 2014 in the Chinese-and English-language literature. There were several studies on the application of balloon dilatation in management of combination of main bronchus and lobe bronchus stenosis, yet rare reports on specific treatment of TB-associated tracheal stenosis by BBD were retrieved. The search of PubMed database yielded 13 articles. A total of 474 patients were involved in the retrieved articles from PubMed database and the present study. The total information retrieved was summarized in Table 3. Of the 474 patients, the tracheal stenosis of 4 infant patients results from endotracheal intubation. The etiologies of the 474 patients include bronchial carcinoma, other malignancy, lung carcinoma post-tracheal resection, endotracheal intubation, tracheal tuberculosis, prolonged mechanical ventilation, lung transplantation, Wegener's granulomatosis, idiopathic stenosis, post-tracheostomy, sarcoidosis and amyloidosis.
A chest computed tomography scan showing tracheal stenosis and right bronchial stenosis of the patient in Case 2.