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Correspondence |

Stenting for Tracheobronchomalacia : Treating Images? FREE TO VIEW

Philippe Girard, MD, FCCP; Raffaele Caliandro, MD
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Institut Mutualiste Montsouris, Paris, France

Correspondence to: Philippe Girard, MD, FCCP, Institut Mutualiste Montsouris, Departement Thoracique, 42 Blvd Jourdan, Paris 75014, France; e-mail: philippe.girard@imm.fr


Chest. 2008;133(3):830-831. doi:10.1378/chest.07-2196
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To the Editor:

We read with interest, and some astonishment, the careful study by Ernst and colleagues1 in a recent issue of CHEST (August 2007) on airway stenting for “severe tracheobronchomalacia.” The only function of airway stenting is the palliation of airway narrowing.

Airway narrowing is a normal event during expiration, and stenting therefore should be considered only when excessive and/or premature narrowing results in airflow limitation. Whereas Ernst and colleagues, to their credit, made every effort to document airway narrowing, airflow limitation was either poorly documented or not documented at all in their study. Only 42 of the 58 patients underwent pulmonary function tests before stenting, and only 10 patients (17%) underwent both prestenting and poststenting pulmonary function tests; in these10 patients, an absolute (nonsignificant) decrease in the median FEV1 value was observed. Regarding the “significant” improvements in dyspnea and other quality-of-life scores, their interpretation is delicate as 50 to 60% of patients did not have prestenting and poststenting comparisons and, as the authors acknowledge, there was no control group for these rather subjective values.

From a physiology point of view, the frontier between normal and abnormal narrowing of the central airways is far from established. Even a 90% reduction in the tracheal section at the end of a forced expiration, when the flow in central airways physiologically nears zero, may well be within normal limits. Also, airway narrowing during cough efforts is pivotal to the efficacy of airway clearance, and this might well explain some of the 21 stent obstructions that Ernst and colleagues observed.

Therefore, given the evaluation biases and the complication rate of this invasive procedure, we remain unconvinced that airway stenting provided any real clinical benefit to this group of patients. Until more solid data emerge (we certainly support the prospective series and databases that Ernst and colleagues suggest), we contend that objective documentation of airflow limitation in central airways should be part of the definition of “severe tracheobronchomalacia.” Otherwise, we take the risk of treating images, not diseases.

The authors have reported to the ACCP that no significant conflicts of interest exist with any companies/organizations whose products or services may be discussed in this article.

Ernst, A, Majid, A, Feller-Kopman, D, et al (2007) Airway stabilization with silicone stents for treating adult tracheobronchomalacia: a prospective observational study.Chest132,609-612
 

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References

Ernst, A, Majid, A, Feller-Kopman, D, et al (2007) Airway stabilization with silicone stents for treating adult tracheobronchomalacia: a prospective observational study.Chest132,609-612
 
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