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Ann Thorac Surg 2005;80:1485-1488
© 2005 The Society of Thoracic Surgeons

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New technology

Microdebrider Bronchoscopy: A New Tool for the Interventional Bronchoscopist

^a Interventional Pulmonology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
^b Thoracic Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts

Accepted for publication December 20, 2004.

^_* Address reprint requests to Dr Ernst, Interventional Pulmonology, BIDMC, 330 Brookline Ave, Boston, MA 02215 (Email: aernst{at}bidmc.harvard.edu).

	Abstract

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PURPOSE: We report our experience with a new airway tool, the microdebrider, in treating central airway obstruction.

DESCRIPTION: From April 2002 to April 2004, 23 patients undergoing treatment of central airway obstruction were managed with the microdebrider. All procedures were done under general anesthesia with either a rigid bronchoscope (19 patients) or a suspension laryngoscope (4 patients). The microdebrider was used in an oscillating mode with rotation speeds of 1,000 to 3,000 rpm to resect obstructing tissue.

EVALUATION: Fourteen patients (61%) had tracheal granulation tissue from prior intubation or tracheostomy, 6 (26%) had idiopathic subglottic stenosis, and 3 (26%) had malignant disease. Obstructing lesions were rapidly removed in all patients with interventions lasting between 2 and 15 minutes. There were no procedure-related complications. No patients required reoperation for airway obstruction in follow-up ranging from 1 to 24 months.

CONCLUSIONS: Microdebrider bronchoscopy is a new technique that allows for precise, rapid, and safe removal of lesions obstructing the central airways. Complications of thermal modalities such as airway injury, tracheoesophageal fistulas, and airway fires can be avoided.

	Introduction

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Interventional pulmonologists and thoracic surgeons often encounter patients with obstruction of the central airways requiring bronchoscopy for re-establishment of a patent airway. There is a paucity of data in the literature that detail the frequency of airway obstruction. However, it has been estimated that 20% to 40% of patients with lung cancer will eventually experience tracheobronchial obstruction [1]. When one adds nonmalignant causes of airway obstruction, such as laryngotracheal intubation injury, relapsing polychondritis, and Wegener's granulomatosis, the incidence is even higher. The ideal technique for resection would be effective, quick, and free of complications.

A new generation of tools may bring us closer to the goal: microdebriders are powered instruments composed of a hollow metal tube with a rotating bit or blade coupled with suction. Dissection is accomplished by resecting tissue and debris away from the operative field under microscopic or telescopic guidance. The predecessor of the current day microdebrider was a rotary vacuum shaver developed in 1968 by Urban. The device was designed to help remove acoustic neuromas and was met with limited enthusiasm by other physicians. Orthopedic surgeons began using powered shavers for joint dissections in the 1980s, and Kennedy and Kennedy [2] introduced the modality to otolaryngologists in the United States in 1985 for use in endoscopic sinus surgery. Microdebriders are now used for a wide variety of applications including joint surgery, liposuction, sinus surgery, and laryngeal surgery [3].

After encouraging initial experience, employing this modality for dealing with supra stomal granulation tissue in patients with tracheostomies, we hypothesized that the microdebrider could be effectively used in patients with central airway obstruction from other causes.

	Technology

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There are three key components of a microdebrider: (1) the console, (2) the hand piece, and (3) the blade or bit. The console controls the hand piece by a foot pedal, setting speed, and direction of rotation of the blade or bit. The hand piece drives the blade or bit and integrates it with suction to allow rapid clearance of debris (Fig 1). The blade or bit consists of a hollow metal tube with a port for suction. This is a single use device and is disposable. The tracheal blades currently available are 37 cm in length and 4 mm in diameter. They are configured with either smooth or serrated blades, and the tips can be straight or angled (Fig 2). We prefer angle tip tracheal blades because they allow for excellent access to the entire tracheal lumen and proximal mainstem bronchi (Xomed, Jacksonville, FL).

View larger version (97K): [in this window] [in a new window]   Fig 1. The microdebrider equipment. Depicted is the main unit in the center, which drives the blades and allows for dialing in rotational speed and mode. Also shown are the hand piece in front, which accommodates the blades, and the foot control activating the unit.

View larger version (118K): [in this window] [in a new window]   Fig 2. Example of an angled blade as used in patients in this report. Visible is the fenestration in the outer tube and the serrated edge of the inner rotating knife.

	Technique

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From April 2002 to April 2004, 23 patients undergoing rigid bronchoscopy for malignant or benign symptomatic airway obstruction due to tracheal or proximal mainstem tissue masses were managed with microdebrider bronchoscopy. The patient demographic information is displayed in Table 1.

The airways were inspected thoroughly with a rigid telescope, and in some instances, a flexible bronchoscope through the rigid barrel. The rigid tracheoscope or laryngoscope was then positioned just proximal to the obstructing lesion and a microdebrider equipped with a tracheal blade was introduced into the airway through the barrel of the rigid scope. The oscillating mode was used exclusively with rotation speeds of 1,000 to 3,000 rpm.

The obstructing tissue was removed with telescopic guidance with the microdebrider. In cases of mid-tracheal, distal-tracheal, or mainstem disease, the rigid endoscope barrel was then advanced into the airway to tamponade any bleeding. In cases of proximal tracheal disease done with the suspension laryngoscope, the airway was packed temporarily with cottonelles soaked with oxymetazoline (Afrin, Schering-Plough, Kenilworth, NJ) hydrochloride.

	Clinical Experience

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Sixteen subjects were treated as outpatients and 7 as inpatients at the time of their surgery. The majority of patients suffered from benign airway disease with 14 patients (61%) having tracheal granulation tissue from prior laryngotracheal intubation and 6 (26%) suffering from subglottic stenosis. The remaining 3 patients (13%) had malignant airway obstruction (1 metastatic renal cell cancer and 2 metastatic nonsmall cell lung cancer) involving the distal trachea as well as a mainstem bronchus.

Obstructing airway lesions were rapidly removed in all patients with interventions lasting between 2 and 15 minutes. Despite many of the lesions appearing quite friable and vascular, only mild bleeding occurred that was easily controlled by tamponade of the affected area with the rigid scope or instillation of oxymetazoline hydrochloride. At the conclusion of the procedure, all patients were independent of any ventilatory support. There were no procedure-related complications.

Fifteen of the 16 outpatients were discharged home on the afternoon of the day of their surgery. One outpatient required hospital admission after surgery due to persistent symptoms of dyspnea after removal of proximal tracheal granulation tissue associated with prior intubation and tracheostomy. This patient was found to have previously undetected bilateral vocal cord paresis that eventually required replacement of a tracheostomy tube to relieve symptoms of dyspnea. The patient was discharged home with a tracheostomy tube in place.

The inpatients were all hospitalized for critical illness and had co-morbidities that did not allow hospital discharge after their airway surgery was completed. However, all inpatients were eventually discharged home and all were free of symptoms of central airway obstruction at the time of discharge.

We customarily only re-examine patients endoscopically or by airway computed tomography imaging for recurrent complaints of dyspnea. None of the inpatients or outpatients required re-evaluation or intervention for airway obstruction in follow-up that ranged from 1 to 24 months.

	Comment

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Bronchoscopists now have many tools available for dealing with obstructing lesions of the airway including cryotherapy, carbon dioxide laser, neodymium:yttrium–aluminum–garnet laser, electrocautery, and argon plasma coagulation, just to name a few. Although there has been some debate in the literature regarding the ideal bronchoscopic technique (ie, rigid versus flexible), the main benefit of the rigid technique is that it allows better control of the airway, more rapid debridement of obstructing lesions, and the ability to utilize a broader range of available modalities [4]. The main disadvantages of the thermal modalities include the possibility that thermal effects reach unintended tissue causing problems such as tracheoesophageal fistula, that the final result often takes weeks to be seen, and that oxygen or instruments may combust in the airway [5–7]. There is also the possibility of causing severe injury to the airway or other structures in the chest, potentially requiring more interventions. Thermal modalities all require intermittent debridement of tissue and suction to judge results during the intervention. Thus, some interventions may be quite prolonged.

The advantages of the microdebrider include the ability to (1) rapidly remove obstructing tissue, (2) simultaneously remove tissue debris and blood during the dissection allowing for greater visualization of the operative field, and (3) precisely limit the effects of the modality without fear of combustion of instruments or perforation of the airway. This last factor is important for patients with high-grade airway obstruction requiring high flow oxygen to maintain oxygen saturation in an acceptable range.

The microdebrider requires a rigid bronchoscope or laryngoscope. The instruments are currently not amenable to a flexible technique as they are rigid and have too great a diameter to be introduced into the instrument channel of a flexible bronchoscope.

The microdebrider is a relatively new tool in the armamentarium of the airway surgeon and has been mainly used by otolaryngologists through suspension laryngoscopy [8]. In 2003, Simoni and colleagues reported their experience in using the microdebrider as a first line therapy to palliate a group of 27 patients with dyspnea and advanced laryngotracheal carcinoma [8]. All patients had tumor debulking with the microdebrider, and all patients underwent postoperative radiation therapy. Twenty-six of the 27 patients avoided tracheostomy perioperatively. Two additional patients eventually required tracheostomy due to laryngeal edema that was believed to be induced by radiation therapy. These investigators concluded that the microdebrider was a very safe and efficient tool for relief of upper airway obstruction in their patient population.

There are reports of inadvertent resection of normal tissue with microdebriders [9]. This may occur when vigorous suction is applied to the hand piece allowing an excess of tissue to be taken up in the blade aperture. More commonly, it occurs when a drilling bur is used. Care must be taken to inspect the site to make certain normal tissue is not resected by mistake. Used properly, the microdebrider allows better preservation of normal airway mucosa than other methods of treating obstructing lesions of the airway.

In summary, microdebrider bronchoscopy is a new technique that allows for precise removal of lesions obstructing the central airways. The technique is rapid, allows for a near bloodless field, and avoids the potential injuries that may be associated with thermal modalities. Further study is required to assess the long-term outcomes compared with more conventional therapy.

	Disclosures and Freedom of Investigation

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No financial support was received for this study and the equipment used has not been donated for the purposes of this study. The authors had full control of the study design, the methods used, outcome parameters, analysis of the data, and production of this report.

	Disclaimer

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The Society of Thoracic Surgeons, the Southern Thoracic Surgical Association, and The Annals of Thoracic Surgery neither endorse nor discourage use of the new technology described in this article.

	References

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1. Noppen M, Meysman M, D'Haese J, Schlesser M, Vincken W. Interventional bronchoscopy5-year experience at the Academic Hospital of the Vrije Universiteit Brussel (AZ-VUB). Acta Clin Belg 1997;52(6):371-380.[Medline]
2. Kennedy DW, Kennedy EM. Endoscopic sinus surgery AORN J 1985;42(6):932-936.[Medline]
3. Yanagisawa E, Christmas D, Mirante J. Powered instrumentation in otolaryngology. head & neck surgery. 1st ed.. San Diego: Singular; 2001.
4. Mathisen DJ, Grillo HC. Endoscopic relief of malignant airway obstruction Ann Thorac Surg 1989;48:469-473.[Abstract]
5. Waller DA, Gower A, Kashyap AP, Conacher ID, Morritt GN. Carbon dioxide laser bronchoscopya review of its use in the treatment of malignant tracheobronchial tumours in 142 patients. Respir Med 1994;88(10):737-741.[Medline]
6. Sutedja G, Koppenol W, Stam J. Nd-YAG laser under local anaesthesia in obstructive endobronchial tumours Respiration 1991;58(5–6):238-240.[Medline]
7. Personne C, Colchen A, Leroy M, Vourc'h G, Toty L. Indications and technique for endoscopic laser resections in bronchologya critical analysis based upon 2,284 resections. J Thorac Cardiovasc Surg 1986;91(5):710-715.[Abstract]
8. Simoni P, Peters GE, Magnuson JS, Carroll WR. Use of the endoscopic microdebrider in the management of airway obstruction from laryngotracheal carcinoma Ann Otol Rhinol Laryngol 2003;112(1):11-13.[Medline]
9. Kuhnel T, Hosemann W, Rothammer R. Evaluation of powered instrumentation in out-patient revisional sinus surgery Rhinology 2001;39(4):215-219.[Medline]

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This Article Abstract Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Simon Ashiku Robert L. Thurer Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Lunn, W. Articles by Ernst, A. Search for Related Content PubMed PubMed Citation Articles by Lunn, W. Articles by Ernst, A.