Bronchoscopic laser in the management of airway disease in adults
- Henri G Colt, MD
Henri G Colt, MD
- Professor of Medicine
- University of California Irvine
Bronchoscopic laser therapy is a thermally-ablative technique. It has cutting and coagulant properties which make it a useful tool to treat symptoms associated with airway disease. Its indications, efficacy, contraindications, equipment, and technique are reviewed here. Other bronchoscopic techniques used to manage airway obstruction are described separately. (See "Clinical presentation, diagnostic evaluation, and management of central airway obstruction in adults" and "Endobronchial electrocautery" and "Endobronchial photodynamic therapy in the management of airway disease in adults" and "Bronchoscopic argon plasma coagulation in the management of airway disease in adults" and "Airway stents" and "Flexible bronchoscopy balloon dilation" and "Endobronchial brachytherapy" and "Bronchoscopic cryotechniques in adults".)
INDICATIONS AND EFFICACY
In general, bronchoscopic laser therapy is an immediate-acting, palliative, or adjunctive therapy used to relieve central airway obstruction (CAO; trachea and main stem bronchi) due to malignant or benign conditions [1-3]. Ideal lesions are intraluminal and short (ie, <4 cm) such that the region beyond the obstruction can be visualized and the distal lung is functional. It is not suitable for lesions causing CAO from extrinsic compression or distal lesions (ie, beyond the mainstem bronchus). Lesions that extend a long distance in the trachea or mainstem bronchus are generally not suitable for laser debulking but laser may be used to photocoagulate and devascularize tumor tissues prior to mechanical debulking. Less commonly, it is used to treat hemoptysis, and rarely, it is used to treat inoperable radiographic occult lung cancer that is limited to the airway.
The approach to and choice of modality used to treat patients with central airway obstruction as well as a comparison between the locally ablative bronchoscopic techniques are discussed separately (table 1 and table 2). (See "Clinical presentation, diagnostic evaluation, and management of central airway obstruction in adults".)
Malignant central airway obstruction
Patient or tumor characteristics — CAO from bronchogenic carcinoma is the most common indication for laser resection (table 3) [4-10]. In general, it is a palliative therapy used in patients for whom other first-line treatment modalities are not feasible (eg, surgery or radiation therapy), and/or in patients who require immediate relief from serious life-threatening obstruction. Occasionally, it is used adjunctively before salvage chemotherapy, radiation (eg, external beam radiation or brachytherapy), or surgical resection. Ideal lesions that are suited to laser resection are short tumors (ie, <4 cm) with a significant intraluminal component with or without concomitant bleeding. Its effects are not generally long lasting such that it is either combined with other bronchoscopic therapies (eg, electrocautery, cryotherapy, stenting, dilation, and brachytherapy) or repeated (usually for palliative purposes). (See "Endobronchial electrocautery" and "Airway stents" and "Flexible bronchoscopy balloon dilation" and "Endobronchial brachytherapy" and "Clinical presentation, diagnostic evaluation, and management of central airway obstruction in adults" and "Bronchoscopic cryotechniques in adults".)
Non-small cell lung cancer (NSCLC), particularly squamous cell carcinoma, is the most common malignancy subjected to laser resection. However, case reports of successful management of other types of malignancy have been described including carcinoid, cystic carcinoma, mucoepidermoid carcinoma, and endobronchial metastases from melanoma, colon, kidney, and breast cancer [11-13].
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- INDICATIONS AND EFFICACY
- Malignant central airway obstruction
- - Patient or tumor characteristics
- - Efficacy
- - Comparison with other bronchoscopic techniques
- Benign central airway obstruction
- Radiographic occult lung cancer
- Patients with extrinsic compression
- Patients with stents
- Patients on high flow oxygen
- Patients with extensive or distal lesions
- EQUIPMENT AND TECHNIQUE
- Types of laser
- Principles of laser resection
- Procedural technique
- - Anesthesia and ventilation
- - Choosing flexible versus rigid bronchoscopy
- - Personnel and equipment
- - Procedure
- POSTOPERATIVE CARE
- SUMMARY AND RECOMMENDATIONS