What special precautions should patients with relapsing polychondritis take before and after airway stent placement?

Author: Wang Guangfa, Chief Physician, Peking University First Hospital

Reviewer: Wu Xueyan, Chief Physician, Peking Union Medical College Hospital

For patients with relapsing polychondritis, when the tracheal cartilage is severely damaged and airway narrowing causes severe breathing difficulties, airway stents sometimes have to be inserted.

Stent implantation is a very rigorous matter, so we need to evaluate the patient before implanting the stent.

First, how is the primary disease controlled? Because if the primary disease is not controlled, cartilage destruction is still ongoing, and the effect of stent placement is not good. We must make sure that the patient has been fully controlled, his airway inflammation is not too severe, but he still has difficulty breathing, then we can consider stent placement.

Second, we need to use CT to see where the stenosis is located and how long it is, and then decide whether we must place a stent.

Third, we need to evaluate lung function to see the degree of lung function damage and airflow obstruction. Many patients are very serious and have very poor lung function. The flow rate and capacity curve is a very small ring. The airway inflammation of this patient has been controlled now, but he still has severe dyspnea. What should we do? This patient may need a stent.

Fourth, we need to measure the size of his normal airway. The inserted stent should be close to the normal diameter. Should we put in a Y-shaped one or a straight one? If it is a lesion of the trachea or a simple main bronchus, we put in a straight one. If there is both a trachea and the left and right main bronchi, we have to put in a Y-shaped one. This is the choice of shape.

Fifth, measure the length of the narrow section of the left main bronchus, right main bronchus, and trachea, and choose stents of different lengths. If it is too long, it cannot be inserted, or when it is inserted, it will cause granulation at the bifurcation of the bronchus below. If it is too short, it cannot support the narrow part, so there are many considerations.

Sixth, because stent placement is usually done under general anesthesia, anesthesia assessment must be done to ensure tolerance. General anesthesia is very important to ensure safety, shorten the operation time, and reduce the patient's pain.

If general anesthesia is possible, try to do it, and then place it under mechanical ventilation with safety assurance. It can be placed through endotracheal intubation or by inserting a rigid endoscope.

Silicone stents are more difficult to place because they cannot be shrunk to a small size like metal stents and can be placed through an endotracheal tube. Silicone stents require a hard endoscope to place, so it is necessary to evaluate whether the hard endoscope can be inserted.

Seventh, evaluate the laryngeal cartilage. Some patients may have laryngeal cartilage involvement. If the laryngeal cartilage is severely deformed, not to mention the hard endoscope, even the endotracheal tube cannot be inserted. At this time, the patient may have no other choice but to do a tracheotomy. Therefore, these preoperative evaluations are very important for patients.

What everyone needs to understand is that there may be some problems after stent implantation.

Because the stent is a foreign body, the patient may feel uncomfortable. Most patients will be fine and adapt to it after a long time, so they will not cough. However, some patients will cough frequently, so special attention should be paid at this time. Because the newly inserted stent is easy to shift, it will be troublesome if the cough is particularly severe. If it shifts, the stent must be taken out, so some cough suppressants should be used at this time.

Figure 1 Original copyright image, no permission to reprint

Another problem is that after the stent is placed, there will be problems with expectoration. The epithelium of the airway is called pseudostratified ciliated columnar epithelium. There are some cilia on the epithelial cells that are constantly swinging. There is a layer of mucus on it. This layer of mucus is transported to the large airway level by swinging, and then coughed out. When you have a foreign body here and the stent is blocked here, it will be difficult to transport mucus. So some people can't cough up phlegm after the stent is placed, and it accumulates in the lungs and causes infection. So how to solve the phlegm problem at this time?

One is to dilute the phlegm. You can use some expectorants, or give him nebulization, the purpose is to dilute the phlegm.

Another way is to let the patient do some postural drainage. For example, if the patient cannot cough up, let the patient take the knee-chest position, kneel on the bed, and then touch the chest to the bed. In this way, the sputum below will flow down by gravity. This is also a way.

Figure 2 Original copyright image, no permission to reprint

Also, please note that some stents have been in place for a long time, and granulation tissue will bleed, so you will cough up blood. At this time, the local granulation tissue needs to be cleaned up, and if necessary, the stent may have to be removed. What happens to very few patients? The stent is placed inside, and the blood vessels under the mucosa are close to each other, rubbing against each other, and once the blood vessels are broken, there will be heavy bleeding. This is very dangerous. If you encounter a case of coughing up blood, you must see a doctor in time.

Another thing to note is that if after the stent is placed, the dyspnea is relieved for a while, but then gradually worsens again, in addition to being particularly vigilant about the worsening of the primary disease, you should also be alert to whether it is the growth of granulation tissue. The airway was originally open, but the growth of granulation tissue has blocked it again. If it is blocked, the granulation tissue must be cleared out in time.

So stent placement can sometimes save lives, but over time, many problems will arise. Patients should strengthen their awareness of this, seek medical treatment in a timely manner, and deal with it in a timely manner.