Oral Presentation Room Lehár 1-2 - 14:45-16:45 T UESDAY, S EPTEMBER 15 TH 2009 Methods: We assessed lateral pressure (Plat) before interventional bronchoscopy in 15 patients with tracheobronchial stenosis (7 lung cancer, 3 esophageal carcinoma, 1 thyroid carcinoma, 1 choriocarcinoma, 1 tracheobronchial malacia, 1 bronchial tuberculosis, 1 cicatricial stenosis). Plat from trachea to lower bronchus was measured using an airway catheter during quiet breathing. For each subject, Plat at both proximal and distal site were plotted during both inspiration and expiration (P-P curve). Then we analyzed the pattern of the P-P curves. Results: There was no significant difference between inspiration and expiration in the angle of P-P curve (11.4±12.6° inspiration vs 9.7±13.8° expiration; P=0.24). In some patients, the shape of P-P curve was not linear as we measured Plat during operation. For patients with extrathoracic fixed stenosis, the angle of P-P curve during inspiratory phase was smaller than during expiratory phase. For patients with tracheobronchial malacia, the angle of P-P curve during expiration was smaller than during inspiration. In patients with bronchial stenosis, the shape of the P-P curve at the narrowest side became loop shaped when comparing left and right sides. When the airway was sufficiently patent after treatment, the loop disappeared. Conclusions: The pressure - pressure curve is useful to estimate the mechanics of the tracheobronchial stenosis and outcomes of interventional pulmonology. 4237 Management of subglottic stenosis (sgs) with endoscopic procedures in patients with Wegener’s granulomatosis Raffaele D’Ippolito 1 , Luigi Fecci 1 , Maria Majori 1 , Augusto Vaglio 2 , Ines Casazza 2 , Angelo Gianni Casalini 1 . 1 Dipartimento Cardio-Polmonare, U.O. Pneumologia ed Endoscopia Toracica Azienda Ospedaliero-Universitaria di Parma, Parma, Italy; 2 Dipartimento di Medicina I, U.O.Clinica Medica Nefrologia Università degli Studi di Parma, Parma, Italy 378. How to deal with tracheal stenosis 4235 Multidisciplinary management of tracheal stenosis Petronela Grigore 1 , Emilia Crisan 1 , Ruxandra Ulmeanu 1 , Mihai Alexe 1 , Radu Stoica 2 , Genoveva Cadar 2 , Iolanda Ion 2 , Ioan Cordos 3 , Nicolae Galie 3 , Codin Saon 3 , Cristian Paleru 3 . 1 Bronchology, 2 ICU, 3 Thoracic Surgery, “Marius Nasta”National Institute of Pneumology, Bucharest, Romania Objectives: To evaluate the indications and outcome of different treatment techniques in tracheal stenosis. Methods: A five years retrospective study of all the cases of tracheal stenosis treated in our hospital. Results: 287 patients with tracheal stenosis were reffered between 2004 - 2008. There were 175 males (61%) and 112 females, median age 48±10.4 years (range 12-84). The etiology of the tracheal stenosis was neoplasic in 182 (67.3%)cases - 154 pulmonary carcinoma, 7 tyroid cancer, 11 esophageal cancer, 2 lymphoma, 3 atypical carcinoid and 5 metastatic lesions. Among the 105 cases of non-malignant stenosis, 81% complicated prolonged intubation or tracheostomy. 212 patients were treated with different therapeutic bronchoscopy methods. 104 stents were inserted: 45 Polyflex, 23 Montgomery, 13 Dumon, 12 metallic and 11 Y Freitag stents. Several endoscopic techniques were combined: Nd:YAG laser resection in 57 patients, electroresection in 75 patients and 45 mechanical dezobstructions/dilatations. All the interventional bronchoscopy procedures were performed under general anesthesia with jet ventilation. In most cases (65%), the indication was palliative, for malignant tracheal stenosis. Among these, 13 patients had former pneumonectomy for pulmonary carcinoma. Tracheal resection was performed in 75 patients, most of them (85.5%) with non-malignant stenosis. 14 cases required endoscopic treatment before surgery and 5 cases with restenosis after tracheal resection needed further bronchoscopic treatment.Major complications occured in less than 1% of cases. Conclusions: An increasing number of complex tracheal stenosis often requires a multidisciplinary management in order to improve the clinical condition and the patients quality of life. 4236 Assessment of tracheobronchial stenosis using pressure-pressure curves by airway catheter Hiroki Nishine, Takehiko Hiramoto, Hirotaka Kida, Takeo Inoue, Teruomi Miyazawa. Internal Medicine, St. Marianna University School of Medicine, Kawasaki, Kanagawa, Japan SGS develops in approximately 16-23% of patients with Wegener’s granulomatosis disease (Langford et al, 1996). Endoscopic procedures are indeed an important treatment option for this complication and its relapses. We retrospectively examined short and longterm efficacy as well as safety of endoscopic management of SGS with laser assisted mechanical dilatation and/or intralesional injection of long-acting corticosteroid (methylprednisolone acetate) into the stenotic segment. We reviewed data from all patients with Wegener’s granulomatosis referring to our institution since 1999. They all showed symptoms of upper airway obstruction or at least 50% obstruction in the subglottis region. Procedures were repeated if re-stenosis occurred. A group of 7 patients (5 F; age range:21-55 yrs) underwent 44 procedures (19 intralesional injection, 24 laser assisted mechanical dilatation and 1 both procedures). Mean follow-up was 65±39 months. Patients required a mean of 6.4 procedures at mean intervals of 8.9 months to maintain subglottic patency. None of the 7 patients required tracheotomy or more aggressive surgical treatments (segmental resection of SGS with primary anastomotic reconstruction). Moreover, there were no complications and adverse longterm sequelae. Our results confirm that SGS and its relapses in patients with Wegener’s granulomatosis should be managed primarily by endoscopic procedures. 4238 An outcome analysis of airway self-expandable metallic stent in central airway obstruction Fu-Tsai Chung, Shu-Min Lin, Hao-Cheng Chen, Chun-Liang Chou, Chih-Teng Yu, Han-Pin Kuo. Department of Thoracic Medicine, Chang Gung Memorial Hospital, Chang Gung University, College of Medicine, Taipei, Taiwan Objective: To analyze the difference of baseline, clinical manifestations, response, and complications of Ultraflex Self-Expandable Metallic Stents (SEMSs) applied in patients with central airway obstruction. Methods: From 2001 to 2006, 149 patients with benign (n=72) and malignant (n=77) airway disease received 211 SEMSs (116 benign lesions and 95 malignant lesions) were retrospectively reviewed in a tertiary hospital. Results: Characters between patients with benign and malignant condition received SEMS implantation were significantly different, including age (63.9±15.6 years vs. 58±12.2 years; p=0.006), gender (male, 62.1% vs. 90.5%; p<0.0001), smoking (47.4% vs. 85.3%; p<0.0001), forced expiratory volume in first one second (FEV1) (0.9±0.4L/s vs. 1.47±0.68L/s; p <0.0001), followed up days after SEMS implantation (median, IQR; 429 (141-856) vs. 57 (19-103); p<0.0001) and covered SEMS (36.2% vs. 94.7%; p<0.0001). Patients with benign condition had higher rate of symptoms resolution after SEMS implantation than that in patients with malignant condition.(76.7% vs. 51.6%; p<0.0001). The overall complication rate (42.2% vs. 21.1%; p=0.001) after SEMS implantation in patients with benign conditions were higher than those in patients with malignant conditions. Successful management rates of SEMS migration, granuloma formation and SEMS fracture were up to 100%, 81.25%, and 85% respectively. Conclusions: Patients received SEMS implantation due to benign conditions had worse lung function and were older than those with malignancy. There was higher complication rate in patients with benign conditions especially granuloma formation and SEMS fracture than it in patients with malignancy. Purpose: To study the pattern of the pressure-pressure curve (P-P curve) to assess the airway mechanics and the outcome of interventional pulmonology. 752s Abstract printing supported by Chiesi Farmaceutici SpA. Visit Chiesi Farmaceutici SpA. at Stand B.40 Oral Presentation Room Lehár 1-2 - 14:45-16:45 T UESDAY, S EPTEMBER 15 TH 2009 4239 Gastroesophageal reflux disease and subglottic stenosis Dilip Nataraj, Michael Kent, Sidharta Gangadharan, Adnan Majid, Gaetane Michaud, Felix Herth, Anthony Lembo, Armin Ernst. Interventional Pulmonology, Beth Israel Deaconess Medical Center, Boston, MA, United States of America Conclusion: GERD seems more prevalent in the TBM population compared with the general population. It may be silent and may negatively impact the outcome of surgical tracheoplasty. Rationale: Subglottic stenosis (SGS) is a narrowing of the airway below the level of the vocal cords. It remains unclear why some individuals develop SGS, but gastroesophageal reflux disease (GERD) may be a contributing factor. Objective: To determine the prevalence of GERD in adult patients with SGS compared with the general population. Methods: Prospective cohort study of 10 adult SGS patients (8 females & 2 males) who underwent GERD testing by pH probe (7 patients) or upper endoscopy (3 patients). Anti-reflux therapy was stopped 7 days prior to testing. A two-sided exact binomial test was used for statistical analysis of prevalence data. Results: All patients were non-smokers and the mean age was 52. The etiology of stenosis was idiopathic (6), post-intubation (1), Wegener’s granulomatosis (1), relapsing polychondritis (1), and radiation (1). 7 of 10 patients were GERD (+) in the SGS population yielding a prevalence of 70% (prevalence in the western world 20%, p=0.002). The mean DeMeester score of GERD (+) and GERD (-) patients was 32.5 and 8.3, respectively (range 4.3-49.7). In 57% of patients, there was poor symptom correlation indicating that reflux may be silent. Concurrent smoking was not a confounding variable Conclusion: GERD seems more prevalent in patients with SGS than in the general population and may be silent in this population. 4240 Surface modification of tracheal stents by silver nano-particles to prevent bacterial colonization Thorsten Walles 1,2 , Heike Mertsching 2 , Iris Trick 2 , Michael Müller 2 , Christian Oehr 2 . 1 General Thoracic Surgery, Schillerhoehe Hospital, Gerlingen, Germany; 2 Cell Systems & Material Sciences, Fraunhofer Institute for Biotechnology and Interfacial Engineering, Stuttgart, Germany 4242 A sheep model for hyperdynamic tracheal collapse Hisashi Tsukada, Carl R. O’Donnell, Diana Litmanovich, Robert Garland, Malcolm DeCamp, Armin Ernst. Chest Disease Center, Beth Israel Deaconess Medical Center, Boston, MA, United States of America Introduction: Tracheobronchomalacia (TBM) is characterized by excessive airway collapse due to increased flaccidity of the membranous portion and/or softening of the supporting cartilage. The treatment of TBM is complex, aiming to stabilize the central airways. A reliable animal model simulating hyperdynamic collapse of the central airways is not available, but highly desirable to develop new therapeutic and diagnostic approaches. Aim: Development of a reliable animal model to test interventions for TBM. Methods: Seven 20kg male sheep were examined in this study. Tracheomalacia was created by submucosal resection of more than 50% of the circumferences of individual cervical tracheal cartilages over a length of 5cm (10 rings) through a midline cervical incision. A silicone stent was placed to prevent airway collapse. Tracheal collapsibility was assessed by bronchoscopy and MDCT imaging while temporarily removing the stent. Esophageal pressure and flow data were collected on 3 sheep to assess flow limitation during spontaneous breathing. Results: All animals tolerated the procedure and required airway stent placement at the TBM site prior to extubation. Three sheep died at 2 weeks and at 3 months due to stent migration. In all sheep, near total airway collapse during forced inspiration was observed. There was evidence of inspiratory flow limitation in 2 of 3 animals during forceful inhalation with negative pleural pressures <- 20 cmH2 O. Conclusion: Hyperdynamic airway collapse can be induced with this technique. It may serve as a model for evaluation of novel diagnostic and therapeutic strategies for TBM. Objective: Airway stenting is increasingly used in the management of obstructive lesions of the central airway. Microbiological colonization of the airway stents causes therapy resistant halitosis and severe airway infections. We coated clinically applied tracheal stents with a thin layer of silver nano-particles to prevent bacterial colonization in vitro. Methods: Tecoflex® Polyurethane sheets (n=5) were coated with silver nanoparticles by immersion in a colloidal silver solution, generated from silver nitrate by reduction with sodium citrate in distilled water, for 2 hours and exposed to a hydrogen plasma glow discharge for silver colloid fixation. To test for bacterial colonization, stent materials were incubated for 1-3 days in vitro with i) Micrococcus luteus (ML), ii) E. coli (EC) and iii) Pseudomonas aeruginosa (PA). Antimicrobial activity was evaluated by bacterial growth inhibition. Stent surface colonization was investigated by raster electron microscopy. Results: The covering procedure resulted in an 80 nm silver nano-coating. It shows antibacterial activity against gram-positive (ML) and gram-negative (EC) bacterial strains, especially PA, by inhibiting bacterial stent surface seeding. Additionally, the coating exerts its antibacterial activity on the stent environment, suppressing colony formation. Conclusions: Nano-silver coating using plasma technology may increase the biocompatibility of tracheal stents in clinical applications, thereby eliminating the cause for halitosis and airway infections. 4241 Prevalence of gastroesophageal reflux in patients with tracheobronchomalacia Armin Ernst 1 , Dilip Nataraj 1 , Adnan Majid 1 , Malcolm DeCamp 1 , Ram Chuttani 2 , Anthony Lembo 2 , Felix Herth 3 , Michael Kent 1 , Sidharta Gangadharan 1 . 1 Interventional Pulmonology, Beth Israel Deaconess Medical Center, Boston, MA, United States of America; 2 Gastroenterology, Beth Israel Deaconess Medical Center, Boston, MA, United States of America; 3 Thoraxklinik Heidelberg, Germany Rationale: Little is known about the etiology of Tracheobronchomalacia (TBM) and exacerbating factors. Gastroesophageal reflux disease (GERD) has been associated with respiratory disorders and a higher prevalence of GERD has been noted in infants with TBM; such data is lacking in adults. Objectives: To determine the prevalence of GERD in an adult TBM population and its impact on outcomes of tracheoplasty. Methods: Prospective cohort study of 30 (12 male) adult TBM patients who underwent testing for GERD by pH probe, impedance, or upper endoscopy. Results: 17 of 30 patients were GERD (+) yielding a prevalence of 56% in this unselected TBM population (prevalence in the western world 20%, p<0.001). The mean DeMeester score of GERD (+) patients was 40.7 (range 17-99.2), there was no reflux symptom correlation in 50% of patients. Twelve of the 30 patients underwent tracheoplasty for treatment. Seven of 12 were GERD (+); 3 of the 7 (42.8%) had an unsuccessful tracheoplasty; 2 of these 3 had DeMeester scores >50 and required fundoplication. Only 1 of 5 (20%) GERD (-) tracheoplasty patients had an unsuccessful repair. 753s Abstract printing supported by Chiesi Farmaceutici SpA. Visit Chiesi Farmaceutici SpA. at Stand B.40