B46-30 The Bronchial Bottleneck: A Case of Complete Left Upper Lobe Stenosis

Abstract Introduction Tracheobronchial stenosis is a condition involving the narrowing of one or more areas of the tracheobronchial tree. There are numerous underlying etiologies, including both benign and malignant causes. Initial bronchoscopic treatment for benign airway stenosis includes radial incisions with electrocautery, balloon dilation, cryotherapy, and steroid injection. We present a challenging case of idiopathic stenosis of the left upper lobe (LUL) causing lobar atelectasis. Case Description A 72-year-old man, former smoker, with past medical history of hypertension and hyperlipidemia presented with persistent cough and dyspnea following an influenza infection. CT chest imaging revealed LUL bronchial obstruction with consolidation. Bronchoscopy identified web-like stenosis in the LUL bronchus, which was treated with balloon dilation. Endobronchial biopsy revealed benign tissue, and bronchoalveolar lavage (BAL) was negative for pathogens. Two years later, the patient presented again with a persistent cough. The CT chest showed complete LUL bronchial obstruction with atelectasis. The patient had very good exercise tolerance at baseline and noted inability to exercise as much as prior due to fatigue. Repeat bronchoscopy revealed complete stenosis of the LUL bronchus. Bronchoscopic and CT chest images were correlated to determine the origin of the left upper lobe proper and lingular bronchi. A 21-gauge needle was successfully used to identify both airways. Subsequently, a Fogarty balloon was passed into the needle track to dilate the airways. The post-obstruction airway had a significant amount of purulent material, which was aspirated. Then, the stenosis was treated with electrocautery knife cuts, cryoablation, and repeated balloon dilation. Afterwards, a P190 bronchoscope was passed across the stenosis, and the segmental airways were well-visualized and clear. Endobronchial biopsy showed fibrosis consistent with web stenosis. BAL was again negative for infection. An anti-nuclear antibody panel completed prior to the procedure was negative. Given the absence of infectious, inflammatory, malignant, or connective tissue disease, the diagnosis of idiopathic stenosis was assigned. Repeat CT imaging following the procedure revealed complete resolution of the left upper lobe collapse. The patient reported post-procedure subjective improvement in breathing and exercise tolerance. Discussion This unique case presents the challenge in identifying airways past an area of complete stenosis. Prior reports of successful recanalization have included use of fluoroscopic, contrast-assisted guidewire placement with balloon dilation. Here, we present a case in which careful review of prior bronchoscopic and CT chest images yielded the path forward. This abstract is funded by: None