We reviewed 13 patients in this study. Of these, 2 were male and 11 were female; patient age ranged from 46 to 76 years (median = 59 years). In total, we performed the procedure 17 times for these patients. All but one of the patients presented with one or more of the following symptoms: wheezing, coughing, pneumonia, or recurrent pneumonia. The remaining patient presented with only atelectasis. All patients had mediastinal, pulmonary, or pleural calcification in addition to the broncholiths, as visualized with chest CT. Acid-fast stain testing was positive only for patient 7, and interferon-γ release assays were positive for all patients (Table.1).
All procedures were performed under general anesthesia and using rigid bronchoscopy. Broncholiths were hard, irregular, and yellow or yellowish white, and several were covered with granulation tissue. For eight patients, the broncholiths were transbronchial, and for five patients they were endobronchial. All attempts under bronchoscope failed including forceps, rigid forceps and snares to remove broncholiths before laser treatment, because broncholiths were too large or embedding into bronchial lumen.
Patient 11 had a large broncholith in the right intermediate bronchus (Fig.1 and Fig.2) , and underwent the procedure five times over half a year. Thereafter, there was no stenosis in the right intermediate bronchus (Fig.3), and chest CT scan revealed no residual broncholiths (Fig.4). Median procedure duration was 100 min. Median procedure time for transbronchial and endobronchial broncholiths was 102 min and 67 min, respectively (Table.2). All broncholiths were successfully extracted after lithotripsy.
Several patients experienced complications:
- Life-threatening hemoptysis: We defined life-threatening hemoptysis as hemoptysis more than 200 ml/h, or caused oxygen saturation <90%, persisting for more than 1 min during bronchoscope procedures. One patient experienced such life-threatening hemoptysis (Patient 2). We hypothesized that it was caused by bronchial artery damage. Therefore, we isolated the right airway with a rigid bronchoscope, and achieved hemostasis using gauze, gelatin compressed sponge, and rigid forceps. Double-lumen endotracheal intubation and single-lung ventilation was initiated, and the patient was transferred to the intensive care unit. On the sixth day after the procedure, the patient was successfully extubated.
- Bronchoesophageal fistula (BEF): Two patients (patient 1 and 11) had a bronchial esophageal fistula after the procedure. Both had a transbronchial broncholith located in the right intermediate bronchus, which was completely removed. Patient 1 expectorated a bean-sized stone after the procedure. For patient 11, the whole body of the broncholith was removed during the last procedure. These patients were diagnosed with BEF via upper gastroenterography and upper endoscopy. Both patients’ fistula was located at the original site of the broncholith. They received enteral nutrition and recovered from BEF after several months.
- Two patients had fever after the procedure, which improved after antibiotic treatment. One patient had an acute asthma attack, which improved after steroid treatment.
There was no airway ﬁre or damage to the bronchoscope.
Prognosis: All patients were followed up until September 2019, with a median follow-up time of 3 years (range: 1-7 years). All patients survived with no clinical symptoms at the final follow-up. The patients with BEF fully recovered within 3-4 months. All patient survived, and there were no long-term complications and no disease recurrence.