14 - Multimodality Approach to Malignant Airway Obstruction

Abstract

Malignant central airway obstruction is defined as malignant disease occluding the trachea, right or left mainstem bronchi, the bronchus intermedius, or lobar orifices. There are three types of malignant central airway obstruction: endobronchial, extrinsic compression, and mixed patterns. The type of therapeutic bronchoscopic intervention used is dictated by the type of obstruction. For endobronchial obstruction, ablative therapies such as laser, electrocautery, or mechanical debridement is required. For extrinsic compression stents are necessary. It there is a mixed pattern of both endobronchial disease and extrinsic compression, then ablative therapies to destroy the intraluminal tumor first followed by possible stenting if required is optimal. Proper patient selection and timing are critical. Indications for therapeutic bronchoscopy for malignant central airway obstruction includes ≥ 50% occlusion with symptoms of shortness of breath or asymptomatic disease that is likely to progress and become symptomatic without bronchoscopic intervention. Technical success is defined as improvement of the obstruction to <50%. The clinical goal is to improve dyspnea and health related quality of life. While therapeutic bronchoscopy for malignant central airway obstruction may occasionally prolong survival, the main benefit for most patients is improved quality of life and relief of dyspnea. Patients with more shortness of breath, higher ASA score, and lower functional status receive greater benefits from bronchoscopic intervention, while patients with isolated lobar obstruction are less likely to benefit. A systematic multidisciplinary approach that integrates therapeutic bronchoscopy with chemotherapy and radiation therapy is necessary to optimally treat malignant central airway obstruction.