ES 07.03 Bronchoscopic Management of Central Airway Obstruction

Abstract

Malignant airway obstruction can result from primary airway tumors, extension of adjacent primary tumors, or metastatic tumors. Partial or complete airway obstruction can deteriorate functional status of patients and result in impending respiratory failure. Malignant airway obstruction is considered to be one of the most distressing causes of morbidity and mortality in lung cancer patients. Bronchoscopic intervention can provide immediate relief from suffocation, improve general condition, and provide a bridge, allowing time for additional treatment such as surgery, radiation, or chemotherapy in patients suffering from malignant airway obstruction. Any patients who suffer from respiratory distress due to central airway obstruction are indicated for bronchoscopic intervention. However, patients should tolerate the morbidity of intervention, the length of the airway obstruction less than 4cm, and the duration of obstruction less than 2 month due to the technical limitation. Due to it is safe from massive hemoptysis and respiratory failure, most experienced bronchoscopists prefer rigid bronchoscopy under general anesthesia, using intravenous propofol injection. After the induction of anesthesia, the patients are intubated with a rigid bronchoscope tube and a flexible bronchoscope is introduced through the rigid bronchoscope tube, and the narrowed central airway was evaluated. In every case, the obstructed airway is dilated gently using an 10 mm rigid bronchoscope tube initially and then progressively larger bronchoscope tubes until an adequate airway caliber was established. When indicated, a controlled radial expansion balloon is used to enlarge the airway sufficiently to allow bronchoscopic dilatation. Any intraluminal mass is removed mechanically using rigid bronchoscopic forceps or a snare. Frequently, a neodymium-yttrium aluminum garnet (Nd-YAG) or diode laser is used to ablate the residual endobronchial tumor or to cauterize the tumor bed after most of the tumor had been excised. After mechanical dilatation, the airway is maintained by inserting a silicone stent (Dumon-style stent) in patients whose airway is not maintained due to extrinsic compression or malacia. The silicone stents are inserted through the rigid bronchoscope using a standard Dumon technique. In experienced center, the overall success rate is more than 90% after the emergency bronchoscopic intervention. A successful outcome is accompanied by subjective improvement in the symptoms and radiographic findings. After stabilizing the airway with the bronchoscopic treatment, favorable outcome is expected if additional definitive therapy can be applied, such as surgery, radiation, or chemotherapy. Nowadays, bronchoscopic intervention can achieve prolonged survival with sustained significant improvement of quality of life. Tracheal perforation, massive bleeding, respiratory failure and cardiac arrhythmia can develop after bronchoscopic intervention. However, the overall complication rate is not over 5% in experienced center. Bronchoscopic intervention in patients with malignant airway obstruction is helpful for the palliation the airway, allowing the multimodality therapeutic approach and prolonging the life of the patients.