Management of malignant tracheobronchial obstruction

Abstract

Malignant airway obstruction produces symptoms of dyspnea, cough, and stridor with a significant impact on quality of life. With progressive airway narrowing, a critical stenosis is life threatening, due to impending suffocation. Bronchoscopy provides the mainstay of establishing the diagnosis as well as defining the extent and degree of airway obstruction. Therapeutic bronchoscopy provides the ability to achieve prompt airway stabilization while completing a patient evaluation and workup. Patients may have malignant airway obstruction from primary tracheobronchial tumors, adjacent primary tumors with airway invasion, or metastatic disease to the airway. Surgical resection is the preferred definitive therapy for primary airway tumors. A subset of lung or thyroid malignancies that invade the airway may also be amenable to primary surgical resection, as long as a complete resection of tumor can be obtained along with primary airway reconstruction. The majority of patients with malignant airway obstruction will be unresectable due to locally advanced disease, metastatic disease, or contraindicating comorbidity. In these patients, therapeutic bronchoscopy provides a prompt and reliable palliation of the airway obstruction. The simplest and most immediately reliable strategy for endoluminal tumor is mechanical core-out of the tumor. Laser vaporization, photodynamic therapy, cryotherapy, and endobronchial brachytherapy all are adjuncts to the coring out of endoluminal tumor that may prolong the period of palliation achieved. Airway stenting is the only endoluminal therapy available for the management of malignant obstruction from extrinsic disease, and is also a useful adjunct to providing coverage of endoluminal tumor. Flexible and creative application of these techniques provides the best chance for successful airway palliation. Although the long-term outlook in these patients is often dismal, relief of airway obstruction results in a marked improvement in quality and length of life.