Central airway obstruction is a life-threatening condition causing severe dyspnea and poor prognosis, often due to lung cancer or other malignancies. It is classified as intrinsic, extrinsic, or mixed based on anatomical involvement. Despite advancements in treatment, management remains complex with limited high-quality evidence. A multidisciplinary expert panel conducted a systematic review, screening 9,688 abstracts and analyzing 31 studies. Using the Delphi technique, they developed one good practice statement and 10 graded recommendations, though evidence certainty was low. Expanding interventional pulmonary programs aims to improve specialized care and outcomes for affected patients.
1. For patients with suspected central airway obstruction, a detailed medical history, thorough physical examination focusing on the respiratory system, chest CT scan, and relevant laboratory tests for nonmalignant airway obstruction and preoperative evaluation are recommended. (Good Practice Statement).
2. For patients with symptomatic malignant or nonmalignant central airway obstruction, therapeutic bronchoscopy is recommended as an adjunct treatment alongside systemic medical therapy and/or local radiation (Conditional Recommendation, Very Low Certainty of Evidence).
3. For patients with symptomatic malignant or nonmalignant central airway obstruction, rigid bronchoscopy is recommended over flexible bronchoscopy for therapeutic interventions (Conditional Recommendation, Very Low Certainty of Evidence).
4. For patients with symptomatic malignant or nonmalignant central airway obstruction undergoing therapeutic bronchoscopy, the use of general anesthesia or deep sedation is preferred over moderate sedation (Conditional Recommendation, Very Low Certainty of Evidence).
5. For patients with symptomatic malignant or nonmalignant central airway obstruction undergoing rigid therapeutic bronchoscopy under general anesthesia, either jet ventilation or controlled/spontaneous assisted ventilation is recommended (Conditional Recommendation, Very Low Certainty of Evidence).
6. For patients with symptomatic malignant or nonmalignant central airway obstruction with endobronchial disease, tumor or tissue excision and/or ablation is recommended to restore airway patency (Conditional Recommendation, Very Low Certainty of Evidence).
7. For patients with nonmalignant central airway obstruction with stenosis undergoing therapeutic bronchoscopy, airway dilation is recommended either as a standalone procedure or in combination with other therapeutic approaches (Conditional Recommendation, Very Low Certainty of Evidence).
8. For patients with symptomatic malignant or nonmalignant central airway obstruction, stent placement is recommended when other bronchoscopic and systemic treatments have failed and if suitable for the underlying condition (Conditional Recommendation, Very Low Certainty of Evidence).
9. For patients with malignant or nonmalignant central airway obstruction with a stent placement, either routine surveillance bronchoscopy or bronchoscopy based on symptom presentation is recommended (Conditional Recommendation, Very Low Certainty of Evidence).
10. For patients with malignant or nonmalignant central airway obstruction undergoing therapeutic bronchoscopy, the use of local bronchoscopic therapy may be considered or withheld based on clinical judgment (Conditional Recommendation, Very Low Certainty of Evidence).
Remark: Local bronchoscopic therapy is a non-ablative intervention designed to lower the risk of recurrence or slow the progression of an endobronchial condition.
11. For patients with nonmalignant central airway obstruction, either open surgical resection or therapeutic bronchoscopy is recommended as a treatment option (Conditional Recommendation, Very Low Certainty of Evidence).
12. For patients with malignant central airway obstruction due to an endobronchial tumor, either surgical resection or therapeutic bronchoscopy is recommended for initial obstruction relief (Conditional Recommendation, Very Low Certainty of Evidence).
Therapeutic bronchoscopy enhances symptoms, quality of life, and survival in malignant and nonmalignant CAO. Multi-modality options, including rigid bronchoscopy, debridement, ablation, dilation, and stenting, should be used as appropriate. Treatment outcomes depend on CAO etiology, requiring a multidisciplinary approach and patient-centered decision-making.