Malignant Airway Obstruction

Author: Daniel Raymond, MD
Institution: Cleveland Clinic Foundation
Date Reviewed: 2014
Learning Domain: General Thoracic
Learning Objective: Management of Malignant Airway Obstruction
PowerPoint File: Malignant Airway Obstruction

Discussion Points for Conference

• Patient and Family desires
• Overall Oncologic prognosis
• Therapeutic Options 
  • Further radiation
  • Chemotherapy
  • Bronchoscopic ablation
  • Brachytherapy
• Anesthetic management
• Management of Bleeding
• Follow up needs

Principles in Management of Malignant Airway Obstruction

• Multidisciplinary approach:  thoracic surgery, interventional pulmonary, anesthesia, oncology, radiation oncology
  • Establish a multimodal treatment plan and determine utility of therapy
  • Establish anesthetic plan for intervention
• Clearly define anatomy using CT scan
• For proximal obstructions:
  • Heliox
  • Careful anesthetic planning – maintain spontaneous breathing until patent airway is established
• Must avoid full thickness airway injury
  • In this case, the stent provided guidance
  • Without the stent, blind debridement could result in catastrophic airway/vascular injury
• These patients require close follow up to prevent future airway compromise

General Principles in Management of Malignant Airway Obstruction

Endoscopic management

• Rigid and flexible bronchoscopy
• Modalities to relieve obstruction
  • Debridement
  • Ablation
    • Laser
    • Cautery
    • Cryotherapy
  • Stenting – covered stent preferred to avoid ingrowth
  • Direct injection
  • Brachytherapy
• Must be prepared for bleeding!
  • Iced Saline or dilute epi lavage
  • Thermal coagulation
  • Balloon tamponade