Central airway obstruction (CAO) may present in a wide variety of ways, and patients are frequently misdiagnosed with asthma or chronic obstructive pulmonary disease. A high degree of suspicion is necessary to ascertain the diagnosis.
The approach to the patient should be expeditious but with particular attention to securing the airway. Once this has been accomplished, a variety of airway interventions including bronchoscopy, mechanical debulking, balloon bronchoplasty, and stent placement can be employed.
Imaging of the chest with plain x-rays and computed tomography, as well as flow-volume loops are useful ancillary tests.
Definitive diagnosis requires diagnostic bronchoscopy that permits airway inspection and assessment of the lesion or foreign body, removal of secretions, and diagnostic biopsies to be taken when indicated. In the hands of an experienced bronchoscopist, aggressive endoscopic management does not preclude future surgical procedures if necessary.
A multidisciplinary approach to management, with the involvement of a pulmonologist, otolaryngologist, thoracic surgeon, thoracic radiologist, and interventional bronchoscopist, is the key to short- and long-term success.
The distinction between malignant and non-malignant CAO is very important as this affects the prognosis and therapeutic approach. If malignancy is suspected or confirmed, the opinion of an oncologist and radiation oncologist should be sought.
Surgical resection may be considered in patients likely to tolerate surgery who present with benign diseases or resectable malignancies. The input of a thoracic surgeon with experience in complex airway disease is invaluable.
Central airway obstruction (CAO) refers to a variety of obstructive processes that impede airflow within the central airways, trachea, and mainstem bronchi. CAO may be secondary to malignant or benign disease, and represents a significant source of morbidity and mortality with a significant impact on quality of life. As CAO frequently presents with life-threatening respiratory failure, some experts recommend that the word non-malignant be used instead of benign.
History and exam
Key diagnostic factors
- presence of risk factors
- shortness of breath
Other diagnostic factors
- chest pain
- accessory muscle use
- lung cancer
- primary airway malignancy
- artificial airways
- tracheobronchial stents
- transtracheal oxygen catheters
- lung transplantation
- neurocognitive and neuromuscular disorders
- relapsing polychondritis
- granulomatosis with polyangiitis (formerly known as Wegener's granulomatosis)
- endobronchial infections
- extrathoracic and distant malignancies
1st investigations to order
- chest x-ray
Investigations to consider
- bronchoscopy (flexible and/or rigid)
- CT chest
- MRI of chest
- flow-volume loops (FVL)
- endobronchial ultrasound (EBUS)
Jose Fernando Santacruz, MD, FCCP, DAABIP
Bronchoscopy & Interventional Pulmonology
Houston Methodist Lung Center
Houston Methodist Hospital
JFS is a consultant for Boston Scientific and is the author of several studies referenced in this topic.
Krishna M. Sundar, MD
Adjunct Assistant Professor
University of Utah
Pulmonary & Critical Care Research
IHC Urban South Intermountain Utah Valley Pulmonary Clinic
KMS declares that he has no competing interests.
Andrew Parfitt, MBBS, FFAEM
Associate Medical Director
Consultant Emergency Medicine
Guy's and St Thomas' NHS Foundation Trust
Clinical Lead and Consultant
Accident Emergency Medicine
St Thomas' Hospital
AP declares that he has no competing interests.
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