Central airway obstruction - Symptoms, Causes, Images, and Treatment Options

Diseases

Highlights & Basics

Key Highlights

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.

Types of central airway obstruction: intrinsic, extrinsic, and mixed

From the collections of Jose Fernando Santacruz MD, FCCP, DAABIP and Erik Folch MD, MSc; used with permission

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History & Exam
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Diagnostics Tests
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Treatment Options
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Definition

Epidemiology

Etiology

Pathophysiology

Images

Types of central airway obstruction: intrinsic, extrinsic, and mixed
Central airway obstruction: malignant obstruction of the right mainstem
Tracheal-bronchial papillomatosis
Post-lung transplant anastomotic bronchial stenosis
Chest x-ray showing right mainstem endobronchial stent occlusion with mucus
Airway stenosis secondary to granulomatosis with polyangiitis (formerly known as Wegener granulomatosis)
Golden-S or reverse S-sign on chest CT (left image) traced by yellow line. Flexible bronchoscopy (right image) shows the central obstructive lesion at the left mainstem bronchi.
Malignant endobronchial obstruction on multidetector chest CT: lung window demonstrating right mainstem malignant obstruction
Malignant endobronchial obstruction on multidetector chest CT: mediastinal window demonstrating right mainstem malignant obstruction
Malignant endobronchial obstruction on multidetector chest CT: coronal reconstruction demonstrating right mainstem malignant obstruction
Malignant endobronchial obstruction on multidetector chest CT: 3D volume rendering reconstruction demonstrating right mainstem malignant obstruction
Malignant endobronchial obstruction on multidetector chest CT: 2D multiplanar reconstruction (minimal intensity projection) demonstrating right mainstem malignant obstruction
Dynamic airway collapse: A. bronchoscopic view on inhalation; B. bronchoscopic view on exhalation showing dynamic airway collapse; C. CT chest showing normal airway on inhalation; D. CT chest showing significant airway collapse on exhalation
Dynamic (nonfixed or variable) extrathoracic upper airway obstruction: flow-volume loop shows "flattened" inspiratory limb during forced inspiration
Dynamic (nonfixed or variable) intrathoracic upper airway obstruction: flow-volume loop shows "flattened" expiratory limb during forced exhalation
Fixed upper airway obstruction: flow-volume loop shows "flattened" inspiratory and expiratory loops
Post-lung transplant anastomotic bronchial stenosis: right mainstem anastomosis post-multimodal endoscopic therapy
Bronchoscopic therapy for central airway obstruction of the right mainstem: laser photoresection
Post-lung transplant anastomotic bronchial stenosis: electrocautery radial incision
Bronchoscopic therapy for central airway obstruction of the right mainstem: argon plasma coagulation
Post-lung transplant anastomotic bronchial stenosis: balloon bronchoplasty
Bronchoscopic therapy for central airway obstruction of the right mainstem: stent placement
Bronchoscopic therapy for central airway obstruction of the right mainstem: post-mechanical debulking

Citations

Key Articles

Murgu SD, Egressy K, Laxmanan B, et al. Central Airway Obstruction: Benign Strictures, Tracheobronchomalacia, and Malignancy-related Obstruction. Chest. 2016 Aug;150(2):426-41.[Abstract][Full Text]
Bolliger CT, Mathur PN, Beamis JF, et al. ERS/ATS statement on interventional pulmonology. European Respiratory Society. Eur Respir J. 2002;19:356-373.[Abstract][Full Text]
Detterbeck FC, Lewis SZ, Diekemper R, et al. Executive summary: diagnosis and management of lung cancer, 3rd ed: American College of Chest Physicians evidence-based clinical practice guidelines. Chest. 2013 May;143(5 Suppl):7S-37S.[Abstract][Full Text]
Ernst A, Silvestri GA, Johnstone D. Interventional pulmonary procedures: guidelines from the American College of Chest Physicians. Chest. 2003;123:1693-1717.[Abstract]

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