Key Points

• It is important to have a working familiarity with the various endobronchial techniques available for bronchoscopic treatment of malignant airway obstruction, as often more than one modality is used.
• An expertise in all of the available therapeutic options for lung cancer is essential, as is a clear understanding of the relevant mediastinal anatomy.
• Silicone stents and self-expanding metallic stents can be deployed with a high success rate for malignant airway obstruction.
• Cryosurgery is performed using a cryoprobe and cooled nitrous oxide that cools tissue to -89 degrees Celsius and can lead to recanalization rates of >95% with low complication rates and at low cost.
• Electrocautery and argon plasma coagulation both provide modalities that lead to thermal damage to tissue leading to its destruction.
• Microdebridement is an emerging technology that can be used to recanalize airways in patients who require >40% FiO2.
• Laser therapy using Nd:YAG is a well-studied, effective modality for tumor destruction in patients who have a central obstructing lesion with visible distal lumen.

A wide variety of disease processes, both benign and malignant, can lead to airway obstruction. The management of benign airway obstruction, such as tracheal stenosis due to prolonged intubation, deserves special consideration and is covered in detail in other chapters of this text (see chapters on Postintubation Injury, Principles of Airway Surgery: Management of Acute Critical Airway Obstruction, and Quality of Life After Antireflux Surgery.) This chapter specifically focuses on the management of malignant airway obstruction, most commonly from lung, esophageal, or thyroid cancer.

Symptoms of central airway obstruction include stridor, shortness of breath, cough, hemoptysis, and failure to clear secretions. Patients can present with signs and symptoms of pneumonia. This will often lead to cross sectional imaging, which can diagnose tracheobronchial obstruction and assist with localization of the offending lesion. Airway obstruction is often the initial presentation for patients with advanced-stage non-small cell lung cancer (NSCLC), seen in up to 20% of these patients. Even in patients who are not candidates for surgical resection, management of central airway obstruction with interventional bronchoscopy can diagnose the lesion, stabilize the airway, and relieve obstruction. Importantly, endobronchial treatment of lung cancer may not prolong survival, but does provide important symptom relief and palliation for these patients[1]. The surgeon who is well trained in these techniques will be able to significantly improve the quality of life that does remain for the patient.

There are numerous endoscopic techniques that the interventionalist must draw upon to competently treat patients with malignant airway obstruction. These include mechanical coring out of tumor, debridement, stenting, laser, argon plasma, cautery, and cryotherapy. More often than not, the surgeon will need to use more than one modality to treat a patient. Therefore, the surgeon must be facile with numerous techniques and individualize therapy for a given patient.

Perhaps even more important, it is essential that the interventionalist, surgeon or otherwise, be familiar with available therapeutic options for lung cancer, including chemotherapy, radiation therapy, and surgery. It is not uncommon for a patient to be sent to a thoracic surgeon for palliation of endobronchial obstruction when instead curative resection may be possible. It cannot be stressed enough that the interventionalist needs to have a working knowledge of all of the options available so these patients can be appropriately evaluated and treated.

In this chapter, the required equipment, advantages, and disadvantages of techniques for the endobronchial palliation of lung cancer are reviewed. In addition, data from randomized clinical trials, where available, are presented to help guide clinical decision-making in this area.