Principles of Airway Surgery: Management of Acute Critical Airway Obstruction

Alberto de Hoyos, G. Alexander Patterson

Key Points

  • Acute central airway obstruction (CAO) is a life-threatening emergency.
  • Expeditious diagnosis and management are necessary to avoid suffocation and death.
  • Rigid bronchoscopy is the preferred method to stabilize the airway.
  • The most common benign cause of CAO is postintubation tracheal injury.
  • Malignant CAO may be caused by intraluminal lesions, extrinsic compression, or mixed lesions.
  • Close communication with the anesthesiologist is essential during airway interventions.
  • A multidisciplinary and multimodality approach ensures the best possible results.
  • Stenoses need to be dilated; endobronchial tumors need to be removed and extrinsic compressions stented.
  • Most intraluminal tumors can be safely cored out with the rigid bronchoscope.
  • Microdébridement is an effective procedure to recanalize obstructive airway tumors to the level of the main stem bronchi.
  • Adjunct modalities include Nd:YAG laser, electrocautery, and argon plasma coagulation.

Acute airway obstruction is a life-threatening emergency that requires expeditious and effective diagnosis and treatment to avoid suffocation and death.[1],[2],[3],[4] The location, severity, and etiology of the obstruction dictate the methodology of management (Box 1). For obstruction proximal to the carina, control is established by securing an airway below that level to provide adequate ventilation and oxygenation. A discussion of upper airway obstruction (oronasal to glottic area) is beyond the scope of this chapter and is covered elsewhere.[5] Thoracic surgeons, however, should be familiar with the “cannot intubate—cannot ventilate” scenario and provide the necessary assistance to establish and secure an airway. Central airway obstruction (CAO), as defined in this chapter, includes the area from the subglottic space to the level of the five lobar orifices. Acute obstruction above this level can be successfully treated with an expeditious tracheostomy if necessary. Management of patients with CAO requires a thorough knowledge of the physiology, etiology, and diagnostic and treatment options, as well as a multidisciplinary team approach that includes chest radiologists, thoracic anesthesiologists, medical and radiation oncologists, interventional pulmonologists, otolaryngologists, and thoracic surgeons.[6],[7],[8] A team approach provides patients with a variety of open or bronchoscopic alternatives and prevents physicians and surgeons from burning their bridges if one technique is initially chosen over another, more favorable, one.

Box 1: Location of Airway Obstruction









Central airway obstruction

Main bronchi


Lobar bronchi

Although surgical resection and airway reconstruction provide the best opportunity for definitive management of CAO, it can only be achieved in a minority of patients and is not the first step in management.[9],[10] For the majority of patients, bronchoscopic management is the first step in providing an accurate diagnosis and achieving effective recanalization of the obstructed airway. Box 2 depicts the goals in the emergency management of patients with CAO. In general, endobronchial intervention for CAO is indicated in two situations: (1) acute life-threatening obstruction of the central airways and (2) obstruction causing symptoms (dyspnea, postobstructive pneumonia, and hemoptysis), atelectasis, or reduction of the airway lumen of more than 50%. A variety of interventional bronchoscopic techniques can be utilized to provide recanalization or palliation of CAO as described in Box 3 and the chapter on Interventional Bronchoscopy for the Management of Airway Obstruction. Although the role of these interventions in the oncologic patient is predominantly palliative, in carefully selected patients these bronchoscopic techniques can improve the quality of life, lower the level of care, allow withdrawal of mechanical ventilation, and, on occasion, prolong survival.[11],[12],[13],[14],[15],[16],[17],[18],[19],[20],[21],[22],[23],[24] Selected patients can undergo definitive surgical resection and airway reconstruction after emergent recanalization and subsequent evaluation of an obstructed airway.

Box 2: Goals in the Management of Patients with Central Airway Obstruction

Relief of airway obstruction

Recruitment of functional lung

Improvement in quality of life

Decrease in level of care (e.g., wean from mechanical ventilation)

Allow time for more definitive therapy (e.g., resection, radiotherapy, chemotherapy)

Bridge to definitive operative management

Box 3: Bronchoscopic Procedures to Treat Central Airway Obstruction

Argon plasma coagulation

Balloon dilation (bronchoplasty)



Endobronchial brachytherapy (high dose rate [HDR])

Laser (Nd:YAG)


Photodynamic therapy

Rigid bronchoscopy (core out, dilation)


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Last updated: April 6, 2020