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Abstract
Central airway obstruction produces symptoms of dyspnea, stridor, and obstructive pneumonia and is frequently life threatening, with patients having impending suffocation. In most cases, resection and surgical reconstruction provides the best opportunity for definitive management. However, bronchoscopic management is the first step in providing diagnosis, stabilizing the obstructed airway, and evaluating resectability. In patients in whom the obstruction is unresectable because of anatomic limitations, metastatic disease, or overall medical condition, endoscopic techniques are minimally invasive and can provide significant palliation. Although the long term outlook in these cases is often dismal, the temporary or permanent relief of airway obstruction provides significant palliation with marked improvement in quality of life and in many cases prolongation of life.
The essential principles of endoscopic management of malignant airway obstruction have been outlined concisely by Mathisen and Grillo(1). Advances in airway prosthetics have provided a variety of silicone stents, expandable metal stents, and pneumatic dilators, enabling the surgeon to correct increasingly complex anatomic problems. Several series have been published describing the application and results of these techniques. (1-4).
Bronchoscopic interventions are many including dilation, core-out of tumor, electrocautery resection, cryotherapy, laser ablation, high-dose intraluminal radiation (brachytherapy), photodynamic therapy and stenting.
Dilation:
Dilation was used primarily for benign airway stenosis. Serial dilation is attempted with successive larger bronchoscopes until an adequate airway caliber had been established.
Pneumatic or hydrostatic balloon dilation with angioplasty balloons are other alternatives to bronchoscopic dilation. (5)
Core-out resection:
Blunt resection involves the simple removal of a tumor using a large forceps through a rigid bronchoscope under general anesthesia and can only be used if no other treatment is available because of the high risk of asphyxia from hemorrhage.(6)
Electrocautery resection:
Electrocautery was used in tracheal and bronchial tumors, but most of the generators induced burns. Furthermore, complications occurred as perforation and fatal heamoptysis. Thus, this method was deemed dangerous and virtually disappeared. (7)
A renewed interest in the technique recently arose with the use of assorted types of electrodes and new generators of high frequency current. (7)
Cryotherapy: