Treatment algorithm

Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups: see disclaimer

ACUTE

acute presentation

1st line – establishment of secure airway

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ACUTE
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acute presentation
1st line – 

establishment of secure airway

In patients presenting with severe tracheal or bronchial obstruction who are unstable and with impending respiratory failure, initial stabilization is focused on immediate action to promptly and effectively re-establish and secure a patent airway. These patients should be evaluated and managed in an ICU setting.

The establishment of a secure airway may require endotracheal intubation or rigid bronchoscopy. In severe proximal upper airway obstruction, urgent cricothyroidotomy or tracheotomy are the procedures of choice.[2][67] Fiberoptic-assisted intubation with endotracheal tube (ETT) placement under direct visualization should be considered for proximal tracheal obstructions.[60] A laryngeal mask airway (LMA) or suspension laryngoscopy are alternative options to endotracheal intubation.[82]

A foreign body obstructing the central airway may be removed using a variety of instruments including forceps, grasping hooks or baskets, a Fogarty balloon, or a cryotherapy probe.[72]

If there is any doubt regarding airway stability in severe obstruction, rigid bronchoscopy is the procedure of choice as it provides a secure airway, enabling oxygenation and ventilation.[2][70]​​ Rigid bronchoscopy is also preferred given its capacity for both diagnostic and therapeutic airway intervention.​[58][59]

Consider – heliox

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ACUTE
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acute presentation
Consider – 

heliox

Treatment recommended for SOME patients in selected patient group

Heliox, a mixture of 60% to 80% helium and 20% to 40% oxygen, may be used in acute patients as a bridging therapy to avoid intubation or to perform a more secure or stable intubation.

It reduces the work of breathing by reducing the turbulent flow of gases in the large airways and allows a faster establishment of a laminar flow after changes in airway diameter.[15][82] This effect results in a lower driving pressure required to obtain a given flow, or improved flow at the same driving pressure. The resultant reduced work of breathing allows for a more stable intubation with an endotracheal tube (ETT) or rigid bronchoscopy.

The major limitation of the use of heliox is the inability to deliver gas with a FiO2 of >40%.

Plus – endoscopic airway intervention

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ACUTE
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acute presentation
Plus – 

endoscopic airway intervention

Treatment recommended for ALL patients in selected patient group

Bronchoscopic therapy results in an improvement in symptoms, quality of life, and survival, and involves less risk, discomfort, and morbidity than surgical treatment. Rigid bronchoscopy is preferred over flexible bronchoscopy for any therapeutically intended relief of obstruction in symptomatic patients.[59]

There are 3 modalities of endoscopic airway intervention: thermal (laser therapy, electrosurgery, argon plasma coagulation, cryotherapy), nonthermal (photodynamic therapy, airway dilation with a rigid bronchoscope or balloon bronchoplasty, airway stenting, endobronchial microdebrider), and radiation (brachytherapy). Selection of the appropriate intervention depends on the acuity of the presentation, the underlying cause and type of lesion, the stability of the patient, the patient's general, cardiac, and pulmonary status, quality of life, overall prognosis, physician expertise, and the technology available.[2][58][62]​​

A multimodal treatment with the combination of various endoscopic techniques is usually used, as some techniques such as laser therapy or electrosurgery with airway stenting are complementary to one another.[16][58]

Consider – extracorporeal membrane oxygenation (ECMO)

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ACUTE
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acute presentation
Consider – 

extracorporeal membrane oxygenation (ECMO)

Treatment recommended for SOME patients in selected patient group

In some cases, ECMO support may be considered if the degree of stenosis and risk of respiratory decompensation is deemed prohibitive for a conventional bronchoscopic approach.[83][84]​​ The potential therapeutic adverse outcome should outweigh the risk of ECMO itself.[23][85]​​

Consider – diagnostic flexible bronchoscopy once stabilized

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ACUTE
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acute presentation
Consider – 

diagnostic flexible bronchoscopy once stabilized

Treatment recommended for SOME patients in selected patient group

Once initial stabilization is achieved, a detailed and careful flexible bronchoscopy, as well as other additional studies required for diagnosis and treatment planning, may be performed. This is not necessary in patients who are initially managed with rigid bronchoscopy or in patients who require urgent intervention.

Consider – external beam radiation

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ACUTE
|
acute presentation
Consider – 

external beam radiation

Treatment recommended for SOME patients in selected patient group

External beam radiation (EBR) is only variably effective for malignant CAO, with success rates for hemoptysis, airway obstruction, and atelectasis of 84%, 21%, and 23% respectively. The effects of EBR are delayed and unreliable, and with the recent advances in interventional bronchoscopy, treatment is shifting from EBR to bronchoscopy.

Occasionally, EBR can be performed in a stable patient with an improved performance status following bronchoscopic intervention in order to consolidate the effects of this treatment.

EBR results in the unwanted radiation exposure of normal tissue, including the lung parenchyma, heart, spine, and esophagus, and approximately 50% of patients treated with EBR for local control develop disease progression in the irradiated field.

Consider – surgery

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ACUTE
|
acute presentation
Consider – 

surgery

Treatment recommended for SOME patients in selected patient group

Surgery may be indicated in both malignant and nonmalignant CAO, depending on the extent of malignant disease at presentation, the nature of the benign disease, and the existence of comorbid medical conditions.[58][70][128]​​

It is a highly specialized field and should be performed by a thoracic surgeon with significant experience in complex airway procedures. The goal of surgery is to increase the size of the available airway or to resect the stenotic segment. Thus, the most common procedures are end-to-end anastomosis or tracheal sleeve resection.

Radical surgical resection with systemic nodal dissection is the standard therapeutic approach in resectable tumors, but malignant CAO normally presents as advanced disease with no chance of curative surgical resection.[18]

Surgical resection and anastomosis is the treatment of choice in benign tracheal strictures, but tracheal resection is only possible in approximately 50% of patients who are otherwise suitable for surgery, and no satisfactory prosthesis has yet been developed that permits a more extensive tracheal resection.[128]

subacute presentation

1st line – supplemental oxygen

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ACUTE
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subacute presentation
1st line – 

supplemental oxygen

Patients with a subacute presentation may be treated with supplemental oxygen via nasal cannulae or a respiratory mask.

Consider – bronchodilators

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ACUTE
|
subacute presentation
Consider – 

bronchodilators

Treatment recommended for SOME patients in selected patient group

Tracheobronchomalacia or symptomatic severe dynamic posterior airway collapse may be managed with conservative therapy such as bronchodilators at standard doses.[13]

Primary options

albuterol inhaled: 2.5 mg inhaled via nebulizer three to four times daily when required, maximum 10 mg/day

Consider – continuous positive pressure ventilation

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ACUTE
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subacute presentation
Consider – 

continuous positive pressure ventilation

Treatment recommended for SOME patients in selected patient group

Tracheobronchomalacia or symptomatic severe dynamic posterior airway collapse may be managed with conservative therapy such as continuous positive pressure ventilation.[13]

Plus – diagnostic flexible bronchoscopy

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ACUTE
|
subacute presentation
Plus – 

diagnostic flexible bronchoscopy

Treatment recommended for ALL patients in selected patient group

A detailed and careful flexible bronchoscopy, as well as other additional studies required for diagnosis and treatment planning, should be performed under local anesthesia with intravenous sedation, or under general anesthesia.

In flexible bronchoscopy procedures without an endotracheal tube (ETT), ventilation is spontaneous, while in those undertaken through an ETT or laryngeal mask airway, intermittent positive pressure ventilation is required.[60]

Plus – endoscopic airway intervention

Back
ACUTE
|
subacute presentation
Plus – 

endoscopic airway intervention

Treatment recommended for ALL patients in selected patient group

Bronchoscopic therapy results in an improvement in symptoms, quality of life, and survival, and involves less risk, discomfort, and morbidity than surgical treatment. Rigid bronchoscopy is preferred over flexible bronchoscopy for any therapeutically intended relief of obstruction in symptomatic patients.[59]

There are 3 modalities of endoscopic airway intervention: thermal (laser therapy, electrosurgery, argon plasma coagulation, cryotherapy), nonthermal (photodynamic therapy, airway dilation with a rigid bronchoscope or balloon bronchoplasty, airway stenting, endobronchial microdebrider), and radiation (brachytherapy). Selection of the appropriate intervention depends on the acuity of the presentation, the underlying cause and type of lesion, the stability of the patient, the patient's general, cardiac, and pulmonary status, quality of life, overall prognosis, physician expertise, and the technology available.[2][58][62]​​

A multimodal treatment with the combination of various endoscopic techniques is usually used, as some techniques such as laser therapy or electrosurgery with airway stenting are complementary to one another.[16][58]

Patients with inoperable lung cancer and symptomatic airway obstruction should be offered therapeutic bronchoscopy with mechanical or thermal ablation, brachytherapy, or stent placement, with the aim of improving dyspnea, cough, hemoptysis, and quality of life.[87]

A large retrospective study of more than 800 patients showed that interventional bronchoscopic procedures for severe neoplastic airway obstruction have an 85% success rate.[88] Another retrospective study has shown that rigid bronchoscopy and mechanical debulking as a sole therapy is safe and successful in up to 83% of cases of central airway tumors.[92]

Consider – external beam radiation

Back
ACUTE
|
subacute presentation
Consider – 

external beam radiation

Treatment recommended for SOME patients in selected patient group

External beam radiation (EBR) is only variably effective for malignant CAO, with success rates for hemoptysis, airway obstruction, and atelectasis of 84%, 21%, and 23% respectively. The effects of EBR are delayed and unreliable, and with the recent advances in interventional bronchoscopy, treatment is shifting from EBR to bronchoscopy.

Occasionally, EBR can be performed in a stable patient with an improved performance status following bronchoscopic intervention in order to consolidate the effects of this treatment.

EBR results in the unwanted radiation exposure of normal tissue, including the lung parenchyma, heart, spine, and esophagus, and approximately 50% of patients treated with EBR for local control develop disease progression in the irradiated field.

Consider – surgery

Back
ACUTE
|
subacute presentation
Consider – 

surgery

Treatment recommended for SOME patients in selected patient group

Surgery may be indicated in both malignant and nonmalignant CAO, depending on the extent of malignant disease at presentation, the nature of the benign disease, and the existence of comorbid medical conditions.[58][70][128]​​

It is a highly specialized field and should be performed by a thoracic surgeon with significant experience in complex airway procedures. The goal of surgery is to increase the size of the available airway or to resect the stenotic segment. Thus, the most common procedures are end-to-end anastomosis or tracheal sleeve resection.

Radical surgical resection with systemic nodal dissection is the standard therapeutic approach in resectable tumors, but malignant CAO normally presents as advanced disease with no chance of curative surgical resection.[18]

Surgical resection and anastomosis is the treatment of choice in benign tracheal strictures, but tracheal resection is only possible in approximately 50% of patients who are otherwise suitable for surgery, and no satisfactory prosthesis has yet been developed that permits a more extensive tracheal resection.[128]

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Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups. See disclaimer

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