Central airway obstruction (CAO) may present in a wide variety of ways, and patients are frequently misdiagnosed with asthma or COPD. 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 CT, as well as flow-volume loops are useful ancillary tests.
Definitive diagnosis requires a 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.
The distinction between malignant and nonmalignant CAO is very important as this affects the prognosis and therapeutic approach. If malignancy is suspected or confirmed, the opinion of an oncologist and radiation oncologist should be sought.
Surgical resection may be considered in patients likely to tolerate surgery who present with benign diseases or resectable malignancies. The input of a thoracic surgeon with experience in complex airway disease is invaluable.