Central airway obstruction (CAO) is a devastating condition for patients, resulting in debilitating dyspnea and associated with a poor prognosis. The condition is defined as an at least 50% occlusion of the central airways. CAO can be life-threatening and often presents with nonspecific symptoms such as cough, dyspnea, dysphagia, fatigue, and weight loss. While lung cancer is the most common cause of CAO, both primary airway malignancies and metastatic disease can result in CAO. Likewise, there are a number of nonmalignant etiologies, including postintubation, inflammatory conditions and transplant-related complications. Significant heterogeneity exists in the management of CAO due to the differences in clinical conditions, clinical practices, and training programs.1
Given the complexity and variability in the management of CAO, CHEST systematically evaluated current evidence to develop clinical practice guidelines.
A multidisciplinary expert panel conducted a thorough review of existing literature, screening nearly 10,000 abstracts and answering 11 population, intervention, comparator, and outcome (PICO) questions. The guidelines created by CHEST make key recommendations to standardize the core principles of the diagnosis and management of CAO and identify important research priorities. The resulting recommendations cover several aspects of CAO management, including the use of therapeutic rigid and flexible bronchoscopy, the type of anesthesia, and the roles of stenting and surgical resection.
For patients with symptomatic CAO, the guidelines suggest therapeutic bronchoscopy in addition to systemic therapy and/or local radiation. While the evidence for this is based on a limited number of low-quality studies due to small sample sizes and heterogenous cohorts, it suggests that therapeutic bronchoscopy can improve symptoms, quality of life, and, potentially, survival for select patients. Additionally, they advise rigid over flexible bronchoscopy, particularly for proximal and critical obstructions, due to the versatility added by rigid bronchoscopy.2 Furthermore, the guidelines suggest general anesthesia or deep sedation over moderate sedation to try to minimize complications and improve patient tolerance of procedures.3 A multidisciplinary approach, including shared decision-making with patients, is emphasized to optimize patient care.
While the guidelines offer a valuable framework for practicing clinicians, they also underscore the need for further research. Nearly all the recommendations are conditional and based on low-quality evidence. This highlights the significant gaps in knowledge that may contribute to variation in practice. For example, there are limited data on the comparative effectiveness of different therapeutic interventions, and there is a dearth of information on long-term outcomes for various treatments. The panel calls for well-designed studies to address identified gaps in the current evidence.
The publication of these clinical practice guidelines is a significant achievement in the field of interventional pulmonology. By providing clear, evidence-based recommendations, highlighting the lack of high-quality evidence, and identifying important areas that warrant further investigation, these guidelines will hopefully help to standardize and improve the diagnosis and management of patients with CAO. Ideally, this will enhance patient care and improve patient-centered outcomes. These guidelines will serve as the foundation for ongoing improvements in the management of a challenging clinical condition.
References
1. Mahmood K, Frazer-Green L, Gonzalez AV, et al. Management of central airway obstruction: an American College of Chest Physicians clinical practice guideline. Chest. 2025;167(1):283-295. Preprint. Posted online July 18, 2024. PMID: 39029785. doi: 10.1016/j.chest.2024.06.3804
2. Marchioni A, Andrisani D, Tonelli R, et al; EVERMORE Study group. Integrated intErventional bronchoscopy in the treatment of locally adVanced non-small lung cancER with central Malignant airway Obstructions: a multicentric REtrospective study (EVERMORE). Lung Cancer. 2020;148:40-47. Preprint. Posted online August 2, 2020. PMID: 32795722. doi: 10.1016/j.lungcan.2020.07.032
3. George PJ, Garrett CP, Nixon C, Hetzel MR, Nanson EM, Millard FJ. Laser treatment for tracheobronchial tumours: local or general anaesthesia? Thorax. 1987;42(9):656-660.PMID: 3686456; PMCID: PMC460902. doi: 10.1136/thx.42.9.656