Thoracic Oncology: Guidelines and Consensus Statement

Management of Central Airway Obstruction: An American College of Chest Physicians Clinical Practice Guideline

Kamran Mahmood, Lindsy Frazer-Green, Anne V. Gonzalez, et al

Chest 2024 in press https://doi.org/10.1016/j.chest.2024.06.3804

Background

Central airway obstruction (CAO), seen in a variety of malignant and non-malignant airway disorders, is associated with a poor prognosis. The management of CAO is dependent on provider training and local resources, which may make the clinical approach and outcomes highly variable. We reviewed the current literature and provided evidence-based recommendations for the management of CAO.

Methods

A multidisciplinary expert panel developed key questions using the PICO (Patient, Intervention, Comparator, and Outcomes) format and conducted a systematic literature search using MEDLINE (PubMed) and the Cochrane Library. The panel screened references for inclusion and used vetted evaluation tools to assess the quality of included studies and extract data, and graded the level of evidence supporting each recommendation. A modified Delphi technique was used to reach consensus on recommendations.

Results

A total of 9,688 abstracts were reviewed, 150 full-text articles were assessed, and 31 studies were included in the analysis. One good practice statement and 10 graded recommendations were developed. The overall certainty of evidence was very low.

Conclusions

Therapeutic bronchoscopy can improve the symptoms, quality of life, and survival of patients with malignant and non-malignant CAO. Multi-modality therapeutic options, including rigid bronchoscopy with general anesthesia, tumor/tissue debridement, ablation, dilation, and stent placement, should be utilized when appropriate. Therapeutic options and outcomes are dependent on the underlying etiology of CAO. A multidisciplinary approach and shared decision-making with the patient are strongly encouraged.

Summary of Recommendations

1. For patients with suspected central airway obstruction (CAO), we recommend a comprehensive history and physical examination with a focus on the respiratory system, a CT scan of the chest, and appropriate laboratory investigations pertinent to non-malignant CAO and preoperative assessment (Good Practice Statement).

2. For patients with symptomatic malignant or non-malignant CAO, we suggest therapeutic bronchoscopy as an adjunct to systemic medical therapy and/or local radiation (Conditional Recommendation, Very Low Certainty of Evidence).

3. For patients with symptomatic malignant or non-malignant CAO, we suggest the use of rigid bronchoscopy over flexible bronchoscopy for therapeutic interventions (Conditional Recommendation, Very Low Certainty of Evidence).

4. For patients with symptomatic malignant or non-malignant CAO, we suggest the use of general anesthesia/deep sedation over moderate sedation for therapeutic bronchoscopy (Conditional Recommendation, Very Low Certainty of Evidence).

5. For patients with symptomatic malignant or non-malignant CAO undergoing rigid therapeutic bronchoscopy with general anesthesia, we suggest the use of either jet ventilation or controlled/spontaneous assisted ventilation (Conditional Recommendation, Very Low Certainty of Evidence).

6. For patients with symptomatic malignant or non-malignant CAO with endobronchial disease, we suggest the use of tumor or tissue excision and/or ablation to help achieve airway patency (Conditional Recommendation, Very Low Certainty of Evidence).

7. For patients with non-malignant CAO with stenosis undergoing therapeutic bronchoscopy, we suggest airway dilation be performed either alone or in combination with other therapeutic modalities (Conditional Recommendation, Very Low Certainty of Evidence).

8. For patients with symptomatic malignant or non-malignant CAO, we suggest stent placement if other therapeutic bronchoscopic and systemic treatments have failed and when feasible for the underlying disorder (Conditional Recommendation, Very Low Certainty of Evidence).

9. For patients with malignant or non-malignant CAO with stent placement, we suggest either routine surveillance bronchoscopy or bronchoscopy when patients are symptomatic (Conditional Recommendation, Very Low Certainty of Evidence).

10. For patients with malignant or non-malignant CAO undergoing therapeutic bronchoscopy, we suggest either using or holding local bronchoscopic therapy (Conditional Recommendation, Very Low Certainty of Evidence).

Remark: Local bronchoscopic treatment is defined as a non-ablative bronchoscopic therapy that may reduce the recurrence or progression of an endobronchial disorder.

11. For patients with non-malignant CAO, we suggest either open surgical resection or therapeutic bronchoscopy (Conditional Recommendation, Very Low Certainty of Evidence).

12. For malignant CAO patients with endobronchial tumor, we suggest either surgical resection or therapeutic bronchoscopy for relief of initial obstruction (Conditional Recommendation, Very Low Certainty of Evidence).

Remarks: There is limited evidence to suggest surgical benefit for non-carcinoid malignant CAO because of advanced locoregional or metastatic disease. Surgery with curative intent might be considered in patients with CAO related to a localized primary lung and airway cancer, including carcinoid.

更多精彩内容，敬请登录CSCCM官方网站（www.csccm.org.cn）或点击屏幕最下方“阅读原文”