Speaker's Highlight

• Don Sin University of British Columbia, St. Paul Hospital (Canada)
  Kenneth R. Chapman Toronto General Hospital Research Institute (Canada)
• Parameswaran Nair McMaster University (Canada)
  Carolyn Calfee UCSF (U.S.A.)
• Gregory P. Downey University of Colorado School of Medicine (U.S.A.)
  David A. Schwartz University of Colorado School of Medicine (U.S.A.)
• Neil Schluger Tuberculosis Control Branch, California Department of Public Health (U.S.A.)
  Nick Kim Critical Care & Sleep Medicine, University of California San Diego (U.S.A.)
• Nicola Hananiah Baylor College of Medicine (U.S.A.)
  Jae-Joon Yim Seoul National University College of Medicine (Republic of Korea)
• Koichiro Asano Tokai University School of Medicine (Japan)
  Diahn-Warng Perng Taipei Veterans General Hospital (Taiwan)
• Konstantinos Kostikas University of Ioannina (Greece)
  Karin Klooster University Medical Center Groningen (Kingdom of the Netherlands)

• Interventional Bronchoscopy for Central Airway Obstruction

  Central airway obstruction refers to a narrowing of the trachea, main bronchi, or bronchus intermedius that compromises ventilation and threatens life. Causes fall into malignant categories, such as primary lung tumours or metastatic disease involving the carina, and benign categories, including post-intubation stenosis, tuberculosis-related scarring, and post-transplant airway complications. Patients typically present with dyspnoea, stridor, refractory wheeze, and recurrent post-obstructive pneumonia, often with diagnosis delayed until the airway calibre is critically reduced.

  Interventional bronchoscopy has reshaped this care pathway over the past two decades. Rigid and flexible platforms now permit immediate mechanical debulking, thermal ablation, and airway stent deployment within a single procedural session. Coordination between respiratory physicians, thoracic surgeons, anaesthetists, and oncology teams is standard in tertiary centres across Australia. Public funding through Medicare and the Pharmaceutical Benefits Scheme supports procedural access, while state-based equipment registries help distribute reusable silicone stents between high-volume sites.

  Causes and clinical presentation

  Endobronchial malignancy, particularly squamous cell carcinoma and adenoid cystic carcinoma of the trachea, remains the leading indication for urgent intervention in adults. Benign aetiologies include post-tracheostomy stenosis, granulomatosis with polyangiitis, sarcoidosis, and fibrotic strictures following lung transplantation. Within Australia's Asia-Pacific catchment, tuberculous bronchostenosis continues to contribute in selected patients.

  Clinical recognition depends on a high index of suspicion. Stridor signals critical tracheal narrowing, while unilateral wheeze points to a main bronchial lesion. Targeted therapies for eosinophilic asthma should never substitute for cross-sectional imaging when central obstruction is suspected, as the inflammatory phenotype can mask coexistent large airway disease. Indigenous Australians experience disproportionately high rates of chronic respiratory disease, reinforcing the value of culturally safe assessment when differentiating obstructive patterns.

  Diagnostic workup and pre-procedural planning

  Contrast-enhanced computed tomography of the neck and chest with thin-slice reconstruction defines the length, location, and nature of the obstruction. Virtual bronchoscopy guides procedural planning, and flexible bronchoscopy under conscious sedation provides direct visualisation with biopsy. Pulmonary function testing with flow-volume loops characterises physiological severity, particularly for fixed or variable intrathoracic obstruction.

  Multidisciplinary discussion is essential before intervention. Decisions balance resectability, anticipated disease course, performance status, and prosthesis availability. In Brisbane's quaternary thoracic service and at Royal Melbourne Hospital, weekly airway meetings integrate thoracic surgery, interventional pulmonology, radiation oncology, and pathology, weighing surgical resection, external beam radiotherapy, and endoscopic palliation together. Smaller centres across regional Western Australia and Tasmania link into these networks through telehealth referral pathways coordinated by the Lung Foundation Australia.

  Interventional bronchoscopy techniques

  Rigid bronchoscopy under general anaesthesia remains the cornerstone for critical central airway obstruction. It maintains ventilation, allows forceful coring of tumour, and provides a conduit for stent placement. Mechanical debulking using the bevel of the rigid tube or a cryoprobe rapidly re-establishes patency, followed by adjunctive thermal modalities such as argon plasma coagulation, electrocautery, or neodymium laser for haemostasis and tumour devitalisation.

  For malignant extrinsic compression or recurrent endoluminal tumour, airway stenting provides scaffold support. Silicone stents, such as the Dumon prosthesis, are favoured for adjustability and removability, while self-expanding metallic stents suit tortuous anatomy or rapid deployment. In benign disease, balloon bronchoplasty with topical mitomycin application has reduced the need for repeated stenting. Anaesthetic teams familiar with jet ventilation and extracorporeal support at Royal Prince Alfred and The Alfred in Melbourne allow hybrid procedures that would otherwise be considered too risky.

  Outcomes, complications, and follow-up

  Successful recanalisation is achieved in over 90% of procedures performed in experienced centres, with immediate symptomatic improvement in most patients. Quality of life gains are particularly meaningful for those transitioning from hospice-bound dyspnoea to functional ambulation. Procedure-related mortality is below 2% when performed by high-volume operators, although complications including pneumothorax, massive haemorrhage, and stent migration require vigilant monitoring.

  Long-term success depends on disease biology. Malignant obstructions often need repeat interventions every two to four months, while benign stenoses may resolve after a single dilatation period. Structured follow-up with interval bronchoscopy and integration with community-based pulmonary rehabilitation supports durable outcomes. Australian centres contribute to the Thoracic Society of Australia and New Zealand registry, refining indications and benchmarking against international peers. Stent registries maintained at St Vincent's Sydney and The Prince Charles Brisbane inform shared purchasing decisions.

  Choosing the right approach for each patient

  Selection of the optimal technique depends on lesion characteristics, patient comorbidities, and procedural urgency. Operators balance the speed of mechanical debulking against the durability of stent placement, weighing procedural morbidity against anticipated disease trajectory.

  For patients with rapidly progressive malignant obstruction, a rigid bronchoscopy session combining mechanical debulking with stent placement often restores airway patency within minutes. For web-like benign stenosis following lung transplantation, repeated balloon bronchoplasty with interval weaning of immunosuppression may be sufficient. Quality of life considerations, including voice preservation in proximal tracheal lesions and avoidance of long-term stent dependence in young patients, shape the shared decision-making conversation.

  Technique	Best indication	Duration of effect	Key limitation
  Rigid mechanical debulking	Critical malignant obstruction	Weeks to months	Requires general anaesthesia
  Thermal ablation (APC, laser, electrocautery)	Endoluminal tumour, haemoptysis	Weeks	Depth control in long lesions
  Silicone airway stent	Benign stenosis, reversible disease	Months to years	Migration, mucus plugging
  Self-expanding metallic stent	Extrinsic compression, palliation	Permanent in malignant disease	Difficult removal, granulation
  Balloon bronchoplasty	Web-like stenosis, post-transplant	Variable	Restenosis risk
  Cryotherapy or photodynamic therapy	Residual microscopic disease	Months	Delayed effect, photosensitivity

  Practical considerations when deciding on intervention

  • Symptom severity and rate of decline, particularly the transition from dyspnoea on exertion to stridor at rest
  • Underlying disease biology, expected survival, and responsiveness to systemic therapy
  • Local expertise, equipment availability, and access to thoracic surgical backup
  • Patient preference, functional status, and willingness to undergo repeat procedures

  Triggers for urgent procedural referral

  • New-onset stridor or rapidly progressive dyspnoea in a patient with known malignancy
  • Post-obstructive pneumonia that fails to resolve with standard antibiotics
  • Critical tracheal narrowing above fifty percent reduction in luminal diameter on imaging
  • Inability to wean from mechanical ventilation due to a suspected airway lesion

  A practical takeaway for clinicians is to maintain a low threshold for cross-sectional imaging in any patient with disproportionate dyspnoea, atypical wheeze, or unresolving pneumonia, even when eosinophilic biomarkers are elevated. Early referral to a high-volume interventional pulmonology service preserves the window in which minimally invasive bronchoscopic management can restore airway patency, relieve suffering, and avoid emergency surgical airway intervention. Embedding these referrals within existing respiratory and thoracic surgery networks across metropolitan and regional Australia ensures that procedural expertise reaches patients regardless of postcode.

  Richard Russell Nuffield Department of Clinical Medicine, University of Oxford (United Kingdom)
• Mona Bafadhel King’s College London (United Kingdom)
  David Jackson Guy’s and St Thomas’ Hospital, King’s College London (United Kingdom)
• James Chalmers University of Dundee (United Kingdom)
  David Price University of Aberdeen (United Kingdom)