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)

• Therapeutic bronchoscopy for central airway obstruction

  Central airway obstruction can rapidly compromise ventilation, gas exchange, and quality of life. The blockage may arise in the trachea or main bronchi because of lung cancer, metastatic disease, benign scarring, post-intubation stenosis, inflammatory conditions, or external compression. Symptoms often include progressive breathlessness, wheezing that resembles asthma, cough, recurrent pneumonia, and stridor.

  Therapeutic bronchoscopy offers a minimally invasive way to restore airway patency, obtain tissue, control bleeding, and guide further treatment. It is usually performed by an experienced interventional pulmonology team alongside oncology, thoracic surgery, radiology, anesthesia, and respiratory care specialists.

  Why airway obstruction requires urgent attention

  A narrowed central airway increases resistance to airflow and can make even a modest reduction in diameter clinically significant. Patients may compensate for weeks before presenting with severe dyspnea, noisy breathing, fatigue, or an inability to lie flat. Complete obstruction of a main bronchus can cause distal atelectasis, infection, and loss of functional lung volume.

  Evaluation begins with clinical examination, oxygenation assessment, and imaging. Contrast-enhanced computed tomography helps define the location, length, wall characteristics, and cause of the lesion. Flexible bronchoscopy provides direct visualization, while rigid bronchoscopy may be preferred when substantial debulking, dilation, bleeding control, or stent placement is anticipated.

  Selecting patients and defining the lesion

  The treatment strategy depends on whether the obstruction is intraluminal, extrinsic, or mixed. Intraluminal tumors may respond to mechanical removal, thermal ablation, cryotherapy, or other tissue-directed methods. Extrinsic compression generally requires airway splinting with a stent, while mixed disease may need both debulking and stenting.

  The degree of obstruction is important, but symptoms, functional status, tumor biology, and treatment goals matter just as much. Bronchoscopy may provide immediate relief in patients who need to breathe more comfortably, become fit for systemic therapy, or receive radiotherapy. In selected cases, it also avoids urgent open surgery or allows a patient to recover before definitive treatment.

  Techniques used to restore airway patency

  Rigid bronchoscopy provides a stable, wide working channel and protects the airway during complex interventions. The operator can use the rigid barrel to displace obstructing tissue, remove bulky material, and maintain ventilation while treating the lesion. Flexible bronchoscopes remain valuable for inspection, biopsy, distal airway access, and procedures performed with moderate sedation.

  Mechanical debulking, electrocautery, laser therapy, argon plasma coagulation, and cryotherapy each have distinct roles. Thermal tools can rapidly cut or coagulate vascular tissue, but they require careful control of oxygen concentration and awareness of airway fire risk. Cryotherapy freezes tissue and can be useful for delayed removal of tumor fragments or selected non-bleeding lesions. Balloon dilation may widen stenotic segments, although recurrence is possible when the underlying scar remains active.

  Clinical situation	Common bronchoscopic approach	Main consideration
  Intraluminal malignant growth	Mechanical debulking with thermal or cryotherapy techniques	Control bleeding and preserve viable airway
  Extrinsic compression	Airway stent placement	Match stent size, shape, and expected duration
  Benign fibrotic stenosis	Balloon dilation, incision, or selected ablative treatment	Recurrence and need for repeat procedures
  Mixed obstruction	Debulking followed by dilation or stenting	Treat both the intraluminal and external components
  Secretions or clot causing blockage	Suction, lavage, and mechanical extraction	Identify and address the precipitating cause

  Stents, dilation, and individualized treatment

  Airway stents can maintain patency when cartilage support is compromised or external pressure persists. Silicone stents are removable and can be customized in certain settings, whereas self-expanding metallic stents conform well to irregular anatomy but may be difficult to remove. The choice should consider malignancy, anticipated survival, infection risk, migration, mucus retention, and the possibility of future surgery.

  Stenting is not a substitute for careful follow-up. Migration, granulation tissue, tumor ingrowth, mucus plugging, and fracture can lead to recurrent symptoms. Patients need clear instructions about worsening breathlessness, hemoptysis, fever, and changes in cough. Scheduled bronchoscopy may be necessary when the device is temporary or complications are likely.

  Measuring benefit beyond technical success

  Opening an airway is an important procedural endpoint, but clinical benefit should be assessed more broadly. Improvements may include reduced dyspnea, better exercise tolerance, fewer infections, improved sleep, and the ability to receive cancer treatment. Pulmonary function tests and oxygen requirements can support assessment, although symptom relief may occur even when numerical changes are modest.

  Patient-reported outcomes are especially relevant when the intervention is palliative or intended to improve daily function. Research in respiratory medicine increasingly emphasizes consistent quality-of-life measures, helping clinicians compare treatment effects in ways that reflect patients’ experiences rather than relying only on imaging or procedural findings.

  Safety, anesthesia, and recovery

  Therapeutic airway procedures carry risks that include bleeding, hypoxemia, airway perforation, pneumothorax, arrhythmia, infection, and complications related to anesthesia. Pre-procedure planning should review anticoagulants, antiplatelet agents, cardiopulmonary reserve, airway anatomy, and the likelihood of difficult ventilation. In high-grade obstruction, induction of anesthesia requires particular caution because spontaneous breathing may be supporting the remaining airway lumen.

  After intervention, monitoring should continue until oxygenation, ventilation, and airway stability are satisfactory. Chest imaging may be indicated after dilation, extensive tumor removal, or suspected perforation. A multidisciplinary plan should address definitive cancer therapy, infection management, pulmonary rehabilitation, and follow-up bronchoscopy where appropriate.

  Practical planning priorities

  • Confirm the obstruction’s location, length, severity, and mechanism with high-quality imaging and bronchoscopy.
  • Choose rigid or flexible bronchoscopy according to the need for ventilation control, debulking, dilation, biopsy, or stent placement.
  • Coordinate anticoagulation management, anesthesia support, blood availability, and rescue strategies before the procedure.
  • Define treatment goals with the patient, including symptom relief, preservation of lung function, and preparation for oncologic therapy.
  • Arrange follow-up for stent surveillance, recurrent stenosis, mucus plugging, infection, or new respiratory symptoms.

  The best outcomes come from matching the intervention to the anatomy and the patient’s goals. Therapeutic bronchoscopy can provide rapid relief, but it should form part of a wider respiratory care pathway that includes diagnosis, definitive treatment, rehabilitation, and longitudinal evaluation.

  Review the APSR 2022 congress resources to deepen understanding of interventional pulmonology, central airway disease, and multidisciplinary respiratory care, and use these principles to support safer, more individualized treatment decisions.

  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)