Q&A: Managing patients with central airway obstruction

Key takeaways:

• The American College of Chest Physicians published a clinical practice guideline on management of central airway obstruction.
• Panelists emphasize the need for a multidisciplinary, patient-centric approach.

Patients with central airway obstruction are often treated by multiple clinicians from different specialties, leading to varied management of the patients, according to a press release.

In an effort to get everyone who treats patients with malignant and nonmalignant central airway obstruction (CAO) on the same page, the American College of Chest Physicians has published a clinical practice guideline on management of this disorder.

Twelve panelists participated in the creation of this guideline, which involved a systematic literature review and resulted in 12 evidence-based recommendations.

To learn more about CAO and key recommendations from the guideline, Healio spoke with Kamran Mahmood, MD, MPH, FCCP, chair of the guideline panel and associate professor of medicine in the division of pulmonary, allergy and critical care medicine at Duke University.

Healio: What is CAO? How prevalent is it today? What patients face heightened susceptibility?

Mahmood: CAO is greater than 50% obstruction or blockage of the main airways, including trachea, mainstem bronchi, bronchus intermedius and lobar bronchi. It is seen in about 20% to 30% of patients with lung cancer. Cancers from other areas like breast, colon or kidney, etc, can also metastasize to airways and present with CAO.

Healio: What causes are behind the varying management of CAO?

Mahmood: Multiple specialties are involved in the care including interventional pulmonology, thoracic surgery, otolaryngology, radiation oncology, medical oncology, etc. There is a wide variability in the clinical practice for management of CAO. Interventional pulmonary fellowship training is now standardized with the recent shift to Accreditation Council for Graduate Medical Education (ACGME). With accredited training, high-quality research studies and guidelines like the current CHEST guideline, this variability will continue to decrease.

Healio: What are the key/most important recommendations from the guideline?

Mahmood: In the guideline, we suggest a multidisciplinary, patient-centric approach to CAO management, including therapeutic bronchoscopy, treatment of the underlying malignancy or nonmalignant disorders and appropriate surgical interventions. For therapeutic bronchoscopy, we suggested the use of general anesthesia and rigid bronchoscopy for central and critical airway lesions. In addition, a multi-modality bronchoscopic approach is essential with the use of ablative tools and Judicious use of airway stents.

Healio: How does care of malignant CAO differ from care of nonmalignant CAO based on your findings?

Mahmood: The approach in malignant and nonmalignant CAO is similar in the management of relief of airway obstruction. However, the underlying condition dictates the concurrent or adjunct therapies.

Healio: In a press release from CHEST, you said the quality of overall evidence on CAO management is very low. What efforts can be made to improve evidence quality? What are you doing personally to improve the quality of evidence related to CAO?

Mahmood: We need well-designed studies to assess the patient outcomes with different therapeutic modalities and approaches. In addition, research in education and training of the trainees is critical. We have developed a rigid bronchoscopy competence assessment tool to help improve training (PMID: 26989810, PMID: 33849039). In addition, we are devising randomized, controlled, multicenter studies to address the current evidence gaps through the Interventional Pulmonary Outcomes Group.

Healio: What do you hope clinicians take away from the guideline?

Mahmood: A multidisciplinary, patient-centric approach by trained providers is the key to improving CAO outcomes.

References:

• Guideline on management of central airway obstruction released by CHEST. https://www.chestnet.org/newsroom/Press-Releases/2024/07/Guideline-on-Management-of-Central-Airway-Obstruction-Released-by-CHEST. Published July 23, 2024. Accessed July 24, 2024.
• Mahmood K, et al. CHEST. 2024;doi:10.1016/j.chest.2024.06.3804.