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Clinical presentation, diagnostic evaluation, and management of central airway obstruction in adults

Felix JF Herth, MD, PhD
Section Editor
Praveen N Mathur, MB;BS
Deputy Editor
Geraldine Finlay, MD


Central airway obstruction (CAO) is an uncommon but potentially life-threatening condition that can be due to a number of malignant and benign processes. A low threshold of suspicion for CAO is critical so that it can be recognized and managed promptly. The diagnosis and general approach to CAO will be reviewed here. Specific bronchoscopic management modalities are discussed in detail separately. (See "Endobronchial brachytherapy" and "Bronchoscopic laser in the management of airway disease in adults" and "Bronchoscopic argon plasma coagulation in the management of airway disease in adults" and "Endobronchial photodynamic therapy in the management of airway disease in adults" and "Bronchoscopic cryotechniques in adults".)


Central airway obstruction – Central airway obstruction (CAO) refers to the obstruction of air flow in the trachea and mainstem bronchi (figure 1).

Upper airway obstruction – Upper airway obstruction (UAO) refers to the obstruction of flow in the portion of the airway that extends from the mouth through the length of the trachea and therefore also includes the nasopharynx and larynx (figure 2). It is not discussed in this topic, although some conditions that involve this region of the airway may also involve the proximal trachea (eg, laryngeal, esophageal, or nasopharyngeal cancer), such that CAO and UAO can coexist. (See "Flow-volume loops", section on 'Upper airway obstruction'.).  

Lower airway obstruction – Airflow obstruction due to chronic obstructive lung diseases including asthma, bronchiectasis, and chronic obstructive pulmonary disease (COPD) involves the smaller bronchi in the lower airway distal to the mainstem bronchi and is not typically associated with CAO or UAO.  


Airway obstruction complicates approximately 20 to 30 percent of patients with lung cancer (eg, shortness of breath, atelectasis) although not all reported cases are associated with central airway obstruction (CAO) [1].

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Literature review current through: Oct 2017. | This topic last updated: Aug 22, 2017.
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  1. Ernst A, Feller-Kopman D, Becker HD, Mehta AC. Central airway obstruction. Am J Respir Crit Care Med 2004; 169:1278.
  2. Cosano Povedano A, Muñoz Cabrera L, Cosano Povedano FJ, et al. [Endoscopic treatment of central airway stenosis: five years' experience]. Arch Bronconeumol 2005; 41:322.
  3. Chhajed PN, Eberhardt R, Dienemann H, et al. Therapeutic bronchoscopy interventions before surgical resection of lung cancer. Ann Thorac Surg 2006; 81:1839.
  4. Blackledge FA, Anand VK. Tracheobronchial extension of recurrent respiratory papillomatosis. Ann Otol Rhinol Laryngol 2000; 109:812.
  5. Cosío BG, Villena V, Echave-Sustaeta J, et al. Endobronchial hamartoma. Chest 2002; 122:202.
  6. An HS, Choi EY, Kwon BS, et al. Airway compression in children with congenital heart disease evaluated using computed tomography. Ann Thorac Surg 2013; 96:2192.
  7. Hoheisel G, Chan BK, Chan CH, et al. Endobronchial tuberculosis: diagnostic features and therapeutic outcome. Respir Med 1994; 88:593.
  8. Kaya G, Ladas A, Howlett D. Laryngocele causing airway obstruction. BMJ 2016; 352:i1368.
  9. Silva FS. Neck haematoma and airway obstruction in a patient with goitre: complication of internal jugular vein cannulation. Acta Anaesthesiol Scand 2003; 47:626.
  10. LoCicero J 3rd, Costello P, Campos CT, et al. Spiral CT with multiplanar and three-dimensional reconstructions accurately predicts tracheobronchial pathology. Ann Thorac Surg 1996; 62:811.
  11. Colt HG, Harrell JH. Therapeutic rigid bronchoscopy allows level of care changes in patients with acute respiratory failure from central airways obstruction. Chest 1997; 112:202.
  12. Bolliger CT, Mathur PN, Beamis JF, et al. ERS/ATS statement on interventional pulmonology. European Respiratory Society/American Thoracic Society. Eur Respir J 2002; 19:356.
  13. Ernst A, Silvestri GA, Johnstone D, American College of Chest Physicians. Interventional pulmonary procedures: Guidelines from the American College of Chest Physicians. Chest 2003; 123:1693.
  14. Stephens KE Jr, Wood DE. Bronchoscopic management of central airway obstruction. J Thorac Cardiovasc Surg 2000; 119:289.
  15. Seijo LM, Sterman DH. Interventional pulmonology. N Engl J Med 2001; 344:740.
  16. Cavaliere S, Venuta F, Foccoli P, et al. Endoscopic treatment of malignant airway obstructions in 2,008 patients. Chest 1996; 110:1536.
  17. Rodrigues G, Videtic GM, Sur R, et al. Palliative thoracic radiotherapy in lung cancer: An American Society for Radiation Oncology evidence-based clinical practice guideline. Pract Radiat Oncol 2011; 1:60.
  18. Simoff MJ, Lally B, Slade MG, et al. Symptom management in patients with lung cancer: Diagnosis and management of lung cancer, 3rd ed: American College of Chest Physicians evidence-based clinical practice guidelines. Chest 2013; 143:e455S.
  19. Boyd M, Rubio E. The utility of interventional pulmonary procedures in liberating patients with malignancy-associated central airway obstruction from mechanical ventilation. Lung 2012; 190:471.
  20. Turner JF Jr, Wang KP. Endobronchial laser therapy. Clin Chest Med 1999; 20:107.
  21. Sheski FD, Mathur PN. Cryotherapy, electrocautery, and brachytherapy. Clin Chest Med 1999; 20:123.
  22. Sutedja TG, Postmus PE. Photodynamic therapy in lung cancer. A review. J Photochem Photobiol B 1996; 36:199.
  23. Diaz-Jiménez JP, Martínez-Ballarín JE, Llunell A, et al. Efficacy and safety of photodynamic therapy versus Nd-YAG laser resection in NSCLC with airway obstruction. Eur Respir J 1999; 14:800.
  24. Ernst A, Simoff M, Ost D, et al. Prospective risk-adjusted morbidity and mortality outcome analysis after therapeutic bronchoscopic procedures: results of a multi-institutional outcomes database. Chest 2008; 134:514.
  25. Oviatt PL, Stather DR, Michaud G, et al. Exercise capacity, lung function, and quality of life after interventional bronchoscopy. J Thorac Oncol 2011; 6:38.
  26. Amjadi K, Voduc N, Cruysberghs Y, et al. Impact of interventional bronchoscopy on quality of life in malignant airway obstruction. Respiration 2008; 76:421.
  27. Ost DE, Ernst A, Grosu HB, et al. Complications Following Therapeutic Bronchoscopy for Malignant Central Airway Obstruction: Results of the AQuIRE Registry. Chest 2015; 148:450.
  28. Kvale PA, Selecky PA, Prakash UB, American College of Chest Physicians. Palliative care in lung cancer: ACCP evidence-based clinical practice guidelines (2nd edition). Chest 2007; 132:368S.
  29. Duhamel DR, Harrell JH 2nd. Laser bronchoscopy. Chest Surg Clin N Am 2001; 11:769.
  30. Hetzel M, Hetzel J, Schumann C, et al. Cryorecanalization: a new approach for the immediate management of acute airway obstruction. J Thorac Cardiovasc Surg 2004; 127:1427.
  31. Mathur PN, Wolf KM, Busk MF, et al. Fiberoptic bronchoscopic cryotherapy in the management of tracheobronchial obstruction. Chest 1996; 110:718.
  32. Mehta AC, Lee FY, Cordasco EM, et al. Concentric tracheal and subglottic stenosis. Management using the Nd-YAG laser for mucosal sparing followed by gentle dilatation. Chest 1993; 104:673.
  33. Noppen M, Schlesser M, Meysman M, et al. Bronchoscopic balloon dilatation in the combined management of postintubation stenosis of the trachea in adults. Chest 1997; 112:1136.
  34. Hautmann H, Gamarra F, Pfeifer KJ, Huber RM. Fiberoptic bronchoscopic balloon dilatation in malignant tracheobronchial disease: indications and results. Chest 2001; 120:43.
  35. Lunn W, Garland R, Ashiku S, et al. Microdebrider bronchoscopy: a new tool for the interventional bronchoscopist. Ann Thorac Surg 2005; 80:1485.
  36. Mehta HJ, Begnaud A, Penley AM, et al. Restoration of Patency to Central Airways Occluded by Malignant Endobronchial Tumors Using Intratumoral Injection of Cisplatin. Ann Am Thorac Soc 2015; 12:1345.
  37. Grillo HC, Mathisen DJ. Surgical management of tracheal strictures. Surg Clin North Am 1988; 68:511.
  38. Grillo HC. Development of tracheal surgery: a historical review. Part 1: Techniques of tracheal surgery. Ann Thorac Surg 2003; 75:610.
  39. Grillo HC. Development of tracheal surgery: a historical review. Part 2: Treatment of tracheal diseases. Ann Thorac Surg 2003; 75:1039.
  40. Bisson A, Bonnette P, el Kadi NB, et al. Tracheal sleeve resection for iatrogenic stenoses (subglottic laryngeal and tracheal). J Thorac Cardiovasc Surg 1992; 104:882.
  41. Wright CD, Grillo HC, Wain JC, et al. Anastomotic complications after tracheal resection: prognostic factors and management. J Thorac Cardiovasc Surg 2004; 128:731.
  42. Saito Y, Minami K, Kaneda H, et al. New tubular bioabsorbable knitted airway stent: feasibility assessment for delivery and deployment in a dog model. Ann Thorac Surg 2004; 78:1438.
  43. Kim J, Suh SW, Shin JY, et al. Replacement of a tracheal defect with a tissue-engineered prosthesis: early results from animal experiments. J Thorac Cardiovasc Surg 2004; 128:124.
  44. Kojima K, Ignotz RA, Kushibiki T, et al. Tissue-engineered trachea from sheep marrow stromal cells with transforming growth factor beta2 released from biodegradable microspheres in a nude rat recipient. J Thorac Cardiovasc Surg 2004; 128:147.
  45. Bugmann P, Rimensberger PC, Kalangos A, et al. Extratracheal biodegradable splint to treat life-threatening tracheomalacia. Ann Thorac Surg 2004; 78:1446.
  46. Jaquet Y, Pilloud R, Lang FJ, Monnier P. Prefabrication of composite grafts for long-segment tracheal reconstruction. Arch Otolaryngol Head Neck Surg 2004; 130:1185.
  47. Grimmer JF, Gunnlaugsson CB, Alsberg E, et al. Tracheal reconstruction using tissue-engineered cartilage. Arch Otolaryngol Head Neck Surg 2004; 130:1191.
  48. Kamil SH, Eavey RD, Vacanti MP, et al. Tissue-engineered cartilage as a graft source for laryngotracheal reconstruction: a pig model. Arch Otolaryngol Head Neck Surg 2004; 130:1048.
  49. Martinod E, Seguin A, Holder-Espinasse M, et al. Tracheal regeneration following tracheal replacement with an allogenic aorta. Ann Thorac Surg 2005; 79:942.
  50. Cibantos Filho JS, de Mello Filho FV, Campos AD, Ellinguer F. Viability of a 12-ring complete tracheal segment transferred in the form of a compound flap: an experimental study in dogs. Laryngoscope 2004; 114:1949.
  51. Olias J, Millán G, da Costa D. Circumferential tracheal reconstruction for the functional treatment of airway compromise. Laryngoscope 2005; 115:159.
  52. Speiser B, Spratling L. Intermediate dose rate remote afterloading brachytherapy for intraluminal control of bronchogenic carcinoma. Int J Radiat Oncol Biol Phys 1990; 18:1443.
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