Newsletter of Hong Kong Society of Palliative Medicine

Palliative Medicine Doctors’ Meeting

Major Airway Obstruction

Dr. Ma Chi Ming,
Department of Pulmonary and Palliative Care, Haven of Hope Hospital.
Correspondence: [email protected]
ABSTRACT
Major airway obstruction (MAO) is often diagnosed too late for definitive intervention. High index of susipicion
and early diagnosis are crucial for successful management. Common clinical presentations of MAO include
dyspnoea, cough, mucus secretions and stridor. Spirometry, imaging and bronchoscopy are the main
investigations for MAO. Management strategies include interim measures, treatment targeted on the aetiology,
and symptom palliation. A brief review of these interventions will be presented.
HKSPM Newsletter 2010 Apr Issue No.1 p10-11.

Introduction Pathophysiology and clinical features

Major airway obstruction (MAO) poses a Stridor, dyspnoea, cough and mucus
management challenge in palliative medicine. secretion are the most common clinical features
Often it is either too late or too difficult to reverse of MAO. Stridor is caused by turbulent air flow
this life-threatening situation. Early diagnosis and when gas molecules pass through the site of
management is the key for successful MAO obstruction. Inspiratory stridor is more likely with
management. extrathoracic obstruction. During inspiration, the
surrounding atmospheric pressure of the
Case History
extrathoracic airway is higher than the tracheal
Madam C, a 58 year-old-lady, suffered from pressure, causing compression of the extra-
breast cancer with metastases to lung, thoracic airway and inducing inspiratory stridor.
peri-bronchial and hilar lymph nodes. She Expiratory stridor is more likely to occur in
developed dyspnoea and stridor while she was intrathoracic obstruction. During expiration, the
hospitalized in Haven of Hope Hospital for surrounding pleural pressure of intrathoracic
symptom control. ENT surgeon was consulted. airway is higher than the tracheal pressure,
Flexible larygngoscopy showed left vocal cord causing compression of the intrathoracic airway
palsy while right vocal cord was mobile. There and inducing expiratory stridor. Cough and
was no obstruction seen below the glottis. mucus secretion are related to the direct
Intrathoracic tracheal obstruction was suspected. mechanical effect of the obstruction. Dyspnoea
She was given intravenous dexamethasone and is related to the work of breathing, neuro-
low dose alprazolam. Her dyspnoea initially mechanical dissociation, and chemoreception of
improved and she managed to spend some good blood oxygen and carbon dioxide levels; all these
time with her grandchildren in the ward garden. are in turn related to the obstruction.
However, her condition suddenly deteriorated
soon after, and she was too ill for transferral to Pathology of MAO
the oncology clinic. Palliative sedation was MAO can be caused by endoluminal tumors,
started and she died peacefully after one day. extrinsic compression by tumors or mediastinal
masses, and bilateral vocal cord palsy. Common
Physiology cancers causing MAO include head and neck
Upper airway refers to the air passage from cancer, lung cancer, and mediastinal lymph node
the nose or mouth to the carina and obstruction or endobronchial metastasis due to primary
means anything that leads to increase in airway malignancy in the breast, gastrointestinal tract,
resistance. Airway resistance is proportional to kidneys, ovaries, uterus, testis, thyroid gland,
the length of the airway, inversely proportional to nasopharygnx and adrenal gland. Less likely, it
the fourth power of airway radius, and is affected can be due to primary tracheal tumour.
by gas density. As central airway contributes to
Investigations
eighty percent of the total airway resistance, even
Spirometry, imaging and bronchoscopy are
a small obstruction in the upper airway can pose
the mainstay of investigations for MAO. As
a significant increase in airway resistance.
spirometry can only detect airway resistance

Major Airway Obstruction

HKSPM Newsletter 2010 Apr Issue 1 P10

 Newsletter of Hong Kong Society of Palliative Medicine

when its diameter is less than 8 mm, it is not a 5-10% had stent migration, 4-8% had stent
sensitive method until late in the course of MAO. obstruction for those using silicone stents and
The sensitivity of detecting upper MAO by Chest 40% required repeated stenting.5
X-ray is only 66 %. Helical computer tomography Brachytherapy delivers a relatively high dose
can detect intramucosal, submucosal and extra- of a radiation source via bronchoscopy. Follow-
luminal lesions with a sensitivity up to 97%. With up bronchoscopy is needed for removal of
3-Dimension reconstruction, it allows better necrotic tissue. It allows treatment for both endo-
visualization of the extent of the disease and luminal and extrinsic tumour. In a case study6,
airway obstruction. MRI is inferior to CT scan for 60-90% showed symptom palliation, but 1-3%
airway visualization but superior in visualizing developed bronchovascular fistula and stenosis,
vascular structures surrounding the airway. 10% developed radiation bronchitis and 5-20%
Management had massive hemoptysis. A Cochrane review7
Factors affecting the clinical management of showed no single regimen that could give greater
MAO include urgency of presentation, aetiology, palliation. In addition, high dose regimens led to
localization, extent of obstruction and prognosis. more acute toxicity especially radiation
Interim measures while waiting for definitive oesophagitis. There was a modest increase in
treatment and interventions with palliative intent survival of 5% at 1 year and 3% at 2 years in
include proper head positioning, oxygen patients with higher performance status and
supplement, helium-oxygen (Heliox) inhalation, receiving higher dose radiotherapy. The risk of
systemic corticosteroids, securing the airway, radiation myelitis is a concern.
cardiopulmonary bypass and palliative sedation. Photodynamic therapy induces tumor
Heliox, a gas with nitrogen replaced with necrosis by administration of a photosensitizing
helium, is a lower density gas that reduces airway agent followed by activation of the agent with light
resistance. In one case-control study, it reduces of specific wavelength. Follow-up bronchoscopy
around 30 % of breathing work.1 Systemic steroid is needed. Sunlight exposure should be avoided
mainly acts on the edema of inflamed tissue.2 Its for 4 to 6 weeks.
effect is directly proportional to the local Conclusion
concentration of steroids in the inflamed tissue. Early diagnosis is required for successful
Measures targeted at the cause of obstruction management of MAO. Some measures can be
include dilatation, resection techniques, stenting, used as interim measures before more definitive
brachytherapy, external irradiation and photo- treatment, but none is consistently better than
dynamic therapy, depending on their availability. others. Treatment decision is mainly determined
Resection techniques include tissue removal by the balance of risks and benefits, patient’s
with rigid bronchoscopy, laser - Neodynmium goals and wishes, aetiology, disease trajectory
yttrium aluminium garnet (Nd:YAG) and and prognosis, and available resources.
cryotherapy. A systematic review of more than
2500 patients undergoing Nd:YAG showed a References

80% dyspnoea relief rate, and success rates of 1. Gailius J Skrinskas et al, Using Helium-oxygen mixtures in the
management of acute upper airway obstruction, Can Med Assoc
70-95%, 40-60%, 57% for central lesions, lobar J, Vol 28, March 1, 1983.
lesions and complete obstruction respectively. 2. Hawkins et al, Corticosteroid in airway management, Head and
Neck Surgery , 91(6):593-6, Dec 1983.
Mortality rate was around 0.4-3%.3 Cryotherapy 3. Detterbeck F, Jones D, and Morris D, Palliative treatment of lung
induces tumor necrosis by freezing the tissue and cancer. In Diagnosis and treatment of lung cancer, an evidence
guideline for the practicing physician (eds. Detterbeck FC,
inducing tissue death, followed by bronchoscopic Riveria MP, Socrinski MC, Roseman JD) pp.419-36, 2001.
examination to remove the resultant necrotic 4. Demosthenes Makris et al, Tracheobronchial stenting and central
airway replacement, Curr Opin Pulm Med 13: 278-283.
tissue. Repeated bronchoscopic treatment may 5. Wood DE et al, Airway stenting, Chest Surg Clin, 2001; 11:841-
be needed. In a systematic review of 411 60.
patients, 65-68 % showed symptom relief. 6. Yao MS et al, Endobronchial brachytherapy, Chest Surg Clin
2001;11:813-27.
Success rates of 60% and 35% for central and 7. Lester JF et al, Palliative radiotherapy regimens for non-small cell
peripheral lesions were reported respectively.3 lung cancer (Review), Cochrane Database Syst Rev, CD002143.

Metallic or silicone stents can be used for

stenting. In one case study, 80% of patients
showed immediate symptom relief with no
immediate peri-operative death.4 However,

Major Airway Obstruction

HKSPM Newsletter 2010 Apr Issue 1 P11