Critical airway obstruction: challenges in airway management and ventilation during therapeutic bronchoscopy

Endobronchial interventions are used to alleviate symptoms of airway stenosis. The ventilatory management may be challenging during these procedures, and may influence the choice of airway device. We report our experiences from 902 procedures.

Patients undergoing interventional bronchoscopy procedures were consecutively registered from 1999 to 2012. Critical airway obstruction (CAO) was defined as stridor, tracheal diameter <5 mm, stenosis of both the main bronchi, or clots/tumor fragments occluding the trachea or both main bronchi. Choice of airway, ventilation strategy, and survival are reported. Results are presented as median (interquartile range), and P≤0.05 was considered significant.

A total of 561 patients underwent 902 interventional bronchoscopy procedures (mechanical debulking, laser resection, balloon dilatation, and stent placement). The procedures were performed using flexible bronchoscope through an endotracheal tube (68.2%) or laryngeal mask airway (10.4%), or by rigid bronchoscopy (9.3%). All patients were primarily ventilated by volume-controlled ventilation. CAO was classified in 60 procedures, with more frequent use of laryngeal mask airway (21.7%), and change of airway device in 20/60 procedures. The survival for patients with malignant disease with or without CAO was 100 and 182 days, respectively, with 90 days survival probability of 0.65 and 0.51 (P=0.14).

Bronchoscopic treatment in patients with CAO may require a change of ventilatory and airway strategy during the procedure. Despite various challenges in the management of patients with CAO, the short-term survival in these patients is comparable to that in patients without CAO.