Narrative review of malignant central airway obstruction: management updates

Malignant central airway obstruction (MCAO) is a life-threatening condition that results from the narrowing of major airways due to malignancies. MCAO may result from intrinsic, extrinsic, or mixed morphologies of obstruction, which along with patient-specific factors determine treatment pathways. This review provides an updated overview of the management of MCAO, highlighting both traditional and emerging therapeutic modalities. Through a nuanced understanding of these therapies, proceduralists can optimize MCAO management and improve patient outcome. For intrinsic or mixed MCAO, bronchoscopic ablative therapies with immediate effects-including laser, electrocautery (EC), argon plasma coagulation (APC), and cryo-debulking-are essential for restoring airway patency and symptom relief. Delayed-effect modalities, such as photodynamic therapy (PDT), endobronchial brachytherapy (EBBT), and cryotherapy via sequential freeze-thaw cycles, serve as alternative strategies when immediate recanalization is unnecessary or poses risks. Airway stenting remains the gold standard for re-establishing patency in cases of extrinsic or predominantly extrinsic mixed MCAO. This review discusses these ablative modalities and novel technologies, such as microwave ablation (MWA), as well as advancements in stenting techniques like three-dimensional (3D)-printed and biodegradable stents (BDS), offering promising options for MCAO treatment.

We conducted a narrative review based on literature identified through PubMed and Google Scholar searches, manual review of references from relevant articles, and expert consultations. Personal clinical experience also informed the interpretation and contextualization of the data.

Despite the range of available treatments, the choice of modality is primarily influenced by proceduralist expertise, resource availability, and patient and tumor characteristics. Direct comparisons between treatment modalities are currently lacking, and the diverse clinical contexts present challenges to standardized evaluations in future studies. This review does not address curative-intent endobronchial management of carcinoid tumors.

A thorough understanding of each modality's principles, advantages, and limitations enable proceduralists to optimize treatment strategies for MCAO. Multimodal approaches tailored to patient needs and tumor characteristics are often required. Future research should prioritize patient-centered outcomes and clarify optimal stenting practices, surveillance strategies, and integration with systemic therapy.