Managing malignant central airway obstruction in palliative care

Management of malignant central airway obstruction is guided by the site of obstruction, available management options for the underlying cancer, potential benefits and burdens of treatment, and the patient’s stage of disease, prognosis, preferences and goals of care—see Emergencies in palliative care. A management plan should be discussed in advance with patients who are at risk of central airway obstruction.

Management of malignant central airway obstruction requires a multidisciplinary approach including, as indicated, a respiratory physician, thoracic surgeon, medical oncologist, radiation oncologist, and palliative care physician.

For life-threatening malignant central airway obstruction, urgently decide if intubation will be considered to secure the airway, or if urgent symptom relief is required to manage breathlessness, stridor and anxiety—see Severe acute breathlessness in palliative care.

If death appears to be imminent, see Catastrophic terminal events in palliative care for management.

If death is not imminent, acute management of malignant central airway obstruction in patients with palliative care needs includes:

  • oxygen therapy, titrated to target oxygen saturation measured by pulse oximetry (SpO2)
  • symptomatic management of acute breathlessness
  • intubation for life-threatening obstruction
  • bronchoscopy (interventions such as mechanical debulking, thermal tools, cryotherapy and airway stents can rapidly restore airway patency). In palliative care, therapeutic bronchoscopy can provide rapid improvement in breathlessness and quality of life.

Evidence for use of corticosteroids and their dosing is unclear; however, they can be trialled as a temporising option while specialist advice is being sought or while discussions about prognosis with family or carers occur. Dosing varies in practice.

For temporary relief of life-threatening malignant central airway obstruction, while specialist advice is being sought and discussions about prognosis occur, consider:

dexamethasone 8 to 16 mg intravenously or subcutaneously, daily until specialist advice has been obtained. dexamethasone

If dexamethasone is unavailable, an equivalent dose of another parenteral corticosteroid may be used initially—see Approximate relative potency and duration of effect of glucocorticoids in the Bone and Metabolism guidelines for approximate relative potencies of oral and intravenous corticosteroids.

Malignant central airway obstruction is commonly complicated by pneumonia—see Pneumonia in palliative care.

Postacute care of malignant central airway obstruction may involve managing the underlying cancer, which depends on patient preferences, type of cancer and predicted response. Active management options include radiotherapy, surgery and chemotherapy. Additional options include local brachytherapy or further bronchoscopic ablation. If active management is not appropriate, focus on symptom management—see Principles of care in the last days of life.