Managing malignant upper airway obstruction in palliative care

Management of malignant upper 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 upper airway obstruction (eg those with advanced head and neck cancers).

Management of malignant airway obstruction requires a multidisciplinary approach including, as indicated, a medical oncologist, radiation oncologist, palliative care physician, and an ear, nose and throat (ENT) surgeon.

Tracheostomy is only appropriate in very limited situations in patients with palliative care needs because a tracheostomy results in the loss of voice, and difficulty swallowing and returning home. Tracheostomy is rarely indicated for cancers that have limited treatment options and poor prognosis (eg anaplastic thyroid cancer, relapsed and refractory head and neck cancer). Seek specialist advice if tracheostomy is considered—careful clinical assessment, advance care planning and discussion on whether tracheostomy would be likely to improve quality or length of life is required.

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

If death is not imminent, acute management of malignant upper airway obstruction in patients with palliative care needs includes oxygen therapy (titrated to target oxygen saturation measured by pulse oximetry [SpO₂]) and symptomatic management of acute breathlessness.

Evidence for the use of corticosteroids and nebulised adrenaline (epinephrine), and their dosing, is unclear; however, they can be trialled as temporising options 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 upper 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.

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

adrenaline (epinephrine) 0.1% (1:1000, 1 mg/mL) solution 5 mL by inhalation via nebuliser, repeated at 30-minute intervals, to a maximum of 3 doses. adrenaline (epinephrine)

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

Postacute care of malignant upper airway obstruction involves managing the underlying cancer, which depends on patient preferences, type of cancer and predicted response. Active management options include radiotherapy, surgery and chemotherapy. If active management is not appropriate, focus on symptom management—see Principles of care in the last days of life.