Management of central airway tumor presenting with critical airway obstruction

Sheetal*

ANS, Kauvery Hospital, Tirunelveli, Tamil Nadu

*Correspondence

Abstract

Background

Central airway tumors are uncommon but potentially life-threatening causes of airway obstruction. Prompt recognition and multidisciplinary management are essential to restore airway patency and improve outcomes. Delay in intervention may result in complete airway occlusion, respiratory failure, and death. Therapeutic bronchoscopy plays a pivotal role in restoring airway patency and obtaining tissue diagnosis. This case report describes a 12-year-old female who presented central airway tumor with critical airway obstruction seen by interventional pulmonology and underwent rigid bronchoscopy + electrocautery snare+ cryoextraction of polypoidal mass obstructing the trachea below the vocal cord. Post operatively after tumor Debulking, the patient was managed in the intensive care unit with mechanical ventilation, hemodynamic monitoring, fluid resuscitation, pain management, and infection control measures. Continuous assessment of neurological status, peripheral perfusion, respiratory function, urine output, and bowel function was conducted. The patient showed gradual post-operative improvement without major neurological deficits or significant respiratory complications. This report highlights the importance of early diagnosis, timely surgical intervention, meticulous perioperative management, and multidisciplinary critical care in improving outcomes following rigid bronchoscopy + electrocautery snare + cryoextraction.

Keywords: Central airway obstruction; Central airway tumor; Rigid bronchoscopy; Therapeutic bronchoscopy; Airway debulking; Interventional pulmonology; Electrocautery snare; Cryo extraction; Case report.

Introduction

A central airway tumor is a benign or malignant lesion arising within or compressing the trachea, main bronchi, or bronchus intermedius, leading to partial or complete obstruction of the central airways. Although uncommon, these tumors can cause significant respiratory compromise and may present as a life-threatening emergency when they produce critical airway obstruction. The causes are Primary malignant tumors: Squamous cell carcinoma, Adenoid cystic carcinoma, Carcinoid tumor, Mucoepidermoid carcinoma) Secondary malignant tumors:(Direct invasion from lung, thyroid, or esophageal cancers, Endobronchial metastases from renal cell carcinoma, breast cancer, colorectal cancer, melanoma, and other malignancies) Benign tumors:(Papilloma, Hamartoma, Leiomyoma, Lipoma)

Rigid bronchoscopy with tumor debulking is a procedure used to open an airway that has been narrowed or blocked by a tumor.

  • Rigid bronchoscopy: A straight, hollow metal tube (rigid bronchoscope) is inserted through the mouth into the windpipe while the patient is under general anesthesia. It provides a stable airway and allows the physician to use larger instruments than are possible with a flexible bronchoscope.
  • Tumor debulking: The physician removes as much of the tumor as is safely possible from inside the airway to restore airflow. This is usually done to relieve symptoms rather than to complete eliminate the cancer.

Depending on the tumor and the situation, the physician may use one or more of: Mechanical removal with forceps or a rigid coring technique and Electrocautery.

Potential complications include: Bleeding, Airway injury or perforation, Low oxygen levels during the procedure, Infection, Pneumothorax (collapsed lung), though uncommon, Reactions to general anesthesia, Recurrence of airway obstruction if the tumor grows back., in the recovery phase Patients are monitored until they recover from anesthesia.  Mild sore throat or hoarseness is common for a day or two.

Tumor debulking is often palliative, meaning it is intended to relieve symptoms and improve airway function rather than cure the underlying cancer. In selected cases, especially with benign tumors or certain localized lesions, it may also be part of a definitive treatment plan.

Case presentation

A 12-year-old female patient, no comorbid illness presented with a complaint of loss of appetite/loss of weight, exertional dyspnea, cough for 1 month, tachypenic,tachycardia. Patients were initially treated with bronchodilators and nebulization support. Initiated O2 inhalers and overnight BIPAP support.

Fig (1): A large tumor causing near complete luminal obstruction of trachea,9mm proximal to carina.

Lab investigations

Hb13.4
TC29390
ANC22260
ALC6080
Platelet5.23 lakhs
Na143
K+3.29

Other investigation

Outcome of investigations

Clinical evaluation and imaging studies revealed a polypoidal mass obstructing the trachea 6cms below the vocal cord. Planned for rigid bronchoscopy + electrocautery snare +cryoextraction.

Preoperative management

  • Detailed clinical assessment and imaging evaluation.
  • Cardiac and pulmonary evaluation
  • Baseline investigation: CBC,RFT,LFT,Electrolytes, coagulation profile
  • Cross matching blood products
  • Infection screening and prophylactic antibiotics.

Procedural management- FOB under GA.

Under aseptic precautions, Warthin FOB was done for placing guidewire and frova tube. FOB passed behind the tumor and tube was placed in right lung bronchus. Rigid bronchoscope was introduced and tumor was vislauized,6cm below vocal cord occluding 90% lumen. Snare was introduced via working channel and looped the mass.cautery cryoextraction done.

Fig (2): Rigid intubation followed by tumor debulking using electrocautery snare and cryotherapy

Intraoperatively

BP monitoring done and hemodynamic stability maintained. and mass excised, airway bleeding was managed with topcal 2%lox solution and topical adrenaline (1:4 dilution) mass removed in 2- pieumalvia forceps and mass was sent for HPE examination

Fig (3): Resected Tumor

Fig (4): Post tumor debulking – airway recanalised

Post operatively

  • Spontaneous subcutaneous emphysema noted over neck, anterior chest walls, b/l thigh.
  • Multiple nibs done over chest wall suprasternal space of burns. Hemodynamically stable on spontaneous ventilation with sedation.
  • Continuing ABG monitoring
  • Monitor intake and output chart.
  • Monitor sensorium
  • Repeat chest x ray.
  • Gentle ET suction is necessary only.
  • The patient continued under multidisciplinary postoperative care with regular pulmo and critical care management.

Nursing management

  • Monitor subcutaneous emphysema.
  • Weaning plan
  • Frequent vital monitoring
  • Maintenance of airway and breathing
  • Mild sore throat or hoarseness is improving.
  • Monitoring bowel sounds and urine output.
  • Patient and family education

Outcome

  • Hemodynamic stabilization
  • Immediate improvement in breathing
  • Restoration of airway patency.
  • Improved oxygenation relief of symptoms like Cough, wheezing, and coughing up blood (hemoptysis) frequently decrease.
  • Improved quality of life
  • Facilitates further treatment: Restoring the airway can enable subsequent treatment after histopathological examination results.
  • No major neurological deficits
  • Gradual recovery with multidisciplinary critical care support

Fig (5): Chest X-ray

Discussion

Critical central airway obstruction is an oncologic emergency associated with high morbidity and mortality. rigid bronchoscopy remains the gold standard for airway stabilization, allowing simultaneous ventilation, tumor debulking, and control of bleeding. Adjunctive modalities such as electrocautery cryotherapy and mass extraction are done based on the tumor characteristics and patient status. Therapeutic bronchoscopy intervention not only provides immediate symptomatic relief but also facilitates tissue diagnosis and subsequent cancer-directed therapy. peri-operatively risk including bleeding (usually mild to moderate, occasionally severe) Temporary low oxygen levels during the procedure, Airway swelling, Pneumothorax (collapsed lung), which is uncommon, Residual or recurrent airway obstruction requiring repeat bronchoscopy, Rarely, airway injury or infection.

In this case the patient underwent successful tumor extraction and postoperatively, the patient required intensive monitoring and ventilator support in surgical ICU. Hemodynamic parameters such as blood pressure, heart rate, oxygen saturation, urine output, peripheral perfusion were continuously monitored to detect early complications. Maintenance of adequate blood pressure and tissue perfusion was essential because bleeding, anesthetic agents, and periods of reduced oxygenation can compromise oxygen delivery to tissues.

Conclusion

Central airway tumors presenting with critical airway obstruction require urgent intervention. Therapeutic bronchoscopy+ tumor debulking gave a rapid relieve obstruction, stabilizing the patient and facilitating definitive therapy. Early diagnosis and timely multidisciplinary management significantly improved patient outcomes. This Case highlights the importance of coordinated surgical and critical care management in reducing post-operative complications and promoting successful recovery following tumor debulking.

References

  • American College of Chest Physicians, Ernst A, Feller-Kopman D, Becker HD, Mehta AC. Central Airway Obstruction. 2004;126(6):1993–2001. A classic evidence-based review covering diagnosis and bronchoscopy management of central airway obstruction.
  • American College of Chest Physicians CHEST Clinical Practice Guideline: Management of Central Airway Obstruction. Recent CHEST guidelines provide recommendations on therapeutic bronchoscopy, airway stenting, and multimodality treatment.
  • Armin Ernst, Felix J. F. Herth. Principles and Practice of Interventional Pulmonology. Springer. A comprehensive textbook covering: Mechanical debulking Laser therapy Electrocautery Argon plasma coagulation (APC) Cryotherapy Airway stents
  • David H. Sterman et al. Bronchoscopy Ablative Therapies for Malignant Central Airway Obstruction. Reviews available in leading pulmonary journals discuss indications, outcomes, and complications of bronchoscopy tumor debulking.
  • Cavaliere S, et al. Endoscopic treatment of malignant airway obstructions in 2,008 patients. 1996. One of the largest early series demonstrating the effectiveness of bronchoscopy tumor debulking using laser therapy.
  • Dirk M. Ost et al.
    • Therapeutic Bronchoscopy for Malignant Central Airway Obstruction: Success Rates and Impact on Dyspnea and Quality of Life.
    • Demonstrates rapid symptom improvement and technical success following bronchoscopy intervention.
  • American Thoracic Society reviews on malignant central airway obstruction.
    • Discuss multidisciplinary management including:
      • Tumor debulking
      • Airway stenting
      • Radiation
      • Systemic therapy
  • Mudambi L, Miller R, Eapen GA.
    • Malignant Central Airway Obstruction.
    • Journal of Thoracic Disease.
    • Comprehensive review of current bronchoscopy techniques and outcomes.
  • Guibert N, et al.
    • Interventional Bronchoscopy in Malignant Central Airway Obstruction.
    • European Respiratory Review.
    • Reviews contemporary evidence on rigid bronchoscopy, debulking techniques, and stent placement.

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