Endobronchial Obstruction: The Impact of Interventional Pulmonology on Morbidity & Mortality

 The Case: 

• 64 yo M veteran smoker w PMH severe COPD on 4L O2 by NC, pAfib on AC, admitted in December for progressive dyspnea over weeks, found to have a bronchus intermedius obstruction due to extrinsic compression from a NSCLC mass near the right hilum.  

Portable CXR on admission

Portable CXR 3 days later

• Basic Statistics on Morbidity & Mortality in NSCLC
  • 5 yr Survival NSCLC (w Rx):
    • Stage I: 60-80%
    • Stage II: 40-50%
    • Stage III: 10-20%
    • Stage IV: <<10%
  • 40-85% of NSCLC patients will have symptoms related to the primary tumor.
    • Cough, dyspnea, wheeze, hemoptysis
  • QoL is influenced by:
    • Tumor itself
    • Metastases
    • Treatment
    • Paraneoplastic syndromes
• Indications for airway stenting are:
  • Extrinsic stenosis of central airways with or without intraluminal components due to malignant or benign disorders
  • Complex, inoperable tracheobronchial strictures
  • Tracheobronchial malacia
  • Palliation of recurrent intraluminal tumor growth
  • Central airway fistulae (esophagus, mediastinum, pleura)
• Contraindications
  • Nonviable lung is present beyond the obstruction
  • Extrinsic compression of an airway by a vessel
• Stent related complications
  • Displacement
  • Mucus impaction
  • Granuloma formation at stent ends
  • Re-obstruction by tumor
  • Halitosis
  • Infection
  • Perforation of airway walls
  • Hemoptysis
  • Pain
  • Cough
  • Fire (during laser resection)

NOTE:  No prospective, randomized trials exist on the utility of palliative stenting for proximal airways obstruction for obvious ethical reasons.  The following conclusions were drawn from single-center prospective cohort / observational studies published in the literature about their centers’ experience with these patients and their centers’ available interventions.

Conclusions

• Interventional Pulmonology procedures (such as stenting) should be considered for palliation of large airway obstruction in malignant disease
• Patients can anticipate an improvement in dyspnea and spirometric measures, but overall QoL is not as clear
• Complications are not rare, but most patients demonstrate overall benefit from intervention.
• With achieved airway patency, mortality approximates that of patients without previous obstruction.  However, no center to date has evaluated the impact of large airway stenting versus not-stenting on mortality from malignant endotracheal or endobronchial obstruction.  One can imagine the challenging ethical issues regarding this.