Management of patients with Central Airway Obstruction can be difficult, but new therapeutic and diagnostic tools are now available that are beneficial to most patients and almost all airway obstruction can be relieved expeditiously.
Hitesh Batra, MD examines how the most comprehensive approach to treatment is offered at UAB and that the management of complex airway disorders is enhanced by the availability of highly advanced endoscopic and surgical options.
Selected Podcast
Central Airway Obstruction
Featuring:
Learn more about Hitesh Batra, MD
Release Date: February 11, 2019
Reissue Date: January 13, 2022
Expiration Date: January 12, 2025
Disclosure Information:
Planners:
Ronan O’Beirne, EdD, MBA
Director, UAB Continuing Medical Education
Katelyn Hiden
Physician Marketing Manager, UAB Health System
The planners have no commercial affiliations to disclose
Faculty:
Hitesh Batra, MD, MBA
Director, Interventional Pulmonology and Pleural Disease Program
Dr. Batra has no relevant financial relationships with ineligible companies to disclose.
There is no commercial support for this activity.
Hitesh Batra, MD
Hitesh Batra, MD currently serves as the director of the Interventional Pulmonology and Pleural Disease Program at UAB. He has completed an advanced fellowship in Interventional Pulmonology at Johns Hopkins University School of Medicine. Dr. Batra also holds a degree of Master of Business administration from the Collat School of Business of the University of Alabama at Birmingham.Learn more about Hitesh Batra, MD
Release Date: February 11, 2019
Reissue Date: January 13, 2022
Expiration Date: January 12, 2025
Disclosure Information:
Planners:
Ronan O’Beirne, EdD, MBA
Director, UAB Continuing Medical Education
Katelyn Hiden
Physician Marketing Manager, UAB Health System
The planners have no commercial affiliations to disclose
Faculty:
Hitesh Batra, MD, MBA
Director, Interventional Pulmonology and Pleural Disease Program
Dr. Batra has no relevant financial relationships with ineligible companies to disclose.
There is no commercial support for this activity.
Transcription:
Melanie Cole (Host): Today we're talking about the diagnosis and management of patients with central airway obstruction. Here to tell us about that is Dr. Hitesh Batra. He's an Assistant Professor of Medicine and the Director of Interventional Pulmonology and Pleural Disease Program in the Division of Pulmonary Allergy and Critical Care Medicine at UAB Medicine. Dr. Batra, explain a little bit about central airway obstruction, and who develops obstruction of the central airway. What is the prevalence of this?
Dr. Hitesh Batra, MD (Guest): Central airway obstruction has a wide range of causes, but the most common is lung cancer. Up to 30% of patients with lung cancer will develop some degree of central airway obstruction.
Host: What causes should be considered other than that when acute upper airway obstruction is suspected?
Dr. Batra: Right, so a lot of other conditions that are not related to cancer can also lead to central airway obstruction. Foreign body aspiration can lead to that, conditions that are benign, and I would say 'benign' with quotes because we actually prefer the word 'non-malignant' because these conditions are rarely benign because they could have serious effects on the patient and can sometimes be life-threatening. So those conditions would be- patients with lung transplant will have sometimes have airway complications. Tracheal stenosis because of trauma to the trachea, not uncommonly because of intubation. Idiopathic tracheal stenosis is another cause. A condition such as Wegener’s granulomatosis or what's called granulomatosis with polyangiitis can lead to tracheal stenosis. Those are some of the common non-malignant causes of central airway obstruction.
Host: Then speak about the imaging studies that would be helpful in making or excluding the diagnosis of acute airway obstruction, and are there other disease, Dr. Batra, that can mimic this same condition?
Dr. Batra: So when a patient presents with shortness of breath and airway obstruction is suspected, often the first test that is done is a chest x-ray, but chest x-ray can often be normal or can underestimate the degree of obstruction. So often when malignant or non-malignant airway obstruction is suspected, a CT scan of the chest is the best way test to evaluate the degree of obstruction and to really see what's going on the in airways. Your other question was can something mimic this? Yes, some pathologies of the airway such as severe asthma can sometimes behave like that, and there are some other conditions that are not necessarily mechanical obstruction, such as tracheobronchomalacia, which is collapse of the airway, particularly during expiration, which can look like mechanical central airway obstruction.
Host: So with the growth of sub-specialties, such as interventional pulmonology, have you seen more attention and research directed towards treating patients with complex airway pathology that could result in, as you said, from malignant or benign disease?
Dr. Batra: One thing we have seen, there definitely has been a rise in the prevalence of central airway obstruction and incidents of central airway obstruction over the past few decades, particularly because of the increase in the incidents of lung cancer. Now as that has been growing, there has been more attention to that, and there has been a rise of interventional nausea is a field over the past two or three decades and having more interventional pulmonology fellowships and laryngology fellowships, which is a sub-specialty of ENT. I do think that more and more centers are coming up with complex airway programs, where there's a collaborative and integrated approach to central airway obstruction where physicians from interventional pulmonology, ENT, and thoracic surgery get together to manage these patients, which can often be challenging. The number of complex airway programs in the country are very few though still, so definitely that is increasing and that recognition is increasing. At UAB, we do have a complex airway conference that we do every week or so to discuss these cases and come up with the best collaborative approach to manage these conditions. As for research, we do not see yet a significant increase in research that is going on towards these conditions. And part of that is I think the first step would be to make robust complex airway programs that deal with the condition using the existing knowledge that we have, and having that recognition that if you are at a center and you deal with a patient who has central airway obstruction, the best management for that patient might be referral to a center that has the expertise to deal with that.
Host: How do you determine the type of therapeutic modality to select? Speak about some of the parameters for your decision, and tell us about some of the latest therapeutic and diagnostic tools that are now available and that you're using there at UAB Medicine.
Dr. Batra: Right. So speaking of how do we decide first, the biggest thing that helps with the decision making is what are the symptoms that the patients are having? Now we should recognize the symptoms, because central airway obstruction happen very late in disease. A normal trachea, for example, is anywhere from sixteen to twenty millimeters in diameter. Patients do not develop dyspnea exertion until the trachea is about less than eight millimeters or so, and dyspnea at rest occurs at less than five millimeters. So by the time patients develop symptoms, often the disease is already severe. As far as deciding whether to intervene or not, one thing we need to have is the patient should have symptoms because of the problem. But two, it also depends on the location. Now with the available modalities that we have to handle airway obstruction, we can do very well with obstruction of the trachea, [Inaudible 00:07:08] bronchi, and then bronchus intermedius. But obstruction in distal bronchi is very challenging to deal with or treat.
As far as modalities that we use, there are a lot of ways we can deal with central airway obstruction, and that just comes down to what the etiology of the obstruction is. Often we do mechanical debulking of the tumor or whatever is causing the obstruction by either using a rigid bronchoscope or rigid forceps or microdebrider. While I'm speaking of that, I do think that most central airway obstruction should be managed with rigid bronchoscopy. There are some things, certain foreign bodies and certain obstructions that could be effectively managed with flexible bronchoscopy, but you have a secure airway, and to keep the procedure safe it is best to have rigid bronchoscopy either as the primary modality or have it available as a backup if needed. So these things should be treated at a center with the expertise in doing so.
In terms of the site mechanical methods of tumor debulking, there are several other modalities that we have to treat the obstruction or tumor that might be obstructing the airway such as laser or [Inaudible 00:08:28], and what to use when really depends upon what's the obstruction, where it is, and what all it is involving. We do have all of those modalities available at UAB.
Host: And as we wrap up, Dr. Batra, you mentioned your collaboration with other providers in this department. Please give us your summary of what you would like other providers to take away from this segment on central airway obstruction, your cross-collaboration with other providers, and when to refer to the specialists at UAB Medicine.
Dr. Batra: First and foremost, I would say is that it's really important to recognize that central airway obstruction can be treated, and to recognize that it should be treated urgently. Because it could be, for example, if a patient has lobar collapse or a whole lung collapse because of central airway obstruction, if we do not treat it beyond four to six weeks- treating it beyond that time can have minimum benefit or no benefit at all. So that's first and foremost. Second thing I would say is the treatment of most of the central airway obstructions should happen at a center that has expertise in treating this and has the ability to do rigid bronchoscopy and to use all those modalities that I just mentioned. And finally, like we've discussed, the collaborative approach is really essentially, particularly for the obstruction of the trachea where collaboration with laryngologists and thoracic surgeons is essential to have the best outcomes and best approach to these diseases. So for any physician out in the community, if you are practicing at a center that does not have the resources available that we just discussed or the expertise in treating central airway obstruction frequently, then I would suggest referring those physicians to a center that does, and UAB is one of them.
Host: Thank you so much, Dr. Batra, for joining us today, and sharing your expertise in this very interesting topic. A community physician can refer a patient to UAB Medicine by calling the MIST line at 1(800) UAB-MIST. That's 1(800) 822-6478. You're listening to UAB MedCast. For more information on resources available at UAB Medicine, you can go to www.UABMedicine.org/physician. That's www.UABMedicine.org/physician. This is Melanie Cole, thanks so much for tuning in today.
Melanie Cole (Host): Today we're talking about the diagnosis and management of patients with central airway obstruction. Here to tell us about that is Dr. Hitesh Batra. He's an Assistant Professor of Medicine and the Director of Interventional Pulmonology and Pleural Disease Program in the Division of Pulmonary Allergy and Critical Care Medicine at UAB Medicine. Dr. Batra, explain a little bit about central airway obstruction, and who develops obstruction of the central airway. What is the prevalence of this?
Dr. Hitesh Batra, MD (Guest): Central airway obstruction has a wide range of causes, but the most common is lung cancer. Up to 30% of patients with lung cancer will develop some degree of central airway obstruction.
Host: What causes should be considered other than that when acute upper airway obstruction is suspected?
Dr. Batra: Right, so a lot of other conditions that are not related to cancer can also lead to central airway obstruction. Foreign body aspiration can lead to that, conditions that are benign, and I would say 'benign' with quotes because we actually prefer the word 'non-malignant' because these conditions are rarely benign because they could have serious effects on the patient and can sometimes be life-threatening. So those conditions would be- patients with lung transplant will have sometimes have airway complications. Tracheal stenosis because of trauma to the trachea, not uncommonly because of intubation. Idiopathic tracheal stenosis is another cause. A condition such as Wegener’s granulomatosis or what's called granulomatosis with polyangiitis can lead to tracheal stenosis. Those are some of the common non-malignant causes of central airway obstruction.
Host: Then speak about the imaging studies that would be helpful in making or excluding the diagnosis of acute airway obstruction, and are there other disease, Dr. Batra, that can mimic this same condition?
Dr. Batra: So when a patient presents with shortness of breath and airway obstruction is suspected, often the first test that is done is a chest x-ray, but chest x-ray can often be normal or can underestimate the degree of obstruction. So often when malignant or non-malignant airway obstruction is suspected, a CT scan of the chest is the best way test to evaluate the degree of obstruction and to really see what's going on the in airways. Your other question was can something mimic this? Yes, some pathologies of the airway such as severe asthma can sometimes behave like that, and there are some other conditions that are not necessarily mechanical obstruction, such as tracheobronchomalacia, which is collapse of the airway, particularly during expiration, which can look like mechanical central airway obstruction.
Host: So with the growth of sub-specialties, such as interventional pulmonology, have you seen more attention and research directed towards treating patients with complex airway pathology that could result in, as you said, from malignant or benign disease?
Dr. Batra: One thing we have seen, there definitely has been a rise in the prevalence of central airway obstruction and incidents of central airway obstruction over the past few decades, particularly because of the increase in the incidents of lung cancer. Now as that has been growing, there has been more attention to that, and there has been a rise of interventional nausea is a field over the past two or three decades and having more interventional pulmonology fellowships and laryngology fellowships, which is a sub-specialty of ENT. I do think that more and more centers are coming up with complex airway programs, where there's a collaborative and integrated approach to central airway obstruction where physicians from interventional pulmonology, ENT, and thoracic surgery get together to manage these patients, which can often be challenging. The number of complex airway programs in the country are very few though still, so definitely that is increasing and that recognition is increasing. At UAB, we do have a complex airway conference that we do every week or so to discuss these cases and come up with the best collaborative approach to manage these conditions. As for research, we do not see yet a significant increase in research that is going on towards these conditions. And part of that is I think the first step would be to make robust complex airway programs that deal with the condition using the existing knowledge that we have, and having that recognition that if you are at a center and you deal with a patient who has central airway obstruction, the best management for that patient might be referral to a center that has the expertise to deal with that.
Host: How do you determine the type of therapeutic modality to select? Speak about some of the parameters for your decision, and tell us about some of the latest therapeutic and diagnostic tools that are now available and that you're using there at UAB Medicine.
Dr. Batra: Right. So speaking of how do we decide first, the biggest thing that helps with the decision making is what are the symptoms that the patients are having? Now we should recognize the symptoms, because central airway obstruction happen very late in disease. A normal trachea, for example, is anywhere from sixteen to twenty millimeters in diameter. Patients do not develop dyspnea exertion until the trachea is about less than eight millimeters or so, and dyspnea at rest occurs at less than five millimeters. So by the time patients develop symptoms, often the disease is already severe. As far as deciding whether to intervene or not, one thing we need to have is the patient should have symptoms because of the problem. But two, it also depends on the location. Now with the available modalities that we have to handle airway obstruction, we can do very well with obstruction of the trachea, [Inaudible 00:07:08] bronchi, and then bronchus intermedius. But obstruction in distal bronchi is very challenging to deal with or treat.
As far as modalities that we use, there are a lot of ways we can deal with central airway obstruction, and that just comes down to what the etiology of the obstruction is. Often we do mechanical debulking of the tumor or whatever is causing the obstruction by either using a rigid bronchoscope or rigid forceps or microdebrider. While I'm speaking of that, I do think that most central airway obstruction should be managed with rigid bronchoscopy. There are some things, certain foreign bodies and certain obstructions that could be effectively managed with flexible bronchoscopy, but you have a secure airway, and to keep the procedure safe it is best to have rigid bronchoscopy either as the primary modality or have it available as a backup if needed. So these things should be treated at a center with the expertise in doing so.
In terms of the site mechanical methods of tumor debulking, there are several other modalities that we have to treat the obstruction or tumor that might be obstructing the airway such as laser or [Inaudible 00:08:28], and what to use when really depends upon what's the obstruction, where it is, and what all it is involving. We do have all of those modalities available at UAB.
Host: And as we wrap up, Dr. Batra, you mentioned your collaboration with other providers in this department. Please give us your summary of what you would like other providers to take away from this segment on central airway obstruction, your cross-collaboration with other providers, and when to refer to the specialists at UAB Medicine.
Dr. Batra: First and foremost, I would say is that it's really important to recognize that central airway obstruction can be treated, and to recognize that it should be treated urgently. Because it could be, for example, if a patient has lobar collapse or a whole lung collapse because of central airway obstruction, if we do not treat it beyond four to six weeks- treating it beyond that time can have minimum benefit or no benefit at all. So that's first and foremost. Second thing I would say is the treatment of most of the central airway obstructions should happen at a center that has expertise in treating this and has the ability to do rigid bronchoscopy and to use all those modalities that I just mentioned. And finally, like we've discussed, the collaborative approach is really essentially, particularly for the obstruction of the trachea where collaboration with laryngologists and thoracic surgeons is essential to have the best outcomes and best approach to these diseases. So for any physician out in the community, if you are practicing at a center that does not have the resources available that we just discussed or the expertise in treating central airway obstruction frequently, then I would suggest referring those physicians to a center that does, and UAB is one of them.
Host: Thank you so much, Dr. Batra, for joining us today, and sharing your expertise in this very interesting topic. A community physician can refer a patient to UAB Medicine by calling the MIST line at 1(800) UAB-MIST. That's 1(800) 822-6478. You're listening to UAB MedCast. For more information on resources available at UAB Medicine, you can go to www.UABMedicine.org/physician. That's www.UABMedicine.org/physician. This is Melanie Cole, thanks so much for tuning in today.