Management of tracheobronchial diseases in critically ill cancer patients

Tracheobronchial diseases are uncommon in critically ill oncologic patients but are responsible for significant morbidity and risk of mortality in this population. The most significant tracheobronchial diseases of relevance in oncologic critical care are hemoptysis and central airway obstruction. In the inpatient setting, hemoptysis is most often related to lung cancer or bronchiectasis. After initial stabilization of the airway, localizing the source of bleeding and resuscitation are paramount. Then intervention to control bleeding and prevent recurrence with bronchial artery embolization or therapeutic bronchoscopy is indicated, with surgery most appropriately used for those patients refractory to less invasive management. Central airway obstruction refers to narrowing of the trachea or mainstem bronchi and can result from the direct effect of malignant tumors or complications of treatment. Patients often have severe obstruction before becoming symptomatic. If surgical resection is not possible, therapeutic bronchoscopy is the mainstay of treatment. Effective techniques used in central airway obstruction include laser photoresection, electrocautery, argon plasma coagulation, microdebrider bronchoscopy, bronchoplasty, and stenting. Complex stenoses often require multimodality therapy. A multidisciplinary approach is recommended.