681

Ablative Therapies for Central Airway Obstruction

Kamran Mahmood, MD, MPH1 Momen M. Wahidi, MD, MBA1

1 Division of Pulmonary, Allergy and Critical Care Medicine, Address for correspondence Kamran Mahmood, MD, MPH, Division of
Department of Medicine, Duke University Medical Center, Pulmonary, Allergy and Critical Care Medicine, Department of
Durham, North Carolina Medicine, Duke University Medical Center, DUMC 102356, Durham,
NC 27710 (e-mail: k.mahmood@duke.edu).
Semin Respir Crit Care Med 2014;35:681–692.

Abstract Central airway obstruction (CAO) is seen in malignant and nonmalignant airway
Keywords disorders and can lead to significant morbidity and mortality. Endobronchial ablative
► central airway therapies are used in conjunction with mechanical debridement to achieve hemostasis
obstruction and restore airway patency. These therapies can be classified into modalities with
► ablative therapy immediate or delayed effect. Therapies with immediate effect include heat therapies
► electrocautery (such as electrocautery, argon plasma coagulation, and laser) and cryorecanalization
► argon plasma using a cryoprobe for tissue extraction. These modalities can be used in severe CAO for
coagulation immediate relief of obstruction. Therapies with delayed effect include cryotherapy,

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► airway brachytherapy, and photodynamic therapy. These modalities should not be used for
► laser acutely symptomatic CAO, and typically require follow-up bronchoscopy for removal of
► cryotherapy debris from the airway. Multimodality approach typically leads to better outcomes.
► brachytherapy
► photodynamic
therapy

Central airway obstruction (CAO) is a significant cause of return to a grounding plate, usually applied to the limb of
morbidity and mortality in patients with bronchogenic car- the patient.10
cinoma and metastatic cancer to the lungs.1 It is also seen in Tissue coagulation occurs at approximately 70°C, desicca-
nonmalignant airway disorders such as postintubation tra- tion at
100°C, carbonization at
200°C, and vaporization
cheal stenosis and following lung transplantation.2 A multi- at 500°C.10 The tissue effect is dependent on the power
modality and multidisciplinary approach is required for the (watts) and voltage of the electrocautery as well as tissue
management of these patients.1 Relief of CAO has been shown resistance. In soft coagulation, voltage of < 200 V is applied.
to improve symptoms, spirometry, and quality of life.3–5 In forced coagulation, voltage of > 500 V is applied resulting
Ablative therapies are commonly used in conjunction with in deep coagulation and carbonization. Increasing power or
tumor debridement or airway dilation to achieve airway watts concentrates the energy in the tissues closer to the
patency.1 These can be classified as therapies with immediate probe tip, causing rapid but shallow effect.
or delayed effect,6,7 as shown in ►Table 1. Cutting is achieved by a knife or snare, using voltage
greater than 200 V that creates an electric arc between the
tissue and the electrode. Simultaneous hemostasis or coagu-
Ablative Therapies with Immediate Effect lation is achieved by increasing the voltage and introducing
voltage modulation (blend mode).
Electrocautery
Principle Technique
Electrocautery is a contact thermal ablative modality that Different electrocautery probes and devices are available,
uses the flow of electricity to generate heat to burn the including rigid and flexible probes, snare, knife, and forceps
tissue.6,8,9 A monopolar probe or device is applied to the (►Fig. 1). The flexible electrocautery probe can be inserted
target allowing electricity to flow through the body and through a flexible bronchoscope (►Fig. 2). Although the

Issue Theme Interventional Copyright © 2014 by Thieme Medical DOI http://dx.doi.org/

Pulmonology; Guest Editors: David Publishers, Inc., 333 Seventh Avenue, 10.1055/s-0034-1395501.
Feller-Kopman, MD and Lonny Yarmus, New York, NY 10001, USA. ISSN 1069-3424.
DO, FCCP Tel: +1(212) 584-4662.
682 Ablative Therapies for Central Airway Obstruction Mahmood, Wahidi

Table 1 Types of endobronchial ablative therapies the probe is recommended to mitigate bleeding.11 For treat-
ment of endobronchial lesions, soft or forced coagulation
Ablative therapies with immediate effect mode is used at 20 to 40 W in short bursts of < 5 seconds
I. Thermal therapy (►Table 2).10 Once the tissue is coagulated, it is removed with
• Electrocautery
mechanical debridement. If the contact time is prolonged,
• Argon plasma coagulation
• Laser desiccation, carbonization, and vaporization of the tissue can
II. Cryorecanalization occur.
Ablative therapies with delayed effect The electrocautery snare is typically used for polypoid
I. Cryotherapy lesions. It is looped around the base or stalk of the polyp and
II. Brachytherapy retracted while activating the electrocautery for cut and
III. Photodynamic therapy coagulation (►Fig. 3). As the polyp is cut, hemostasis is
achieved with coagulation and charring of the stalk. A major
benefit of the snare is that it can preserve tissue for
surface area is relatively small, it can be used for both pathologic evaluation. The electrocautery knife is common-
proximal and distal lesions. The rigid probe needs to be ly used for making radial incisions in nonmalignant airway
inserted through a rigid bronchoscope. It has a large surface stenosis, as an adjunct to dilation (►Fig. 4). Electrocautery
area, and is used more efficiently in more proximal lesions forceps can be used for both endobronchial and transbron-
(►Fig. 3). It has a central suction, which can be used to clear chial biopsies and coagulation at the same time to decrease
the airway from blood and debris at the same time. These bleeding (►Fig. 1), but its efficacy in hemostasis is not
probes need to be cleaned frequently, as burnt tissue build up proven.12
on the tip prevents proper functioning.11 As these are contact

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devices, blood in the airway will impair their use, and needs Indication
to be suctioned frequently. Gentle touching of the lesion by
• Endobronchial malignant and nonmalignant lesions caus-
ing CAO as an adjunct to debridement
• Treatment of early lung cancer (carcinoma in situ)
• Hemostasis
• Radial incisions in conjunction with airway dilation

Complications
• Bleeding: Bleeding may be aggravated because of the need
for contact.11 The tip of the probe should gently touch the
target lesion.
• Airway perforation and damage can occur, if attention is
not paid to the duration and power of electrocautery.13,14
It is recommended to use short bursts and appropriate
power settings: 30 W for snare, 20 W for probe, and 10 W
for knife. Duration of electrocautery application should be
limited to less than 5 seconds per pulse.8
Fig. 1 Top (left to right): argon plasma coagulation probe, electro- • Airway fire: FiO2 should be maintained below 0.4, and
cautery forceps, electrocautery flexible probe, snare, and knife. Rigid ideally below 0.3 to prevent airway fire.8,9 The use of
electrocautery probe at the bottom.
electrocautery should be avoided near endotracheal tube
or covered metal and silicone stents.15 The probe should
extend at least 5 mm beyond the bronchoscope to prevent
damage to the scope.
• Electrocautery can be used with caution in patients with
implanted permanent pacemakers or cardioverters.8 The
grounding pad should not be placed on the devices and an
interrogation of the electrical device should be performed
in case of any intraprocedural events.
• The grounding plate should also not be placed on the skin
over a metallic prosthesis.8

Contraindications
• Electrocautery use should be avoided in extrinsic com-
pression with intact mucosa.9
• It should also be avoided if FiO2 cannot be decreased9 to
Fig. 2 Flexible electrocautery probe use.
below 0.4.

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Fig. 3 Electrocautery snare and rigid probe. (A) Tracheal mass. (B) Rigid probe ablation. (C) Snare placed around the lesion. (D) Trachea after mass
excision with the snare.

Evidence van Boxem et al treated 13 patients with radiologically

The use of airway electrocautery was first described by occult early lung cancer with elecrocautery.22 Ten patients
Gilfoy16 in 1932. However, electrocautery did not become achieved a complete response and no other treatment was
popular until reports by Hooper and colleagues in the early necessary, at a median follow-up of 21 months. Other studies
1980s attesting to its efficacy and safety.17,18 Its main advan- have validated this approach in patients who are not eligible
tages include wide availability, as it is used in gastroenterol- for surgical resection.23 Electrocautery has also been success-
ogy endoscopic procedures, and low cost compared with fully used for nonmalignant central airway disorders such as
laser.19 granulation tissue related to stents, papillomas, and airway
Several case series have demonstrated the efficacy of stenosis.11
electrocautery.19,20 Wahidi and colleagues reported their
experience of using electrocautery as the primary heat ther-
Argon Plasma Coagulation
apy for benign and malignant CAO in 94 patients.21 Endo-
scopic improvement was seen in 94% and radiographic Principle
improvement in 78% patients. The complications included Argon plasma coagulation (APC) is a noncontact form of
minor bleeding (2%) and bronchospasm (1%). In a prospective electrocautery. 6,8,9 A flexible probe housing a wire delivers
comparison of electrocautery and laser therapy, Coulter and high-frequency, high-voltage electric current to a monop-
Mehta showed that electrocautery can alleviate the need for olar tungsten electrode present at the tip of the probe.
laser in 89% of 47 patients thought suitable for this therapy.11 Argon gas flows through the probe, and is charged or

Table 2 Suggested initial settings for endobronchial heat therapy

Ablation therapy Accessory Generator mode Power (W) Other specifications

APC Probe Forced 30 Gas flow: 0.3–0.8 LPM
Pulsed 10
Electrocautery Probe Soft 10–20 Activation < 5 s
Probe Forced 20–40
Knife Blend 10–40
Snare Blend 10–40
Laser (Nd:YAG) Probe 20–40 Pulse duration: 0.5–1 s

Abbreviations: APC, argon plasma coagulation; Nd:YAG, neodymium: yttrium-aluminum-garnet.

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Fig. 4 Electrocautery knife use. (A) Bronchus intermedius stenosis. (B) Electrocautery knife. (C) Radial incisions. (D) Balloon dilation. (E) Silicone
stent placement.

ionized to produce “plasma” as it flows around the tungsten objects, such as stents or clips, as electric arc can flash over and
electrode. Electric current flows through the plasma to the damage the object or cause unintended coagulation.
nearest tissue, and heat is produced as it passes through the The tissue effect depends on the power setting (watts),
tissue. Increased resistance created by coagulated tissue duration of activation, and probe distance from the target. The
impairs the flow of electric current, and keeps the ablation higher the power and duration of activation, the more the
depth to 1 to 2 mm.10 This superficial effect makes APC depth of ablation. APC is a noncontact mode and a distance of
unsuitable for vaporization purposes but renders it ideal for 1 mm or more should be kept between the probe and tissue.
coagulation of bleeding and enhances its safety. In addition, In general, it is recommended to start with lower power and
APC seeks the nearest electroconductive areas and, there- activation duration, and increase these as necessary
fore, can target lesions located laterally or “around the (►Table 2).
corner.”24 The newer generation APC machines have forced or pulsed
settings. Forced APC has continuous output, with superficial
Technique to deep ablation depending on power. It is designed for rapid
The APC probe is flexible, 1.5 mm in diameter, and can be devitalization and control of acute bleeding. Pulsed APC has
advanced through the working channel of a flexible broncho- discontinuous output and is suited for situations where
scope (►Figs. 1 and 5). Straight fire, side fire, and circumfer- controlled output is preferred like in thin walled structures.
ential probes are available. Black marks are present at the distal Pulsed APC can be of two frequencies: Effect 1 has higher
tip of the catheters at 10-mm intervals. The distal tip should be energy output at slow pulses (1 pulse/second) causing deeper
at least 10 mm away from the bronchoscope to prevent scope coagulation. Effect 2 has lower energy output with fast pulses
damage. It should not be used in close proximity to metal (16 pulses/second) and superficial coagulation.

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 Ablative Therapies for Central Airway Obstruction Mahmood, Wahidi 685

Fig. 5 (A) Argon plasma coagulation (APC) probe use for an endobronchial lesion. (B) Eschar is left after APC application.

Indication
Laser
• Hemostasis of bleeding from endobronchial lesions
Principle
• Tumor debridement in CAO is possible but less efficient
Laser stands for light amplification of stimulated emission of
• Destruction of granulation tissue and other nonmalignant
radiation. This technique uses heat energy delivered by light
lesions
to coagulate and vaporize tissue.8,9 Several types of laser use

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Complications different media to generate light. The characteristics of
different lasers are shown in ►Table 3.
• Gas embolism: During APC ablation, large vessels may open
up, and with high gas pressure, the argon gas can embolize
Technique
into systemic circulation. Intracardiac gas embolism lead-
Laser is emitted via a flexible fiber that can be inserted
ing to cardiopulmonary arrest has been described. Reddy
through a flexible bronchoscope (►Fig. 6). Most laser pro-
and colleagues reported three cases of gas embolism,
cedures are performed via rigid bronchoscopy.32 The power
when the gas flow was 1 to 2 L/minute.25 Two of these
and the distance of the fiber from the lesion as well as the
patients died. Another fatal case of cerebral gas embolism
ratio of absorption and scattering coefficients of laser deter-
has been described with gas flow of 1 L/minute.26 This
mine the tissue effect. Lower power settings lead to shallow
complication can be avoided by keeping the flow to less
effect and cause tissue coagulation, while higher power
than 0.8 L/minute.27 The authors kept the gas flow at 0.5
settings result in deeper penetration and cause tissue car-
LPM.
bonization and vaporization. The laser fiber’s distance from
• Bleeding.
the lesion also plays a role in the effect with farther distance
• Airway rupture: Despite limited depth of ablation with
(1 cm), causing superficial coagulation and closer distance
APC, a 1.4% rate of airway perforation was described by
(4 mm) causing carbonization and deeper penetration.
Reichle and colleagues.28 It has been suggested to keep
Tissue penetration by neodymium:yttrium-aluminum-gar-
applications short (1–2 seconds), minimize the power,
net (Nd:YAG) laser is approximately 10 mm,1 which is
and keep a distance of 1 to 5 mm between probe and
deeper compared with electrocautery and APC. Therefore,
tissue.
the laser fiber is always aimed at the airway lesion parallel to
• Airway fire: FiO2 should be kept at < 0.4 and the use of APC
the airways to avoid bronchial wall injury. The usual settings
should be avoided close to inflammable material.29

Contraindications
Table 3 Types and tissue effect of laser
• Extrinsic compression
• Inability to decrease the FiO2 to less than 40% Laser type Wavelength Tissue effect
Evidence (nm)
APC was first used in the gastrointestinal tract in 1994, when Coagulation Vaporization
catheters were developed to deliver it endoscopically.30 Nd:YAG 1,064 þþ þþ
Afterward, the modality was rapidly adopted for airway
Nd:YAP 1,340 þþþ þ
use. Reichle and colleagues described their experience of
KTP 532 þþ þ
APC use in 364 patients. Ninety percent of the cases were
done with rigid bronchoscopy. Airway patency was achieved CO2 10,600 þ þþþ
in 67% patients and hemostasis was achieved in 99% pa- Abbreviations: CO2, carbon dioxide laser; KTP, potassium titanyl phos-
tients.28 Many other case series have also shown similar phate; Nd:YAG, neodymium:yttrium-aluminum-garnet; Nd:YAP, neo-
results.24,31 dymium: yttrium-aluminum- perovskite.

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Fig. 6 (A) Left mainstem bronchus mass. (B) Potassium titanyl phosphate laser application. (C) Left mainstem bronchus after laser ablation and
debridement.

are power of 20 to 40 W and pulse duration of 0.5 to 1 second at least 5 mm beyond the bronchoscope to prevent dam-
(►Table 2).1 Laser’s biggest advantage is its precise and age to the scope.
immediate ablation. Its major disadvantages lie in its high • Cardiac and cerebrovascular gas embolism. Keeping the
cost, requirement for additional training, and the need to flow of air coolant of the laser fiber to a low setting and
wear protective eye wear.19 using the laser as a noncontact mode are recommended to
avoid this complication.27,33
Indications • Myocardial infarction.32
• Cardiac arrest.32
• Endobronchial malignant and nonmalignant lesions caus- • Death (0.35%).32
ing CAO as an adjunct to debridement
• Treatment of early lung cancer
Contraindications
• Hemostasis
• Radial incisions along with airway dilation • Laser use should be avoided in extrinsic compression with
intact mucosa.
Complications
• It should also be avoided if FiO2 cannot be decreased to
below 0.4.
• Bleeding (1%).32
• Airway perforation, leading to pneumothorax (0.4%) and Evidence
pneumomediastinum (0.2%).32 Attention is required to the The first airway application of laser was with carbon dioxide
power, proximity of the laser probe to the airway wall, and (CO2) laser described in early 1970s.34,35 Although the CO2
duration of the therapy. Power should be kept at below laser (wavelength 10,600 nm) is extremely precise, it has poor
40 W. coagulating properties. It is used commonly by otolaryngol-
• Airway fire: FiO2 should be maintained at below 0.4, and ogists in upper airway and trachea.1,6
ideally at below 0.3 to prevent airway fire. Use of laser The use of laser in the airways gained popularity with the
should be avoided near an endotracheal tube, covered advent of Nd:YAG, which can be delivered via a flexible quartz
metallic stents, or silicone stents. The fiber should extend fiber and continues to be the most commonly used laser to

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 Ablative Therapies for Central Airway Obstruction Mahmood, Wahidi 687

date. It has a wavelength of 1,064 nm, which lies in the treatment of tracheal hemangiomas and glottis papillo-
invisible infrared range and needs a pilot light for use mas. 39–41 Its use in the lower airways has been limited with
(►Table 3). Dumon et al reported the first large case series only one case report of its application in endobronchial
of Nd:YAG use in 111 patients with benign and malignant tuberculosis.42
CAO.36 Immediate relief was achieved in most patients,
except four patients with extrinsic compression. Cavaliere
and colleagues later published their experience of using Nd: Ablative Therapies with Delayed Effect
YAG laser in 1,000 patients and showed improvement in
Cryotherapy
airway lumen in 92% of patients with malignant CAO and
cure of nearly all carcinoid lesions and benign tumors.32 In Principal
addition, many patients were able to undergo surgery who Cryotherapy ablates tissue using freeze followed by thaw. A
were deemed nonsurgical cases before the laser treatment, or gas is released from high pressure to the tip of a flexible or
underwent less extensive surgery. Mehta et al used Nd:YAG rigid probe, and as it expands, the temperature is brought
for radial incisions followed by dilation of tracheal stenosis, down up to 40°C by Joule–Thompson effect.1,8,9 Nitrous
with good success.37 oxide is the preferred gas, as it brings down the temperature
Neodymium:yttrium-aluminum-perovskite (Nd:YAP) with faster compared with liquid nitrogen.1 The tissue necrosis
higher wavelength of 1,340 nm offers more absorption by occurs by formation of intra- and extracellular ice crystals,
water compared with Nd:YAG (►Table 3). It leads to better dehydration, vasoconstriction, vascular thrombosis, and ap-
coagulation and devascularization, but decreased vaporization optosis.1 There is a speculated immune effect by activation of
and cutting ability. Lee and colleagues described the experi- natural killer cells that may augment the effect of cryotherapy
ence with Nd:YAP laser in 44 patients.38 All patients with CAO on the tissue.1 The major disadvantage of cryotherapy is the

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were recanalized, but radial incisions for benign tracheal delayed effect on the tissue, making it unsuitable for treat-
stenosis were not successful. No complications were ment of acute or symptomatic CAO.43,44 The patients usually
encountered. need a repeat bronchoscopy several days after the cryothera-
Potassium titanyl phosphate (KTP) laser has a wave- py treatment to remove necrotic tissue debris via mechanical
length of 532 nm, which lies in the visible green range debridement.43 The cryotherapy effect depends on water
(►Table 3; ►Fig. 6). It is preferentially absorbed by hemo- content of the tissue. Cartilage-like tissue, collagen, and
globin which makes it well suited for vascular lesions, but poorly vascularized tissue are cryoresistant, decreasing the
tissue penetration is less when compared with Nd:YAG. risk of airway perforation by cryotherapy and making it one of
These characteristics have increased its popularity for the safest ablation modalities.1

Fig. 7 (A) Distal left mainstem bronchus endobronchial lesion. (B) Cryotherapy with flexible probe. (C) Left mainstem bronchus after cryotherapy
and debridement.

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688 Ablative Therapies for Central Airway Obstruction Mahmood, Wahidi

Technique • Cryoextraction can also be used for blood clot, mucus

The probe is applied to the target area and freezing is plugs, and foreign body removal.
performed for 30 to 60 seconds followed by passive rewarm-
ing (►Fig. 7). The freeze–thaw cycle is repeated three to five Complications
times.1 For large lesions, the probe is moved so that all the
• Bleeding48: The risk of bleeding is especially high with
surface of the lesion is covered with some overlap. The probe
cryoextraction, and in one case series, APC and cold saline
should be advanced several millimeters distal to the bron-
were used to achieve hemostasis.45
choscope tip to prevent freezing and damage to the camera
• Bronchospasm.43
chip. The necrotic tissue is then removed with a forceps in a
• Pneumothorax.48
subsequent bronchoscopy.
• Arrhythmias and cardiopulmonary arrest.43
• Death.
Cryorecanalization or Cryoextraction
• Complications unique to cryospray: Cryospray has led to
This is a technique of rapid debulking of central airway
tension pneumothorax, pneumomediastinum, and death
tumors.8 The cryoprobe is brought in contact with the target
due to rapid expansion of gas in the airway causing severe
lesion, lesion is frozen for 3 to 5 seconds, and then flexible
barotrauma. It has been suggested to deflate the endotra-
bronchoscope and cryoprobe are removed together with
cheal tube cuff and allow the gas to escape via and around
adherent tissue.45 This can be performed flexibly via an
endotracheal tube or use an open circuit rigid broncho-
endotracheal tube or via a rigid bronchoscope to facilitate
scope. Newer technology with controlled gas flow has
the procedure. Cryotherapy can be used to remove large blood
been suggested to increase safety.49
clots, mucus plugs, or foreign bodies.1
Evidence

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Cryospray Mathur and colleagues reported their experience with cryo-
Spray cryotherapy uses noncontact delivery of liquid nitrogen therapy in 20 patients with malignant CAO and 2 patients
spray through a bronchoscopic catheter to induce rapid with lung transplantation-related central airway stenosis.43
freeze–thaw cycle and cell death (►Fig. 8).46 Low temper- After one to three freeze–thaw cycles of 1 minute duration
atures up to 196°C are achievable. Large areas can be rapidly each, necrotic tissue was removed with forceps. A repeat
treated with uniform effect. One to two cycles of 5-second bronchoscopy was performed in 1 to 2 weeks for removal of
spray are followed by a thaw period of 1 minute.47 To prevent debris and further treatment. Airway patency was achieved
high intrathoracic pressure during gas reexpansion and baro- in 18 out of 20 patients with malignant CAO, and the
trauma, ventilation is held during cryospray application. An remaining 2 patients with lung transplantation airway ste-
open circuit is required to prevent the detrimental effects of nosis. In two large case series of 476 patients with malignant
high pressure by either deflating the endotracheal tube cuff CAO and 20 patients with nonmalignant endobronchial
and detachment of the ventilator or using an open circuit rigid lesions, cryotherapy and mechanical debridement led to
bronchoscope.46 improvement in symptoms, spirometry, and performance
status.48,50
Indications Schumann and colleagues reported their experience with
cryorecanalization in 225 patients.45 Airway patency was
• Malignant CAO.
achieved in 91% cases. APC was required to control the
• Early-stage lung cancer.
bleeding in 8% patients.
• Granulation tissue in the airway.
Finley and colleagues treated 80 patients with spray
cryotherapy.46 Airway patency was achieved in 98% patients.
However, a high intraoperative complication rate of 19% was
seen, including three pneumothoraces and five deaths. The
complications are thought to be secondary to rapid reexpan-
sion of liquid nitrogen, causing high intrathoracic pressure.
Newer cryospray machines deliver the liquid nitrogen at low
flow (12.5 W), which can potentially decrease the risk of
barotrauma.49

Endobronchial Brachytherapy
Principle
Endobronchial brachytherapy refers to placement of a radia-
tion source within or alongside a tumor in the airway, with
the help of a bronchoscope.1,8 Local radiation is provided to
the lesion with the intent of sparing the tissues in the pathway
Fig. 8 Cryospray (Courtesy: Michael Machuzak, MD, Cleveland Clinic, of external beam radiation. Inverse square law governs the
Cleveland, OH). therapy, which means that radiation dose rate decreases as a

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Fig. 9 Brachytherapy computed tomography (CT) scan planning with delivery catheter in place for right mainstem/bronchus intermedius lesion.
(A) Coronal view. (B) Cross-sectional view. (C) Approximate radiation dosage: pink: 700 cGy, green: 400 cGy, blue: 50 cGy. (Courtesy: Oana I
Craciunescu, PhD, and Nicole Larrier, MD, Radiation Oncology, Duke University, Durham, NC).

function of inverse square of distance from the source.7 • Early-stage lung cancer
Gamma radiation emitted during brachytherapy does not • Airway granulation tissue
cause direct killing of the cells, but rather it causes single
chain breaks of DNA, resulting in apoptosis and decreased cell Contraindications
proliferation.7 The effects are delayed, with visible and maxi-
• Upper lobe lesions of squamous histology
mal effects usually seen after approximately 3 weeks. Hence,
• Concern for bronchovascular fistula
it cannot be used for treatment of acutely symptomatic CAO. It
can be used for treatment of submucosal disease, but it is not Complications
effective for extrinsic disease.
• Fatal hemorrhage: Massive hemorrhage is reported in up to
7% patients.52 Risk is higher in upper lobe locations
Technique
because of the proximity to vessels, in squamous histology
Iridium-192 is the most commonly used isotope or radiation
and with high radiation dose.51,53
source.1,8,51 An afterloading technique is used. A blind-ended
• Radiation bronchitis and bronchial stenosis.
catheter (applicator) with a radiopaque “dummy” wire is
• Bronchospasm.
placed in the desired location, transnasally through a bron-
choscope using fluoroscopy. The bronchoscope is removed and Evidence
the catheter is secured to the nose of the patient. Computer- Since Yankauer first described the use of brachytherapy in
ized planning is done (►Fig. 9) and dose is prescribed at a 1922, it has been used extensively.54 It can provide symptom
distance of 5 to 10 mm from the catheter. The dummy wire is relief in patients with endobronchial tumors. It is very effec-
removed and 192Ir radiation source, attached to a steel cable, is tive for treatment of hemoptysis, but radiological or endo-
loaded in the applicator. It is moved in 5-mm increments or scopic improvement may not be as good.53 Its role may be
dwell positions along the planned pathway. Radiation dose at especially important in patients who have already received
the target volume depends on diameter and length of the definitive external-beam radiation and radiation toxicity
treatment field, which are determined by the dwell time and needs to be minimized.51 It can also be used in combination
dwell positions, respectively. High-dose rate of 12 Gy/hour or with external-beam radiation in previously radiation-naive
more is commonly used, and three fractions of 5 to 7.5 Gy are patients for better local control.55 Brachytherapy has been
administered, about 1 week apart. The treatment session can used for treatment of radiologically occult lung cancer in
be done as outpatient and takes a few minutes. patients who are not surgical candidates, in combination with
external-beam radiation.56 Another use is suppression of
Indications granulation tissue formation related to lung transplantation
• Malignant CAO airway complications or airway stents.57,58

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Indications
Photodynamic Therapy
• Malignant CAO
Principle
• Early-stage lung cancer
Photodynamic therapy (PDT) uses activation of a photosensi-
tizer by light of a specific wavelength to generate singlet Complications
oxygen (Type II photooxidation reaction) that causes cell
• Skin photosensitivity, which can last up to 8 weeks.61
death. There is direct cell damage by singlet oxygen, apoptosis
Patients are advised to avoid sun, and use sunscreen,
and indirect effect due to vascular stasis, inflammation, and
hats, and sun glasses for this duration.
immune repsonse.1,7
• Bleeding.61

Technique Evidence
Porphyrin-based photosensitizers are used for PDT, and First bronchoscopic PDT was performed by Hayata and
porfimer sodium (Photofrin) is currently the most widely colleagues62 in 1982. Since then, PDT has been well estab-
used agent.1,8,59,60 After intravenous injection at a dose of lished in the treatment of inoperable, early and advanced
2 mg/kg, Photofrin is metabolized by the body but selectively endobronchial lung cancer. Moghissi and colleagues re-
concentrated in malignant cells, skin, liver, and spleen, with ported their experience with PDT in 21 patients with ear-
the maximal concentration reaching in 24 to 48 hours. Light ly-stage central lung cancer who were ineligible for
of a specific wavelength that matches the absorption band of surgery.59 Fifteen patients were alive at 12 to 82 months.
the photosensitizer is required for activation of the drug. Endo et al reported their experience with radiologically
Currently, dye or diode laser at a wavelength of 630 nm in the occult bronchogenic squamous cell cancer in 48 patients
red range is used to activate Photofrin. This light is delivered older than 12 years.63 Complete response rate was 94%, with

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via a fiber placed through the working channel of a broncho- 5- and 10- year survival of 81 and 71%, respectively. Moghissi
scope, approximately 2 days after injection of the photosen- and colleagues also described a case series of 100 patients
sitizer. A light dose of 150 to 200 J/cm of tumor is typically with inoperable, advanced lung cancer and endobronchial
used in PDT, achieving tissue penetration of 5 to 10 mm disease.64 Endobronchial obstruction decreased from 85 to
(►Fig. 10). There are no thermal risks associated with PDT. 17%, with improvement in spirometry and median survival
The necrotic tissue is typically debrided 1 to 2 days after of 5 months. PDT has also been successfully used in conjunc-
the initial illumination. Reillumination can be performed tion with brachytherapy.65 The biggest drawback to PDT is
within 6 to 7 days as the drug stays at therapeutic level in the high cost of the drug when compared with other
the tumor.7 modalities.

Fig. 10 Photodynamic therapy. (A) Left lower lobe lesion. (B) Illumination using diode laser (630 nm), with a flexible fiber, 2 days after Photofrin
injection. (C) Lesion 4 months after photodynamic therapy.

Seminars in Respiratory and Critical Care Medicine Vol. 35 No. 6/2014

 Ablative Therapies for Central Airway Obstruction Mahmood, Wahidi 691

Conclusion fulguration and deep x-rays. Arch Otolaryngol 1932;

16:182–187
Immediate and delayed effect ablative therapies are available 17 Hooper RG, Spratling L, Beechler C, Schaffner S. Endobronchial
electrocautery. A role in bronchogenic carcinoma? Endoscopy
to treat patients with CAO. These therapies have unique
1984;16(2):67–70
principles of operation that govern their use for specific 18 Hooper RG, Jackson FN. Endobronchial electrocautery. Chest 1985;
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employed and multimodality approach should be used for 19 Boxem Tv, Muller M, Venmans B, Postmus P, Sutedja T. Nd-YAG
better clinical outcomes. laser vs bronchoscopic electrocautery for palliation of symptom-
atic airway obstruction: a cost-effectiveness study. Chest 1999;
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20 Sutedja G, van Kralingen K, Schramel FM, Postmus PE. Fibreoptic
Acknowledgment
bronchoscopic electrosurgery under local anaesthesia for rapid
The authors thank ERBE USA, Inc, Marietta, GA, for provid- palliation in patients with central airway malignancies: a prelimi-
ing some of the technical information. nary report. Thorax 1994;49(12):1243–1246
21 Wahidi MM, Unroe MA, Adlakha N, Beyea M, Shofer SL. The use of
electrocautery as the primary ablation modality for malignant and
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