The American College of Chest Physicians (CHEST) has published a new clinical guideline offering evidence-based recommendations for the management of central airway obstruction (CAO). The guideline, developed by an expert panel using the GRADE (grading of recommendations, assessment, development, and evaluations) approach, aims to assist clinicians in providing optimal care for patients with this life-threatening condition.

CAO, which refers to obstruction of the trachea and mainstem bronchi, can be caused by various malignant and nonmalignant conditions. The guideline addresses both types of CAO and provides recommendations for diagnostic evaluation, therapeutic interventions, and follow-up care.

Key recommendations from the new clinical guideline, published in the journal CHEST, include:

1. In patients with suspected CAO, chest/neck computed tomography with intravenous contrast should be used as the initial imaging modality to characterize the location, severity, and etiology of the obstruction (strong recommendation, low-quality evidence).
2. Patients with symptomatic CAO should undergo therapeutic intervention regardless of the underlying etiology (strong recommendation, low-quality evidence).
3. Rigid bronchoscopy should be considered the first-line tool for the majority of therapeutic interventions in patients with CAO (strong recommendation, very low–quality evidence).
4. Therapeutic modalities for CAO include mechanical debulking, thermal ablation, stent placement, and balloon dilation. The choice of modality should be based on the etiology, location, and severity of the obstruction, as well as patient factors and available resources (strong recommendation, very low–quality evidence).
5. Patients with malignant CAO should be evaluated by a multidisciplinary team to determine the optimal treatment approach, which may include external-beam radiation therapy, endobronchial brachytherapy, or systemic therapy in addition to interventional bronchoscopy (strong recommendation, very low–quality evidence).

The guideline also highlights the importance of patient education and shared decision-making in the management of CAO. Patients should be informed of the risks and benefits of various treatment options and be actively involved in the decision-making process along with their health-care provider.

Although the quality of evidence supporting the recommendations is generally low or very low, the guideline panel believes that the benefits of the recommended interventions outweigh the risks in most cases. The panel also acknowledged the need for further research to improve the evidence base and optimize the care of patients with CAO.