What is known

• Although there is not high level evidence to support these treatments, treatment guidelines recommend that for central airway obstruction causing dyspnoea, either endobronchial treatments (laser, brachytherapy, electrocautery, cryosurgery, stenting) or external beam radiotherapy may provide effective palliation. [1-2]  A systematic review comparing external beam radiotherapy plus brachytherapy for obstruction with external beam radiotherapy alone showed no strong evidence to support adding brachytherapy to external beam radiotherapy, however. External beam radiotherapy alone seemed to be more effective than brachytherapy. [3]
• There is evidence that both endovascular stenting and radiotherapy are effective in malignant superior vena cava obstruction. [[1-2]
• Steroids are frequently recommended for palliation in superior vena cava obstruction, but this practice has not been studied.

Implications for practice 

• Chemotherapy should be considered, where clinically appropriate, as the first line treatment for chemosensitive tumours causing obstruction. [4]
• Based on a recent systematic review, patients with non-small cell lung cancer who have recurrent obstruction after being treated with external beam radiotherapy, could be considered for treatment with brachytherapy. [3]
• Referral for stenting or radiotherapy for superior vena cava obstruction, or radiotherapy, stenting or endobronchial treatment for central airway obstruction should be offered if clinically appropriate.
• Dyspnoea associated with obstruction can be severe and distressing. If active interventions are either inappropriate or impossible, palliation should focus on pharmacologically minimising distress for the patient (and for their family and caregivers) by promptly treating with opioids, and / or anxiolytics and sedatives [5-6].

Finding out more
Link to prescribing information

• Online Palliative Medicine Handbook 
  Click on “Notes on Prescribing”
  This prescribing information is from the UK and some medications may not be available in Australia
• Therapeutic Guidelines for Palliative Care
  An Australian source of prescribing information not available directly online through CareSearch, but can be accessed online in most hospitals, or purchased.

Free full text overview article

• Bolliger CT, Sutedja TG, Strausz J, Freitag L. Therapeutic bronchoscopy with immediate effect: laser, electrocautery, argon plasma coagulation and stents European Respiratory Journal. 2006 Jun;27(6):1258-71 

Related CareSearch pages 
End of life care
Dyspnoea
Haemoptysis

References 

1. Kvale PA, Simoff M, Prakash UB; American College of Chest Physicians. Lung cancer. Palliative care.  Chest. 2003 Jan;123(1 suppl):284S-311S.  
2. Scottish Intercollegiate Guidelines Network (SIGN).  Management of patients with lung cancer. A national clinical guideline.  2005 Feb;SIGN publication no. 80. 
3. Cardona AF, Reveiz L, Ospina EG, Ospina V, Yepes A.Palliative endobronchial brachytherapy for non-small cell lung cancer. Cochrane Database Syst Rev. 2008 Apr 16;(2):CD004284
4. Ripamonti C. Management of dyspnea in advanced cancer patients. Supportive Care in Cancer. 1999 Jul;7(4):233-43.   
5. Salacz ME, Weissman DE.  Controlled sedation for refractory suffering: part 1. Journal of Palliative Medicine 2005 Feb;8(1):136-7. 
6. Cherny, N. and L. Radbruch, European Association for Palliative Care (EAPC) recommended framework for the use of sedation in palliative care Palliative Medicine, 2009. 23(7): p. 581-593.

 This page was created on 29 April 2008 and was reviewed in April 2010
Last updated 4 May 2010