Synopsis
Recognise dynamic and fixed central-airway obstruction behind unexplained stridor, cough or refractory wheeze, secure the airway safely when unstable, and use dynamic imaging and bronchoscopy to select cause-directed specialist treatment.
- Large-airway obstruction may be fixed, variable or dynamic and can masquerade as asthma or COPD when the main sound is labelled simply as wheeze.
- Tracheobronchomalacia describes weakness of cartilaginous airway support, whereas excessive dynamic airway collapse is exaggerated inward movement of the posterior membranous wall; both can produce symptomatic expiratory narrowing.
- A barking cough, monophonic central wheeze, positional breathlessness, secretion retention, recurrent infection or symptoms triggered by forced expiration should prompt a central-airway assessment.
Key red flags
Increasing stridor, suprasternal recession, inability to lie flat, drooling, exhaustion, agitation or declining air entry signals diminishing reserve. Escalate before complete obstruction makes transfer or conventional intubation impossible.
Investigation priorities
Determine physiological danger and likely level before moving an unstable patient.
Management branches
Stridor, rapidly increasing work of breathing, hypoxaemia, exhaustion or imaging shows a critically narrow central airway.
- Keep the patient monitored in the position that best preserves breathing, call senior anaesthesia and airway specialists, and identify the level and likely mechanism from available information.
- Agree a primary and rescue airway plan before sedation or transfer, including rigid bronchoscopy, surgical airway or extracorporeal support availability where the anatomy makes conventional intubation unsafe.