The forgotten airway: central airway pathology in the ICU

Central airway diseases, though infrequent, represent a critical yet underrecognized cause of respiratory failure in the intensive care unit (ICU). These disorders encompass a wide range of pathologies-including central airway obstruction (CAO), tracheal stenosis, tracheomalacia, tracheomegaly, tracheoesophageal fistulas, and post-intubation lacerations-which can significantly complicate ventilation, extubation, and weaning. This narrative review explores the complex anatomical and physiological properties of the trachea and main bronchi, highlighting the profound impact of their even partial occlusion on airway resistance and work of breathing. We present the pathophysiological bases, diagnostic strategies, and up-to-date management options for both benign and malignant CAO, with particular attention to the ICU setting where urgent interventions are often required. The review also addresses iatrogenic airway injuries related to mechanical ventilation and airway equipment, analyzing both conservative and interventional therapeutic approaches, including endoscopic techniques and airway stenting. Special focus is given to the implications of central airway pathology in weaning failure, emphasizing the importance of early recognition to avoid unnecessary reintubations. Overall, this work aims to raise awareness among intensivists and pulmonologists of the pivotal role that central airway diseases may play in respiratory deterioration, and to advocate for a structured, multidisciplinary approach to their prompt diagnosis and treatment.