Abstract Introduction Airway obstruction from tracheal tumors is a rare, life-threatening emergency, particularly in patients with advanced malignancy. Rapid diagnosis and coordinated multidisciplinary management are critical when conventional airway techniques are likely to fail. Case Description A 70-year-old man with chronic obstructive pulmonary disease (COPD), metastatic small-cell lung cancer on immunotherapy, and prior venous thromboembolism presented with acute dyspnea and oxygen saturation of 45%. In the emergency department, he was tachycardic and severely hypoxic despite a non-rebreather mask. Arterial blood gas showed mild hypercapnia. Initially treated for a presumed COPD exacerbation, he desaturated further to 70%. Computed tomography angiography ruled out pulmonary embolism but revealed a new near-total intraluminal tracheal mass at the mid-thoracic level, absent one month prior. Given imminent airway collapse and high likelihood of intubation failure, a multidisciplinary team (Pulmonary, ENT, Cardiothoracic Surgery, Critical Care) initiated venovenous extracorporeal membrane oxygenation (VV-ECMO) to stabilize oxygenation. Rigid bronchoscopy with tumor debulking was then performed successfully, and biopsy confirmed high-grade neuroendocrine carcinoma. Post-procedure, he developed stress-induced (Takotsubo) cardiomyopathy, managed with beta-blockers and supportive care. He was discharged on 2 L of supplemental oxygen with continuation of immunotherapy. Discussion This case highlights a rare cause of respiratory failure in a patient with COPD and advanced malignancy. Worsening hypoxia despite standard COPD therapy prompted reassessment, revealing near-total tracheal obstruction. VV-ECMO, rarely used in terminal malignancy due to perceived futility, proved lifesaving by enabling safe tumor resection. A comprehensive literature review (PubMed, Google Scholar, up to 2025) did not identify prior reports describing VV-ECMO as a bridge to tumor resection in malignant tracheal obstruction from metastatic small-cell lung cancer. Although ECMO use in advanced cancer raises ethical considerations, it was justified by the potential for reversible respiratory failure and continuation of oncologic therapy. This case underscores the importance of early recognition and multidisciplinary coordination in complex airway emergencies. Conclusion VV-ECMO can be lifesaving in near-total tracheal obstruction, even in advanced malignancy, when used as a bridge to definitive airway intervention. Impact Statement: This case redefines VV-ECMO’s potential role in advanced malignancy, demonstrating its ability to prevent death from malignant airway obstruction and highlighting the power of interdisciplinary teamwork. Learning Objectives: 1. Recognize clinical indicators of malignant airway obstruction in patients with worsening hypoxia despite standard therapy. 2. Understand indications for VV-ECMO as a bridge to airway intervention in high-risk cases. 3. Appreciate the importance of rapid multidisciplinary coordination in airway emergencies. This abstract is funded by: None
Bansal et al. (Fri,) studied this question.