From the Guidelines
Tracheomalacia management should prioritize a multidisciplinary approach, considering the severity of the condition, with options ranging from watchful waiting for mild cases to surgical interventions like aortopexy or tracheobronchoplasty for severe cases, as suggested by the most recent guidelines 1.
Management Options
The management of tracheomalacia can be broadly categorized into conservative and surgical approaches. Conservative management is often appropriate for mild cases, where watchful waiting is recommended, as many children outgrow the condition by age 2-3 years. This approach includes:
- Treating underlying conditions such as GERD with medications like omeprazole (1-2 mg/kg/day) or lansoprazole
- Managing respiratory infections promptly with antibiotics when bacterial infection is suspected
- Chest physiotherapy and postural drainage to help clear secretions
For moderate cases, continuous positive airway pressure (CPAP) at 5-10 cmH2O may be used to stent the airway open.
Surgical Interventions
Severe or life-threatening tracheomalacia may require surgical intervention, including:
- Aortopexy (suturing the aorta to the sternum to pull the trachea forward)
- Tracheopexy (directly suspending the trachea)
- Placement of internal stents or external splints
- Tracheobronchoplasty, which may be considered after a stent trial for patients with severe tracheobronchomalacia refractory to noninvasive ventilation 1 Tracheostomy with mechanical ventilation may be necessary in the most severe cases to bypass the collapsible segment. The choice of management depends on the anatomical location of malacia, its severity, associated conditions, and the patient's overall health status.
Importance of Follow-Up
Regular follow-up with pulmonology and otolaryngology is essential to monitor progression and adjust treatment as needed. This multidisciplinary approach ensures that the management plan is tailored to the individual patient's needs, optimizing outcomes in terms of morbidity, mortality, and quality of life. According to recent clinical practice guidelines, for patients with nonmalignant central airway obstruction, including tracheomalacia, either open surgical resection or therapeutic bronchoscopy may be suggested 1.
From the Research
Management Options for Tracheomalacia
The management options for tracheomalacia (trachea malacia) include:
- Expectant management for mild cases 2
- Aortopexy to suspend the anterior wall of the trachea 2, 3
- Endoluminal or extraluminal stenting 2
- Long-term positive pressure ventilation 2
- Tracheostomy 2
- Tracheobronchoplasty, which involves plicating the posterior wall of the trachea to restore its normal shape 4
- Surgical external stabilization 3
- Tracheoplasty, which seems to be the best choice for selected cases of adult malacia 3
Evaluation and Diagnosis
Evaluation and diagnosis of tracheomalacia involve:
- Clinical history and physical examination 5
- Dynamic 3-phase bronchoscopy to diagnose location and severity 5
- MDCT and other studies as necessary to understand the problems 5
- Functional bronchoscopy, although not yet standardized 3
- Dynamic airway CT, a promising tool for noninvasive diagnosis 3
Treatment Approach
The treatment approach for tracheomalacia should be patient-based, with a thorough approach to the underlying pathology, clinical concerns, and combined abnormalities 5. Patients should undergo maximum medical therapy prior to committing to other interventions 5. Surgical intervention should consider all other associated conditions, including vascular anomalies, chest wall deformities, mediastinal lesions, or other airway pathologies 5.