From the Guidelines
Tracheomalacia is a condition that requires immediate attention to prevent morbidity and mortality, and its management should be based on the most recent and highest quality evidence, which recommends a multidisciplinary approach for optimal outcomes. The causes of tracheomalacia include congenital factors, acquired factors, and secondary factors associated with conditions like COPD or relapsing polychondritis 1. Management depends on severity and underlying cause, with mild cases requiring observation and treatment of underlying conditions, and moderate to severe cases necessitating surgical interventions such as aortopexy, tracheal stenting, or tracheoplasty 1.
Key Considerations
- Medical management includes chest physiotherapy, prompt treatment of respiratory infections with appropriate antibiotics, and continuous positive airway pressure (CPAP) at 5-10 cmH2O to maintain airway patency 1.
- In children, many cases improve with growth as the airway strengthens naturally, but a multidisciplinary approach involving pulmonologists, otolaryngologists, and thoracic surgeons is essential for optimal outcomes 1.
- The use of advanced imaging techniques such as respiratory-gated MRI and ultrashort echo-time MRI has emerged as a diagnostic tool for tracheomalacia, with moderate correlation with bronchoscopy 1.
Management Approach
- A multidisciplinary approach is crucial for the management of tracheomalacia, involving pulmonologists, otolaryngologists, and thoracic surgeons to individualize treatment based on the patient's specific symptoms, severity, and underlying cause.
- The management plan should prioritize the prevention of morbidity and mortality, and improvement of quality of life, with a focus on the most recent and highest quality evidence available 1.
- Surgical interventions should be considered for moderate to severe cases, with aortopexy, tracheal stenting, and tracheoplasty being potential options 1.
From the Research
Causes of Tracheomalacia
- Tracheomalacia can be congenital or acquired, with congenital tracheomalacia being the most common congenital tracheal abnormality, occurring in approximately 1:2,100 children 2
- It can be isolated or associated with other airway anomalies such as laryngomalacia, bronchomalacia, and large laryngeal clefts 2
- An abnormal division of the embryonic foregut is frequently associated with congenital tracheomalacia, often in the form of proximal esophageal atresia with distal tracheoesophageal fistula 2
- Tracheomalacia can also be associated with esophageal atresia without a tracheoesophageal fistula, although this is rare 3
Management of Tracheomalacia
- Tracheomalacia is often self-limited and will resolve or become asymptomatic by the second year of life without intervention 2
- For patients who remain symptomatic, possible treatments include pharmacotherapy, positive pressure application, and surgery 2
- Aortopexy is a surgical treatment option that has been shown to provide long-term relief of severe symptoms of tracheomalacia associated with esophageal atresia and tracheoesophageal fistula 4
- Posterior tracheopexy is another surgical treatment option that has been shown to be effective in treating severe tracheomalacia, with significant improvements in clinical symptoms and degree of airway collapse on bronchoscopy 5
- The timing of surgical treatment, whether primary or secondary, does not appear to affect outcomes, and posterior tracheopexy should be selectively considered at the time of initial esophageal atresia repair 5