From the Guidelines
Diagnosing and treating tracheomalacia involves a systematic approach beginning with clinical evaluation followed by specialized testing, with bronchoscopy being the gold standard diagnostic tool, and treatment options varying based on severity and underlying cause, including conservative management, CPAP, and surgical interventions like aortopexy, tracheal stenting, or tracheoplasty, as recommended by recent guidelines 1. The diagnosis of tracheomalacia typically starts with a thorough history and physical examination, looking for characteristic symptoms like expiratory stridor, barking cough, and recurrent respiratory infections.
- Additional imaging studies include dynamic CT scans, which can show tracheal narrowing during expiration, and pulmonary function tests that may reveal flow-volume loops with flattened expiratory limbs.
- Treatment options vary based on severity and underlying cause, with mild cases managed conservatively, including chest physiotherapy, prompt treatment of respiratory infections with appropriate antibiotics, and avoiding triggers that worsen symptoms.
- Continuous positive airway pressure (CPAP) at 5-10 cmH2O can provide pneumatic stenting of the airway in moderate cases, as supported by studies 1.
- For severe or refractory tracheomalacia, surgical interventions may be necessary, including aortopexy, tracheal stenting with silicone or metal stents, or tracheoplasty to reinforce the tracheal wall, with recent guidelines suggesting the use of these interventions based on individual patient needs and response to treatment 1. The treatment approach should be individualized based on the patient's age, severity of symptoms, and whether the tracheomalacia is primary or secondary to conditions like vascular compression, which may require specific surgical correction of the underlying cause, as highlighted in recent studies 1.
From the Research
Diagnostic Steps for Tracheomalacia
- Clinical history and physical examination are used to diagnose tracheomalacia 2
- Pulmonary function testing, computed tomography, dynamic magnetic resonance imaging, and fiberoptic bronchoscopy are also used for diagnosis 2
- Dynamic airway CT is a promising tool for noninvasive diagnosis 3
- Functional bronchoscopy is still not standardized, but can be used for diagnosis 3
- Expiratory CT scans are the diagnostic test of choice in adults 4
- Dynamic flexible bronchoscopy and/or dynamic computed tomography scan, along with clinical symptoms, are used to diagnose excessive central airway collapse (ECAC) 5
Treatment Options for Tracheomalacia
- Tracheomalacia is often self-limited and will resolve or become asymptomatic by the second year of life without intervention 2
- Possible treatments for symptomatic patients include pharmacotherapy, positive pressure application, and surgery 2
- Bronchoscopy and stent insertion can lead to significant improvement, but with a high complication rate 3
- Surgical options include lateropexia, tracheal resection, and surgical external stabilization 3
- Tracheoplasty seems to be the best choice for selected cases of adult malacia 3
- Aortopexy is the most commonly performed surgery in children 3
- Tracheobronchoplasty is performed to re-shape the trachea and restore the normal D shape, and patients report generally good results with improvement of their symptoms 6
- Plication of the membranous wall to polypropylene mesh to recreate the normal airway shape (membranous wall tracheoplasty) is an effective treatment in adults 4
- Initial treatment of symptomatic ECAC includes treatment of coexisting conditions and supportive treatment of dynamic central airway collapse 5
- A short-term stent trial in selected patients with severe symptomatic ECAC is needed to assess whether patients will have improvement in symptoms and thus identify patients who will benefit from surgical central airway stabilization 5