What is the treatment approach for EDAC (Excessive Dynamic Airway Collapse) and bronchomalacia?

From the Guidelines

The treatment approach for Excessive Dynamic Airway Collapse (EDAC) and bronchomalacia should prioritize noninvasive ventilation as a primary intervention, with consideration of stent placement and tracheobronchoplasty in severe cases refractory to initial management, as suggested by the most recent guideline evidence 1. The management of EDAC and bronchomalacia involves a multifaceted approach, focusing on symptom relief and addressing underlying conditions. Key considerations include:

• Smoking cessation and pulmonary rehabilitation to improve overall lung function
• Treatment of comorbidities such as COPD, asthma, or GERD to reduce airway irritation and inflammation
• Medical therapy with bronchodilators, such as long-acting beta-agonists and anticholinergics, to reduce airway resistance and improve expiratory flow
• Use of continuous positive airway pressure (CPAP) to provide airway stenting during expiration and prevent collapse For patients with severe tracheobronchomalacia unresponsive to noninvasive ventilation, a stent trial followed by tracheobronchoplasty may be considered, as indicated by recent clinical practice guidelines 1. However, the utility of these interventions should be weighed against potential risks and benefits, and individualized based on symptom severity, anatomical involvement, and underlying conditions.

In terms of specific treatment options, the American College of Chest Physicians clinical practice guideline suggests either open surgical resection or therapeutic bronchoscopy for patients with nonmalignant central airway obstruction, which can include EDAC and bronchomalacia 1. The guideline also notes that evidence suggests the utility of noninvasive ventilation as a primary intervention, and that further studies are needed to fully understand the role of stent placement and tracheobronchoplasty in the management of these conditions.

While older studies, such as those from 2006, may suggest other treatment options, such as surgical resection of the affected airway segment or insertion of an airway prosthesis (stent) 1, the most recent and highest quality evidence should be prioritized in guiding clinical decision-making. Therefore, noninvasive ventilation should be considered as the primary intervention for EDAC and bronchomalacia, with other treatment options reserved for severe cases or those refractory to initial management, as supported by the most recent clinical practice guideline evidence 1.

From the Research

Causes of EDAC and Bronchomalacia

• EDAC (Excessive Dynamic Airway Collapse) is marked by excessive bulging of the posterior membrane into the airway lumen during exhalation 2
• Bronchomalacia is characterized by a weakness of the cartilaginous structures in the bronchi 3
• Tracheobronchomalacia (TBM) is characterized by a weakness of the tracheobronchial cartilaginous structures 2
• The malacia or weakness of cartilage that supports the tracheobronchial tree may occur only in the trachea, in both the trachea and bronchi, or only in the bronchi 3

Treatment Approach for EDAC and Bronchomalacia

• Current therapeutic management depends on the extent, type, and severity of airway abnormalities noted and the clinical presentation 2
• Proposed management alternatives include:
  • Conservative medical therapy
  • Minimally invasive and open surgical interventions
  • Inhaled bronchodilators (only if symptoms and ventilatory function improve after use)
  • Continuous positive airway pressure (as a pneumatic stent)
  • Endoluminal stent insertion (to improve symptoms and pulmonary function in patients with central airway obstruction)
• Surgical procedures have also been performed, including tracheostomy, airway splinting, tracheal resection, and external tracheal stents 2
• Experimental treatments include endobronchial laser therapy, resorbable stents, application of grafting materials, and cartilage regeneration techniques 2
• A novel approach to surgical treatment of tracheobronchomalacia has been described, which includes standardizing the approach to these complex patients and developing a prospective grading scale 4
• Treatment modification, such as using N-acetylcysteine and adjustable positive expiratory pressure valves, can lead to improvement in patients' quality of life 5
• Airway stenting and tracheobronchoplasty can improve respiratory symptoms in patients with Mounier-Kuhn syndrome, a condition characterized by tracheobronchomegaly and concomitant tracheobronchomalacia 6