What is the treatment for expiratory airway collapse disease?

Treatment of Expiratory Airway Collapse Disease

The treatment of expiratory airway collapse disease should follow a stepwise approach, beginning with conservative measures and advancing to more invasive interventions for severe cases that significantly impact quality of life.

Initial Assessment and Classification

• Expiratory central airway collapse (ECAC) encompasses tracheobronchomalacia (TBM) and excessive dynamic airway collapse (EDAC), characterized by excessive narrowing of the airway lumen during exhalation 1, 2
• Diagnosis should be confirmed via dynamic flexible bronchoscopy (gold standard) and/or dynamic CT imaging 1
• Severity is typically classified based on the degree of airway collapse, with severe collapse defined as >90% reduction in airway lumen 3

First-Line Management

• Treatment of coexisting conditions is essential, including COPD, asthma, gastroesophageal reflux disease, and vocal cord dysfunction 4
• Supportive treatment includes:
  • Aggressive pulmonary hygiene and airway clearance techniques 5
  • Manually assisted cough techniques for patients with expiratory muscle weakness 5
  • Pulmonary rehabilitation 4
  • Antibiotics for respiratory infections 4

Airway Clearance Techniques

• Forced expiratory technique (huffing) is recommended for patients with COPD to enhance secretion clearance without excessive effort 5
• Manually assisted cough should be considered for patients with expiratory muscle weakness but avoided in patients with airflow obstruction from COPD as it may be detrimental 5
• Body positioning and mobilization can enhance airway secretion clearance 5

Positive Pressure Ventilation

• Continuous positive airway pressure (CPAP) is recommended as a non-invasive approach to maintain airway patency during exhalation 4, 6
• For patients with severe symptoms, noninvasive positive pressure ventilation (NIPPV) may be beneficial, though some patients may not tolerate it 6

Pharmacological Management

• Bronchodilators may have variable effects depending on the specific mechanism of airway collapse:
  • In collapsible trachea, bronchoconstrictor agents may increase airway smooth muscle tone and improve airway stiffness 5
  • In dynamic airway collapse due to small airway obstruction, bronchodilators may relieve obstruction and decrease expiratory pressure effort 5
  • Caution is advised as bronchodilators may worsen dynamic airway collapse in some cases of fixed small airway obstruction 5
• Long-acting bronchodilators (LABA, LAMA) should be considered for patients with concurrent COPD 5, 7

Advanced Interventions for Severe Cases

For patients with severe central airway collapse (>90%) and severe symptoms that significantly impact quality of life, corrective treatments should be considered:

1. Temporary stent trial:

   • Patients should undergo a trial of tracheal "Y" stent placement to assess symptom improvement 3, 1
   • If symptoms improve (positive trial), patients who are good surgical candidates should be considered for tracheobronchoplasty 3

2. Tracheobronchoplasty (TBP):

   • Surgical stabilization of the central airways is recommended for appropriate surgical candidates with a positive stent trial 3, 4
   • While effective, perioperative complications remain a serious concern, and long-term efficacy observation is required 1

3. Permanent stenting:

   • For patients who are poor surgical candidates due to comorbidities but have a positive stent trial, permanent stenting can be offered for symptom palliation 3, 4
   • Long-term stent implantation should be considered after a thorough risk-to-benefit assessment 1

Special Considerations

• Management should be coordinated by a multidisciplinary airway team in specialized centers with experience in treating this condition 4
• Patients with respiratory failure due to ECAC may require mechanical ventilation and should be evaluated for possible stent placement to facilitate weaning 6
• Anesthetic management for patients undergoing stent placement or tracheobronchoplasty is complex and requires special considerations 3, 2

Treatment Algorithm

1. Confirm diagnosis with dynamic bronchoscopy or CT imaging
2. Treat coexisting conditions and implement supportive care
3. Trial appropriate airway clearance techniques and CPAP
4. For severe symptoms despite conservative management, consider stent trial
5. Based on stent trial results and surgical candidacy:
   • Positive trial + good surgical candidate → Tracheobronchoplasty
   • Positive trial + poor surgical candidate → Permanent stenting
   • Negative trial → Continue conservative management