What are the treatment options for a trachea deformity with symptoms like difficulty breathing, wheezing, or coughing?

Treatment Options for Tracheal Deformity

For patients with symptomatic tracheal deformities causing breathing difficulties, wheezing, or coughing, treatment should be tailored to the specific type of deformity, with surgical intervention being the definitive treatment for severe cases that don't respond to conservative management. 1

Types of Tracheal Deformities and Their Presentations

Tracheomalacia/Bronchomalacia

• Characterized by flaccidity of airways due to structural weakness of airway walls, with significant narrowing of the coronal diameter during forced expiration or cough 1
• Common symptoms include chronic cough, expiratory wheeze, dyspnea, and decreased quality of life 1
• May be present in up to 10% of symptomatic patients undergoing bronchoscopy 1
• Often misdiagnosed as asthma due to similar symptoms 1, 2

Tracheal Stenosis

• Can be caused by various neoplastic and nonneoplastic etiologies 1
• Presents with cough, dyspnea, stridor, or wheezing 1
• May be idiopathic or result from trauma, intubation, infections, or other conditions 1

Other Deformities

• Tracheobronchopathia osteochondroplastica: characterized by multiple cartilaginous or bony submucosal nodules protruding into the airway lumen 1
• Tracheal deviation: can cause difficult airway management and ventilation issues 3

Diagnostic Approach

Initial Imaging

• CT chest with IV contrast is the first-line imaging evaluation for suspected tracheal deformities 1
  • Provides assessment of location, shape, dimensions, and extent of deformity
  • Allows evaluation of enhancement characteristics and hilar/mediastinal adenopathy
  • Shows high correlation with bronchoscopic findings

Dynamic Imaging

• Modern multidetector CT during end expiration or forced expiration can detect dynamic airway collapse 1
• Low-dose volumetric CT (40-80 mA) is comparable to standard higher-dose techniques in demonstrating tracheal collapse 1

Bronchoscopy

• Essential for direct visualization of the airway and assessment of dynamic changes 1
• In tracheobronchomalacia, coronal narrowing with coughing is >50%, compared to <40% in healthy individuals 1
• Allows examination of the laryngeal structure and function during inspiration and expiration 1

Treatment Options

Conservative Management

• All patients with mild to severe tracheobronchomalacia benefit from medical management to optimize airway clearance of mucus 4
• Milder cases may become asymptomatic with conservative therapy, allowing time for growth and airway enlargement 4

Interventional Options

1. Tracheobronchial stenting

   • Used for symptomatic expiratory central airway collapse (ECAC) 1
   • Can provide immediate relief of symptoms 1
   • Often used as a trial before definitive surgical treatment 1

2. Surgical interventions

   • Tracheoplasty or tracheobronchoplasty: Considered the definitive treatment for symptomatic ECAC after a successful stent trial 1
   • Surgical resection: For localized segments of stenosis or malacia 1
   • Tracheopexy: Anterior cervical approach is simpler than lateral thoracic approach 5
   • Tracheal transplantation: Considered for extensive circumferential defects >6cm that cannot be addressed with end-to-end reconstruction 6

3. Continuous positive-pressure breathing

   • Can provide symptomatic relief in some cases of tracheomalacia 1

Special Considerations

Pediatric Patients

• Flexible endoscopy is indicated in children with persistent stridor, unexplained wheezing, or chronic cough 1
• Laryngomalacia is the most common congenital laryngeal anomaly causing persistent stridor in children 1

Patients with COPD

• TBM/EDAC (excessive dynamic airway collapse) is common in patients with obstructive airway disorders (found in 40% of patients with persistent expiratory wheezing) 2
• Should be evaluated in patients with persistent expiratory wheezing despite medical management 2

Common Pitfalls

• Misdiagnosing tracheal deformities as asthma when wheezing is present 7
• Failure to perform complete airway evaluation when upper airway symptoms are present 1
• Not considering tracheal deformities in patients with persistent symptoms despite appropriate treatment for other respiratory conditions 7