How are tracheomalacia symptoms managed?

Management of Tracheomalacia Symptoms

Most patients with tracheomalacia improve with time alone and conservative management, with approximately 90% showing improvement without invasive interventions. 1

Assessment and Diagnosis

• Tracheomalacia presents with symptoms including cough, expiratory wheeze, dyspnea, stridor, recurrent respiratory infections, and in severe cases, life-threatening airway obstruction 1
• Diagnosis is confirmed through flexible bronchoscopy, which allows direct visualization of excessive airway collapse during expiration 1, 2
• CT imaging during end-expiration or forced expiration can detect dynamic airway collapse and is recommended as first-line imaging 2

Management Approach Based on Severity

Mild to Moderate Tracheomalacia

• Observation alone is appropriate for most cases with mild symptoms, as the vast majority improve over time with conservative therapy 1, 3
• Specific management includes:
  • Treating respiratory infections promptly with antibiotics when indicated 4
  • Chest physiotherapy to improve airway clearance 5, 4
  • Avoiding medications that may worsen symptoms:
    • Beta-agonists may adversely affect airway dynamics in children with airway malacia 1
    • Bronchodilators can worsen dynamic airway collapse in some cases by relaxing central airway smooth muscle 1

Severe Tracheomalacia

For patients with severe symptoms (life-threatening airway obstruction, respiratory failure, recurrent pneumonias, or failure to thrive), more aggressive interventions may be required:

1. Positive airway pressure therapy:

   • CPAP immediately decreases respiratory distress and improves airway patency 1
   • Can be used as a temporary measure in symptomatic cases 4

2. Surgical interventions:

   • Aortopexy: Suspends the anterior wall of the trachea, particularly effective for tracheomalacia (100% success) but less effective for tracheobronchomalacia (25% success) 1, 3
   • Posterior tracheopexy: Addresses posterior membranous tracheal intrusion and has shown significant improvements in clinical symptoms and degree of airway collapse 6
   • Tracheobronchoplasty: Considered definitive treatment for symptomatic expiratory central airway collapse after a successful stent trial 2

3. Tracheostomy:

   • May be necessary when other interventions fail 1
   • Can be used alone or with continuous positive airway pressure 1
   • Elongated tracheostomy tubes can stent the distal trachea 1

4. Airway stenting:

   • Used for symptomatic cases, often as a trial before definitive surgical treatment 2
   • Complications including granulation tissue formation, migration, or erosion occur in approximately 50% of cases and can be associated with mortality 1

Special Considerations

• In patients with concomitant asthma, management is complicated as beta-agonists may worsen airway dynamics in those with malacia 1
• For patients with fixed small airway obstruction, bronchodilators may exacerbate dynamic airway collapse 1
• Pulmonary function testing before and after bronchodilator administration can help determine whether these medications will improve or worsen airflow obstruction 1

Prognosis

• Clinically significant tracheomalacia naturally decreases with age and growth 1
• The estimated prevalence in adolescents and adults is 10-13%, with symptoms including cough, choking, wheezing, shortness of breath, and recurrent infections 1
• Surgical complications occur in approximately 10% of cases, with mortality less than 5% 1