Treatment of Tracheomalacia
Most cases of tracheomalacia are managed conservatively with observation alone, as the vast majority of patients improve spontaneously with age and growth, but severe cases with life-threatening airway obstruction, respiratory failure, recurrent pneumonias, or failure to thrive require intervention with positive airway pressure, surgical correction (primarily aortopexy), or tracheostomy. 1, 2
Conservative Management for Mild-to-Moderate Disease
Observation is the primary approach for most patients, as clinically significant tracheomalacia naturally decreases with age and growth, with prevalence declining from 37-89% in infants to only 10-13% in adolescents and adults. 1, 2 The condition typically resolves spontaneously within the first few years of life in most cases. 3, 4
- Efficient and regular chest physiotherapy is the mainstay of conservative treatment for mild and moderate cases. 5
- Patients should be monitored for persistent symptoms including cough, choking, wheezing, shortness of breath, and recurrent respiratory infections. 1, 2
Critical Pitfall: Bronchodilator Use
Avoid beta-agonists and bronchodilators in patients with tracheomalacia, as these medications can paradoxically worsen airway dynamics by relaxing central airway smooth muscle and exacerbating dynamic airway collapse. 2, 6 This is particularly important when tracheomalacia is misdiagnosed as asthma—a common clinical error. 1
- Pulmonary function testing before and after bronchodilator administration can help determine whether these medications will improve or worsen airflow obstruction. 2
Interventions for Severe Disease
Positive Airway Pressure (First-Line Intervention)
CPAP or positive airway pressure immediately decreases respiratory distress, restores airway patency, and improves pulmonary function in patients with severe symptoms. 1, 2 This is supported by multiple case series demonstrating consistent benefit. 1
Surgical Options
Aortopexy is the most common surgical intervention, suspending the anterior wall of the trachea and achieving virtually 100% success in correcting isolated tracheomalacia. 1, 2 However, effectiveness drops dramatically to only 25% in patients with tracheobronchomalacia or bronchomalacia. 1, 2
- Surgery is indicated for life-threatening airway obstruction, respiratory failure, recurrent pneumonias, or failure to thrive that does not respond to conservative measures. 1, 2
- Surgical complications occur in approximately 10% of cases, with mortality less than 5%. 2
Tracheobronchoplasty is considered definitive treatment for symptomatic expiratory central airway collapse after a successful stent trial. 2
Airway stenting may be used for symptomatic cases, often as a trial before definitive surgical treatment, though complications including granulation tissue formation, migration, or erosion occur in approximately 50% of cases. 2
Tracheostomy is probably essential in most instances of severe primary tracheomalacia and may be necessary when other interventions fail. 2, 4
Diagnostic Confirmation
Flexible bronchoscopy during spontaneous breathing is essential for definitive diagnosis, as tracheomalacia can be significantly underestimated by static assessment in deeply anesthetized patients. 1, 2 Bronchoscopy should be employed early in the diagnostic process when symptoms suggest tracheomalacia. 4
- CT scanning with dynamic imaging during end-expiration or forced expiration can detect dynamic airway collapse and is recommended as first-line imaging. 2
- Bronchoscopy enables assessment of the whole airway and is critical for evaluating severity. 1
Special Clinical Scenarios
In patients with esophageal atresia-tracheoesophageal fistula (EA-TEF), tracheomalacia is the most frequently identified airway pathology, occurring in 37-89% of patients. 1 These patients require systematic evaluation for aspiration, recurrent TEF, and GERD when respiratory symptoms worsen, rather than assuming the cause is asthma. 1
Symptoms are not present at birth but appear insidiously after the first weeks of life, are markedly aggravated by respiratory tract infections, and are made worse by agitation. 4