Treatment of Tracheomalacia
The treatment of tracheomalacia should begin with conservative management and observation, as 90% of cases resolve spontaneously with age and growth, reserving surgical intervention for severe, life-threatening cases that fail medical management. 1
Initial Conservative Management
Observation is the first-line approach for most patients with tracheomalacia. 1 The natural history favors spontaneous resolution, with clinically significant tracheomalacia naturally decreasing as the airway enlarges with growth. 2 The estimated prevalence drops to only 10-13% in adolescents and adults. 2
Medical Therapies to AVOID
Critical pitfall: Do NOT use beta-agonist bronchodilators in tracheomalacia patients. 2, 1 The American College of Chest Physicians specifically warns that beta-agonists adversely affect airway dynamics by relaxing central airway smooth muscle, which paradoxically worsens dynamic airway collapse. 2 This is particularly problematic in patients with concomitant asthma, where standard asthma therapy may actually exacerbate symptoms. 2
Supportive Care Measures
- Aggressive pulmonary hygiene and physiotherapy are the mainstays of conservative treatment, helping clear secretions and prevent recurrent respiratory infections. 3
- Nutritional support is essential for patients with failure to thrive, requiring assessment and potentially swallow evaluation. 1
- Treatment of concurrent conditions including GERD, aspiration, and recurrent infections should be addressed systematically. 4
Escalation to Positive Pressure Support
When conservative management fails to control respiratory distress, CPAP should be the next step. 2, 1 CPAP immediately decreases respiratory distress and improves airway patency by providing a pneumatic stent. 2, 1 Inability to wean from positive pressure support becomes an indication for surgical consultation. 1
Surgical Intervention Criteria
Surgery should be considered when patients develop:
- Life-threatening airway obstruction or respiratory failure 1, 5
- Recurrent pneumonias despite optimal medical management 1
- Progressive or severe failure to thrive despite nutritional intervention 1
- Inability to wean from positive pressure ventilation 1
Surgical Options by Severity
Aortopexy is the primary surgical intervention, suspending the anterior tracheal wall and achieving 100% success for isolated tracheomalacia (though only 25% success for tracheobronchomalacia). 2, 5 This procedure is particularly effective for tracheomalacia associated with esophageal atresia-tracheoesophageal fistula. 3
Airway stenting can be used as a trial before definitive surgery, though complications including granulation tissue, migration, or erosion occur in approximately 50% of cases. 2
Tracheobronchoplasty is considered definitive treatment for symptomatic expiratory central airway collapse after a successful stent trial. 2
Tracheostomy may be necessary when other interventions fail, particularly in severe primary tracheomalacia where resolution may not occur until after 2 years of age. 2, 6
Diagnostic Confirmation Before Surgery
Flexible bronchoscopy during spontaneous breathing is essential to confirm diagnosis and assess severity before surgical intervention. 4 Static assessment under deep anesthesia can underestimate the degree of collapse. 4 CT imaging during end-expiration or forced expiration serves as first-line imaging to detect dynamic airway collapse. 2
Prognosis and Long-term Outcomes
Surgical complications occur in approximately 10% of cases with mortality less than 5%. 2 However, severe tracheomalacia should not be underestimated—it carries significant morbidity and mortality when left untreated. 5 Most patients who survive the severe phase will experience symptom resolution with growth, though persistent symptoms including cough, choking, wheezing, and recurrent infections may continue in 10-13% of adolescents and adults. 2