From the Guidelines
No, a barium swallow is not the appropriate test to assess for tracheomalacia. Tracheomalacia is a condition characterized by weakness of the tracheal cartilage, causing the airway to collapse during breathing. The preferred diagnostic tests for tracheomalacia are dynamic airway imaging studies such as flexible bronchoscopy, dynamic CT scan, or cine MRI. Flexible bronchoscopy is considered the gold standard as it allows direct visualization of the airway collapse during respiration, as noted in a study comparing bronchography with dynamic spiral CT scan to diagnose tracheomalacia 1. A dynamic CT scan with inspiratory and expiratory phases can also demonstrate the excessive collapsibility of the trachea, with a study showing 96% sensitivity, 97% specificity, and 97% accuracy in diagnosing tracheomalacia using free-breathing cine CT 1.
Key Points to Consider
- Barium swallow studies are designed to evaluate the esophagus and swallowing function, not the airway structures.
- While barium swallow might incidentally show external compression of the esophagus by an abnormal trachea, it cannot directly visualize the tracheal lumen or assess its dynamic changes during breathing, which is essential for diagnosing tracheomalacia.
- If tracheomalacia is suspected based on symptoms like chronic cough, stridor, or recurrent respiratory infections, patients should be referred for appropriate airway imaging studies rather than a barium swallow.
- Recent guidelines, such as the ACR Appropriateness Criteria for tracheobronchial disease, support the use of dynamic expiratory CT in evaluating tracheomalacia, highlighting its potential to change treatment approaches 1.
Diagnostic Approach
Given the limitations of barium swallow in assessing tracheomalacia, the focus should be on utilizing the most appropriate diagnostic tools that can accurately visualize the tracheal lumen and its dynamic changes. This approach not only aids in the accurate diagnosis of tracheomalacia but also in planning the most effective treatment strategy, potentially including surgical interventions like tracheobronchoplasty, as supported by studies demonstrating significant decreases in tracheal collapse after such procedures 1.
From the Research
Assessment of Tracheomalacia using Barium Swallow
- The barium swallow is a diagnostic test used to evaluate the pharynx and esophagus, particularly for patients with dysphagia or other pharyngeal or esophageal symptoms 2.
- However, there is no direct evidence to suggest that a barium swallow can be used to assess for tracheomalacia, as it is primarily used to evaluate the esophagus and pharynx.
- Tracheomalacia is a rare tracheal problem that leads to collapse of the airway and expiratory flow obstruction, and expiratory CT scans are considered the diagnostic test of choice in adults 3.
- Other imaging modalities, such as multidetector CT (MDCT), can also be used to evaluate tracheobronchomalacia, with paired end-inspiratory, dynamic expiratory MDCT being the examination of choice for assessing patients with suspected tracheobronchomalacia 4.
- While barium swallow tests are important for diagnosing certain esophageal conditions, such as achalasia, they are not typically used to diagnose tracheomalacia 5.