Tracheomalacia: Definition and Clinical Overview
Tracheomalacia (note: the question appears to contain a typo - "mylagsia" likely meant "malacia") is a condition characterized by flaccidity and structural weakness of the tracheal walls due to loss of cartilaginous integrity, resulting in significant airway collapse (>50% coronal narrowing) during forced expiration or coughing. 1
Pathophysiology
- The fundamental problem is loss of structural support in the tracheal cartilage, causing the airway to become abnormally collapsible 1
- During normal breathing, healthy individuals show <40% coronal narrowing with coughing, but tracheomalacia patients demonstrate >50% collapse during the same maneuver 1
- The weakness affects the cartilaginous framework that normally maintains airway patency during dynamic breathing 1
Causes in Adults
Acquired tracheomalacia develops from multiple etiologies 1:
- Pressure necrosis from prolonged endotracheal intubation 1
- Thyroid lesions compressing the trachea 1
- Vascular anomalies 1
- Trauma to the airway 1
- Chronic or recurrent airway infections (bronchiectasis) 1
- Radiation therapy 1
- Relapsing polychondritis 1
- Collagen disorders including Ehlers-Danlos syndrome, cutis laxa, and Marfan syndrome 1
- Tracheobronchomegaly (Mounier-Kuhn syndrome) 1
Important caveat: The airway collapse seen in COPD patients does not represent true tracheomalacia 1
Clinical Presentation
The two hallmark symptoms present in almost all patients are 1:
- Chronic cough - persistent and often the primary complaint 1
- Expiratory wheeze - due to dynamic airway collapse during exhalation 1
Additional symptoms may include 1:
- Dyspnea on exertion
- Stridor in severe cases
Diagnostic Approach
Bronchoscopy is the gold standard for diagnosis in conscious patients, where direct visualization during coughing demonstrates the characteristic >50% coronal narrowing 1
Other diagnostic modalities 1, 2:
- Flow-volume curves are more helpful than standard imaging 1
- CT chest during forced expiration can detect dynamic airway collapse 2
- Standard chest X-rays and CT scans have limited value for detecting large airway disorders like tracheomalacia 1
Common diagnostic pitfall: Tracheomalacia is frequently misdiagnosed as asthma because both conditions present with wheezing and cough 3, 2. Suspect tracheomalacia when typical asthma treatments fail to control symptoms 3
Treatment Options
Treatment is primarily palliative and tailored to symptom severity 1:
Conservative Management
- Continuous positive-pressure breathing can provide symptomatic relief by maintaining airway patency 1, 2
Interventional Approaches
- Airway stenting (prosthesis insertion) for immediate symptom relief, often used as a trial before surgery 1, 2
- Tracheobronchial stenting specifically for symptomatic expiratory central airway collapse 2
Surgical Options
- Surgical resection of the affected airway segment for localized disease 1, 2
- Tracheoplasty or tracheobronchoplasty as definitive treatment after successful stent trial 2
Etiology-Specific Therapy
- Address underlying causes when identifiable (e.g., treating relapsing polychondritis, removing compressive thyroid lesions) 1
Clinical note: Up to 10% of symptomatic patients undergoing bronchoscopy may have tracheomalacia/bronchomalacia, making it more common than often recognized 2