Tracheobronchomalacia: Detecting and Treating an Underrecognized Menace

By Charles Bakhos, MD

Severe tracheobronchomalacia (TBM), a weakening of the walls of the trachea and/or bronchi leading to airway collapse, can severely complicate patient care and quality of life. Although it occurs in 4.51 to 15 percent2 of patients with significant respiratory disease, physicians are often unfamiliar with the condition and unaware of treatment protocols and available therapies. The Temple Lung Center has the only dedicated TBM program in the region, providing multi-specialty care from symptom control to surgery.

Characterized by almost complete collapse of the airway during forced expiration, TBM can cause or contribute to dyspnea, recurrent respiratory infections, cough, secretion retention and even respiratory failure. It tends to co-occur with conditions like interstitial lung disease, asthma or COPD, which may be unsuccessfully treated for years before TBM is recognized. TBM and its frequent comorbidities likely exacerbate one another; gastroesophageal reflux disease and recurrent bronchitis (or other coughing conditions), for example, may contribute to the weakening of airway walls.

Conventional diagnosis of TBM is 50 percent airway lumen collapse during forced expiration—but to be clinically relevant, airway collapse must be at least 75 percent. At Temple’s dedicated center, a patient suspected of having TBM is evaluated in our advanced bronchoscopy suite, under conscious sedation, by both a pulmonologist and a thoracic surgeon. This may be followed by a CT scan with forced expiration protocol to confirm the diagnosis and accurately quantify airway collapse at the aortic arch, carina, and bronchus intermedius. Diagnosis is also accompanied by questionnaires and discussions to quantify the impacts of TBM on a patient’s condition and quality of life.

Tracheobronchoplasty for severe tracheobronchomalacia.

Whenever possible, treatment focuses on controlling symptoms and comorbid conditions, and preventing exacerbations—one of the reasons that multidisciplinary specialty care is preferred. Antibiotics and mucolytics can help control or prevent infections caused by mucus retention, a common side effect of TBM; CPAP or BiPAP machines can help keep airways open while the patient sleeps; acid reflux can be managed with proton-pump inhibitors; and nebulizers with saline solution can reduce irritation and coughing. If these methods aren’t sufficient, Temple’s specialist team can evaluate the patient’s suitability for more invasive therapies.

Patients with uncontrolled TBM can benefit from placement of a tracheobronchial stent to help stabilize the airway; however, this relief is usually temporary, lasting a few weeks before side effects and the dangers of migration and mucus plugging peak. The only permanent solution is surgical—tracheobronchoplasty—preceded by a trial stent placement to evaluate the likelihood of success. About one-third of TBM patients have severe enough issues to require this surgery and are in good enough health to make it practical. A thoracic surgeon normally enters through the right chest to place a mesh on the outside of the posterior airway wall. Tens of carefully placed sutures lead to scarring that, along with the mesh itself, help stabilize the airway and reduce collapse. Over the course of the next weeks and months, the patient’s symptoms should gradually improve.

If you suspect a patient of having tracheobronchomalacia, call 215-707-9115 to be connected with our comprehensive TBM program and discuss options.


References

1 Jokinen, K., et al. (1977). Acquired tracheobronchomalacia. Ann Clin Res. 9: 52–57.
2 Ikeda, S., et al. (1992). Diagnosis, incidence, clinicopathology and surgical treatment of acquired tracheobronchomalacia [in Japanese]. Nihon Kyobu Shikkan Gakkai Zasshi 30 (6): 1028–1035.