Tracheobronchomalacia

Tracheobronchomalacia (TBM) is characterized by an excessive dynamic collapse of the trachea and main bronchi during expiration. Its presentation includes a range of nonspecific respiratory symptoms, depending on the location, extent, and severity of the airway collapse. Long-segment, multi-level or severe (complete collapse) TBM is typically evident clinically from birth; however, symptoms may not appear until two or three months of age or later in some cases.

The diagnosis should be suspected by a clinical history that would be suggestive of TBM, including barky cough, noisy breathing, recurrent pneumonia, prolonged pulmonary infection, feeding difficulties with dyspnea, cough, and aspiration, transient respiratory distress requiring positive pressure, oxygen dependence, ventilator dependence, blue spells, and apparent life-threatening events (ALTEs).

For the most accurate diagnosis of TBM, direct visualization is achieved through flexible and rigid  bronchoscopy. In recent years, dynamic airway evaluation and angiography using a contrast-enhanced multidetector computed tomography (MDCT) with two-dimensional (2D) and three-dimensional (3D) reconstructions have become an important modality to aid in the evaluation of TBM.

All patients affected by mild to severe TBM may benefit from medical management. The mainstay of medical management while awaiting airway structural stability is the optimization of the ciliary clearance of secretions since the cough clearance mechanism is thwarted by airway collapse. Surgical treatment is reserved for the most severe cases and must be specific to the type and location of the TBM. Non-invasive ventilation is another option as to buy time while waiting for the malacic airway to become stable.