Dynamic Central Airway Obstruction: Tracheomalacia,Tracheobronchomalacia, And Excessive Dynamic Airway Collapse Classifica...
DEFINITION<br />Dynamic Central Airway Obstruction <br />Luminal narrowing > 50% during expiration (Diffuse or segmental )...
Bronchoscopic view<br />A: Normal lumen during inhalation<br />B: Near total collapse during quiet exhalation<br />Tracheo...
CT scan airway reconstruction of the trachea<br />A: the trachea during inhalation<br />B: segmental tracheal collapse dur...
CLASSIFICATIONThe Shape of the Trachea<br />Crescent TM<br />                Scabbard Shape<br />Anteroposterior Tracheal ...
Diffuse TM<br />Excessive collapse of a long segment of the intrathoracic trachea during expiration<br />Segmental TM<br /...
Congenital TM<br />Less common<br />Inherited<br />Presents during childhood<br />Idiopathic Giant Trachea (IGT)<br />Typi...
Idiopathic Giant Trachea (IGT)<br />
Tracheobronchomegaly (TBM)(Mounier-Kuhn Syndrome)<br />The diameter of the trachea > 3.0 cm<br />Right mainstem bronchus >...
Acquired TM Tracheostomy or Endotracheal Intubation<br />Risk factors<br />Recurrent intubation<br />Prolonged intubation<...
Benign mediastinal goiter <br />Malignancy<br />Vascular compression<br />Abscess<br />Cyst<br />Acquired TMChronic Compre...
TM due to vascular compression<br />Double aortic arch  <br />Vascular ring encircling the trachea and esophagus<br />Trac...
Retrospective chart review and data analysis <br />January 2004 through February 2008<br />145 pts with RP<br />Nearly 50%...
Moderate tracheal obstruction from diffuse wall thickening with sparing of the posterior wall<br />Anterior bronchial wall...
Chronic bronchitis <br />Cystic fibrosis (CF)<br />Observational study <br />40 adults with CF and 10 control subjects<br ...
Chronic inflammation due to the inhalation of irritants (cigarette smoking)<br />214 pts with chronic bronchitis <br />50/...
Retrospective study <br />116 infants (between the ages of 3 and 28 months) with chronic respiratory problems<br />54/116 ...
EPIDEMIOLOGY<br />Acquired TM more common in men > 40 yo (Older studies) <br />4283 pts with pulmonary disease underwent b...
HISTOPATHOLOGY<br /><ul><li> Atrophy of the longitudinal elastic fibers
 Fragmentation of the tracheal cartilage</li></li></ul><li>NATURAL HISTORY<br />Progressive<br />17 pts with dynamic centr...
CLINICAL MANIFESTATIONS<br />Asymptomatic in mild cases<br />The severity of airway narrowing progresses in certain clinic...
CLINICAL MANIFESTATIONS<br />Dyspnea, cough, and sputum retention (most common)<br />Expiratory wheezing or stridor<br />P...
DIAGNOSISFlexibleBronchoscopy <br />The diagnostic gold standard<br />The severity of the dynamic central airway collapse:...
DIAGNOSISComputed Tomography <br />In some cases the collapse can not be demonstrated on end- expiration (false negative)<...
Dynamic Expiratory CT vs. Bronchoscopy <br />Retrospective study (19 mon period)<br />Beth Israel Deaconess Medical Center...
Criteria for Diagnosing TM by CT <br />Same as those for diagnosing TM by bronchoscopy<br />Mild: 50% obstruction<br />Mod...
WHAT IS THE OPTIMAL DIAGNOSTIC THRESHOLD FOR LUMINAL NARROWING?<br />Currently: (>50% expiratory reduction in cross-sectio...
Supportive  but not diagnostic<br />The obstruction on the spirometry usually is proportional to the severity of the airwa...
Flow Oscillations on the Flow-volume Loop<br />Sequence of alternating decelerations and accelerations of the expiratory f...
Pt with Parkinson's Disease and UAO<br />Flow-volume loop at baseline <br />Flow oscillations due to UAO<br />Levodopa imp...
TREATMENT<br />Asymptomatic: no treatment<br />Symptomatic:treat the underlying cause <br />TM associated with tracheal st...
TREATMENTIdentifying Patients Who are Most Likely to Benefit from Central Airway Stabilization<br />Stenting trial (Silico...
STENTING<br />Silicone stents are preferred <br />Insertion requires rigid bronchoscopy and general anesthesia<br />Easily...
Short Term Improvement with Silicone Stenting<br />Prospective observational study <br />75 pts<br /><ul><li>58 pts with s...
Tracheal and Bronchial silicone stents<br />For tracheal and bronchial obstructions and stenosis<br />Non-adherent smooth ...
Complications of Silicone Stents<br />Silicone stents often migrate (manifests as a new cough)<br />Requires repositioning...
Retrospective chart review<br />15 pts who failed medical therapy and were not surgical candidates, treated by silicone st...
Metal Stents (Expandable Wire Stents) <br />Not recommended in benign airway obstruction (TM)<br />More useful in malignan...
Fractured metallic stent<br />Torn silicone stent<br />
SURGICAL REPAIR Tracheobronchoplasty <br />The definitive operative technique <br />All surgically candidate pts with symp...
Dynamic Bronchoscopy<br />Forced Expiratory Maneuver<br />Dynamic CT<br />Forced Expiratory Maneuver<br />3 months<br />Po...
Prospective cohort study <br />35 pts with severe symptomatic tracheomalacia underwent tracheobronchoplasty using a polypr...
SURGICAL REPAIROther Possible Surgeries<br />Conventional resection and reconstruction<br />Localized, segmental cervical ...
Tracheostomy<br />Tracheostomy tube should bypass the abnormal tracheal segment <br />May require longer tracheostomy tube...
Tracheostomy and Tracheal T-Tube<br />Functions like a straight stent, spanning the cervical trachea<br />Sometimes used f...
Positive Pressure Ventilation<br />Indicated in diffuse dynamic airway obstruction<br />Indicated in pts failed stenting t...
Treatment Algorithm For Adult Tracheomalacia<br />Tracheomalacia and tracheobronchomalacia in children and adults: An in-d...
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Dynamic Central Airway Obstruction: Tracheomalacia, Tracheobronchomalacia, And Excessive Dynamic Airway Collapse: Classification, Diagnosis, and Treatment

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Dynamic Central Airway Obstruction: Tracheomalacia, Tracheobronchomalacia, And Excessive Dynamic Airway Collapse: Classification, Diagnosis, and Treatment

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  • Hi...My daughter is 24 yrs old and she was born with Tracheo and Laryngo malacia and has malacia of the left bronchus. I was repeatedly told i was an over anxious mother and that i didnt know what i was doing...i ended up becoming and nervous wreck as when ever she hurt herself...just a fall or something really simple, she would cry, then go silent as her airway shut and would not open then go blue and pass out not breathing. It wasnt until she was 8 yrs old they put a camera down and she has these conditions quite badly. We have managed to control it, but now she is an adult she is always ill....she no longer stops breathing but has an awful time with fluid/mucus, it blocks her airway like it did as a child blocks her nose and causes constant illness....she is ill with this all year round and lost her last 5 jobs because of this illness. She is really struggling to get on with her life and is feeling down. I would love to speak to anyone else with this condition to see what they do. i am going to try and add my email address here. it is carolynj22@hotmail.com
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  • After having swine flu in 2009 I knew something was wrong with my breathing. Under a respiratory specialist I was treated for asthma like symptoms with puffers. I was constantly clearing my throat, had a wheezy crackly noise when breathing, that I could hear at night. The specialst thought my clearing of the throat was a 'HABIT'. I insisted not. Then he said it was reflux - I said it was not - so I was sent for a test - which said it was not. I stopped the puffers cos is was the same with or without them. When the weather is humid I feel like one side of my throat was pressing in. After having nasal polyp surgery, puffers/asthma treatment and lots of test, I was sent for a bronchoscopy and guess what I have adult aquired tracheomalacia. I asked my specialist is that why I clear my throat alot - YES, is that why I have a crackle/wheeze sound at night - YES, is that why I feel like its hard to breathe somtimes - YES. Well at least I know now. I am trying my own research on the net for people like me - post swine flu adult aquired tracheomalacia - can't find anyone. Can Anyone help me ?? is their any post swine flu after effects research? I even gave an article to the radiology about detection of AATM on CT with expiration [they did my CT on inspiration] and nothing showed. Dont trust specialist very much - no one seems to know much. Regards Elaine from Australia.,
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  • very good, sir thank you
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  • Really good ,,,came across few cases in past two month
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Dynamic Central Airway Obstruction: Tracheomalacia, Tracheobronchomalacia, And Excessive Dynamic Airway Collapse: Classification, Diagnosis, and Treatment

  1. 1. Dynamic Central Airway Obstruction: Tracheomalacia,Tracheobronchomalacia, And Excessive Dynamic Airway Collapse Classification, Diagnosis, and Treatment<br />Bassel Ericsoussi, MD<br />Pulmonary and Critical Care Fellow<br />University of Illinois Medical Center at Chicago<br />
  2. 2. DEFINITION<br />Dynamic Central Airway Obstruction <br />Luminal narrowing > 50% during expiration (Diffuse or segmental ) <br />Intrathoracic, obstruction, airway collapse typically occurs during expiration<br />Tracheomalacia (TM) - Tracheobronchomalacia (TBM) <br />Cartilageweakness <br />In the trachea (TM)<br />Extending into one or both mainstem bronchi (TBM)<br />Excessive Dynamic Airway Collapse (EDAC)<br />Bulging of the posterior membrane into the airway lumen during exhalation<br />Tracheomalacia and tracheobronchomalacia in children and adults: an in-depth review.<br />Chest. 2005;127(3):984-1005<br />
  3. 3. Bronchoscopic view<br />A: Normal lumen during inhalation<br />B: Near total collapse during quiet exhalation<br />Tracheomalacia and tracheobronchomalacia in children and adults: an in-depth review.<br />Chest. 2005;127(3):984-1005<br />
  4. 4. CT scan airway reconstruction of the trachea<br />A: the trachea during inhalation<br />B: segmental tracheal collapse during exhalation<br />Tracheomalacia and tracheobronchomalacia in children and adults: an in-depth review.<br />Chest. 2005;127(3):984-1005<br />
  5. 5. CLASSIFICATIONThe Shape of the Trachea<br />Crescent TM<br /> Scabbard Shape<br />Anteroposterior Tracheal Narrowing<br /> Saber-sheath TM<br /> Fissure Shape<br /> Lateral Tracheal Narrowing<br />
  6. 6. Diffuse TM<br />Excessive collapse of a long segment of the intrathoracic trachea during expiration<br />Segmental TM<br />Segmental tracheal collapse during exhalation<br />CLASSIFICATIONDistribution<br />
  7. 7.
  8. 8. Congenital TM<br />Less common<br />Inherited<br />Presents during childhood<br />Idiopathic Giant Trachea (IGT)<br />Typically presents during adulthood<br />Atrophy of the longitudinal elastic fibers and thinning of the muscularis mucosa <br />Tracheobronchomegaly. Chest. 1994;106(5):1589-90.<br />
  9. 9. Idiopathic Giant Trachea (IGT)<br />
  10. 10. Tracheobronchomegaly (TBM)(Mounier-Kuhn Syndrome)<br />The diameter of the trachea > 3.0 cm<br />Right mainstem bronchus > 2.3 cm<br />Left mainstem bronchus > 2.3 cm<br />Usually the peripheral airways maintain a normal diameter<br />Chronic accumulation of secretions<br />Recurrent infections<br />Tracheal diverticuli<br />Bronchiectasis<br />Pulmonary fibrosis<br />Tracheobronchomegaly--the Mounier-Kuhn syndrome.<br />Br J Radiol. 1984;57(679):640-4.<br />
  11. 11. Acquired TM Tracheostomy or Endotracheal Intubation<br />Risk factors<br />Recurrent intubation<br />Prolonged intubation<br />Concurrent high-dose steroid therapy<br />Destruction of the tracheal cartilage at the stoma or the inflatedcuff site<br />Pressure necrosis<br />Impaired blood flow<br />Recurrent infections<br />Mucosal friction and inflammation<br />Acquired tracheomalacia: etiology and differential diagnosis.<br />Chest. 1975;68(3):340-5.<br />
  12. 12. Benign mediastinal goiter <br />Malignancy<br />Vascular compression<br />Abscess<br />Cyst<br />Acquired TMChronic Compression of the Trachea <br />Respiratory complications after thyroidectomy and the need for tracheostomy in patients with a large goitre<br />Br J Surg. 1999;86(1):88-90<br />
  13. 13. TM due to vascular compression<br />Double aortic arch <br />Vascular ring encircling the trachea and esophagus<br />Tracheal narrowing caused by the vascular ring<br />Double Aortic Arch<br />Cardiothoracic Surgery Network. 29-Sep-2009<br />
  14. 14. Retrospective chart review and data analysis <br />January 2004 through February 2008<br />145 pts with RP<br />Nearly 50% some degree of TM (focal or diffuse)<br />26% subglottic stenosis <br />The rest focal stenosis in different areas of the bronchial tree<br />40%underwent intervention<br />Balloon dilatation<br />Stent placement<br />Tracheotomy<br />The majority of patients experienced improvement in airway symptoms after intervention<br />Acquired TMRelapsing Polychondritis (RP)<br />Relapsing polychondritis and airway involvement.<br />Chest. 2009;135(4):1024-30<br />
  15. 15. Moderate tracheal obstruction from diffuse wall thickening with sparing of the posterior wall<br />Anterior bronchial wall thickening with posterior wall sparing<br />Relapsing polychondritis and airway involvement.<br />Chest. 2009;135(4):1024-30<br />Sparing of the Posterior Wall in RP<br />
  16. 16. Chronic bronchitis <br />Cystic fibrosis (CF)<br />Observational study <br />40 adults with CF and 10 control subjects<br />Dynamic CT showed TM<br />24/40 (69%) pts with CF<br />None of the controls<br />Acquired TMRecurrent Infection<br />Tracheomalacia in adults with cystic fibrosis: determination of prevalence and severity with dynamic cine CT.<br />Radiology. 2009;252(2):577-86.<br />
  17. 17. Chronic inflammation due to the inhalation of irritants (cigarette smoking)<br />214 pts with chronic bronchitis <br />50/214 pts with TBM<br />2150 pts with TBM<br />53% concurrent chronic bronchitis <br />Acquired TMSevere Emphysema<br />Chronic bronchitis. A bronchologic evaluation. ORL J OtorhinolaryngolRelat Spec. 1976;38(3):178-86<br />Acquired tracheobronchomalacia.Ann Clin Res. 1977;9(2):52-7.<br />
  18. 18. Retrospective study <br />116 infants (between the ages of 3 and 28 months) with chronic respiratory problems<br />54/116 laryngomalacia and tracheomalacia<br />70% had GERD documented by reflux studies<br />62/116 control group<br />39% had GERD<br />GERD is prevalent among infants with large airways malacia<br />Acquired TMGERD<br />The prevalence of gastroesophageal reflux in children with tracheomalacia and laryngomalacia.<br />Chest. 2001;119(2):409-13<br />
  19. 19. EPIDEMIOLOGY<br />Acquired TM more common in men > 40 yo (Older studies) <br />4283 pts with pulmonary disease underwent bronchoscopy <br />542 pts (12.7%): TM (the airway caliber narrowed > 50%) <br />> 70%: age 50-80<br />Diagnosis, incidence, clinicopathology and surgical treatment of acquired tracheobronchomalacia.<br />Nihon Kyobu Shikkan Gakkai Zasshi. 1992;30(6):1028-35 <br />
  20. 20. HISTOPATHOLOGY<br /><ul><li> Atrophy of the longitudinal elastic fibers
  21. 21. Fragmentation of the tracheal cartilage</li></li></ul><li>NATURAL HISTORY<br />Progressive<br />17 pts with dynamic central airway obstruction underwent repeat bronchoscopy<br />76% worse airway narrowing<br />94 pts with dynamic central airway obstruction underwent repeat bronchoscopy (5.2 yrs average follow up)<br />Most pts had worse disease<br />Some had stable disease<br />Non improved<br />Acquired tracheobronchomalacia. Ann Clin Res. 1977;9(2):52-7.<br />Acquired tracheobronchomalacia. A clinical study with bronchological correlations. Ann Clin Res. 1977;9(6):350-5.<br />
  22. 22. CLINICAL MANIFESTATIONS<br />Asymptomatic in mild cases<br />The severity of airway narrowing progresses in certain clinical situations <br />Infection<br /> General anesthesia<br />Progressive hypercapnic respiratory failure<br />Liberation from mechanical ventilation<br />A case of tracheomalacia during isoflurane anesthesia. AnesthAnalg. 1995;80(5):1051-3.<br />Respiratory failure due to tracheobronchomalacia. Thorax. 1996;51(2):224-6.<br />
  23. 23. CLINICAL MANIFESTATIONS<br />Dyspnea, cough, and sputum retention (most common)<br />Expiratory wheezing or stridor<br />Paroxysmal cough<br />Recurrent infection<br />Episodic choking, syncope a/w forced exhalation and cough<br />Maneuvers can sometimes elicit symptoms<br />Forced exhalation<br />Cough<br />Valsalva maneuver<br />Supine position<br />Acquired tracheobronchomalacia. Eur J Respir Dis. 1982;63(5):380-7.<br />
  24. 24. DIAGNOSISFlexibleBronchoscopy <br />The diagnostic gold standard<br />The severity of the dynamic central airway collapse:<br />Mild: 50% obstruction<br />Moderate: 75% obstruction<br />Severe: the anterior and posterior walls touch <br />Acquired tracheobronchomalacia. A clinical study with bronchological correlations.<br />Ann Clin Res. 1977;9(6):350-5.<br />
  25. 25. DIAGNOSISComputed Tomography <br />In some cases the collapse can not be demonstrated on end- expiration (false negative)<br />The collapse is much more prominent on dynamic imaging<br />Acquired tracheomalacia: detection by expiratory CT scan.<br />J Comput Assist Tomogr. 2001;25(3):394-9.<br />
  26. 26. Dynamic Expiratory CT vs. Bronchoscopy <br />Retrospective study (19 mon period)<br />Beth Israel Deaconess Medical Center<br />29 pts with airway malacia identified with bronchoscopy<br />End-expiratory and dynamic expiratory CT performed within 1 week of bronchoscopy<br />CT correctly diagnosed malacia in 28 of 29 patients <br />97% accuracy<br />CT is able to show the distal extent of the disease into segmental and subsegmental bronchi<br />Implications on treatment: neither stenting nor surgery can correct the distal disease<br />Comparison of Dynamic Expiratory CT With Bronchoscopy for Diagnosing Airway Malacia: A Pilot Evaluation. <br />Chest. 2007;131(3):758-64.<br />
  27. 27. Criteria for Diagnosing TM by CT <br />Same as those for diagnosing TM by bronchoscopy<br />Mild: 50% obstruction<br />Moderate: 75% obstruction<br />Severe: the anterior and posterior walls touch <br />
  28. 28. WHAT IS THE OPTIMAL DIAGNOSTIC THRESHOLD FOR LUMINAL NARROWING?<br />Currently: (>50% expiratory reduction in cross-sectional area)<br />This is may be not true<br />Prospective study on 51 healthy volunteers <br />Dynamic expiratory CT (forced exhalation CT)<br />78% (40/51) pts exceeded the current diagnostic criterion for tracheomalacia (P<.001)<br />Tracheal collapsibility in healthy volunteers during forced expiration: assessment with multidetector CT.<br />Radiology. 2009;252(1):255-62.<br />
  29. 29. Supportive but not diagnostic<br />The obstruction on the spirometry usually is proportional to the severity of the airway collapse<br />Rapid decline in the maximal expiratory flow after a sharp peak (collapse of central airways due to negative transmural pressure)<br />DIAGNOSISPulmonary Function Tests <br />Acquired tracheobronchomalacia. A clinical study with bronchologicalcorrelations.<br />Ann Clin Res. 1977;9(6):350-5<br />
  30. 30. Flow Oscillations on the Flow-volume Loop<br />Sequence of alternating decelerations and accelerations of the expiratory flow ("saw-tooth" pattern)<br />Large retrospective survey 2,800 flow-volume loops<br />1.4% (40/2800) flow oscillations<br />Can be due<br />Tracheobronchomalacia<br />OSA<br />Structural or functional disorders of the larynx<br />Neuromuscular diseases<br />Flow oscillations on the flow-volume loop: a nonspecific indicator of upper airway dysfunction. Bull EurPhysiopatholRespir. 1985;21(6):559-67<br />Tracheobronchomalacia: A Cause of Flow Oscillations on the Flow-Volume Loop. Chest 2000;118;1519<br />
  31. 31. Pt with Parkinson's Disease and UAO<br />Flow-volume loop at baseline <br />Flow oscillations due to UAO<br />Levodopa improved of the saw-tooth pattern<br />Effects of Levodopa on Pulmonary Function in Parkinson’s Disease.<br />CHEST February 2001 vol. 119 no. 2 387-393 <br />
  32. 32. TREATMENT<br />Asymptomatic: no treatment<br />Symptomatic:treat the underlying cause <br />TM associated with tracheal stenosis due to prolonged intubation : surgical repair (resection and reconstruction)<br />TM due to COPD: optimize COPD therapy<br />Persistent symptoms following optimization of the coexisting condition<br />Baseline functional status (PFT, 6MWT, QOL)<br />Stenting trial (Silicone) Grade 2C<br />Grade 2C recommendation very weak recommendation; other alternatives may be equally reasonable<br />Tracheomalacia and tracheobronchomalacia in children and adults: An in-depth review. <br />Chest 2005; 127:984. <br />
  33. 33. TREATMENTIdentifying Patients Who are Most Likely to Benefit from Central Airway Stabilization<br />Stenting trial (Silicone)<br />Symptoms/functional status unchanged or worse<br />Remove stent Grade 2C<br />No further intervention <br />Positive pressure therapy or T-tube may be beneficial<br />Symptoms improved<br />Surgical candidate: surgery Grade 2C<br />Not surgical candidate: long term stenting Grade 2C<br />Tracheomalacia and tracheobronchomalacia in children and adults: An in-depth review. <br />Chest 2005; 127:984. <br />
  34. 34. STENTING<br />Silicone stents are preferred <br />Insertion requires rigid bronchoscopy and general anesthesia<br />Easily repositioned and removed<br />Airway stabilization with silicone stents for treating adult tracheobronchomalacia: a prospective observational study.<br />Chest. 2007;132(2):609-16.<br />
  35. 35. Short Term Improvement with Silicone Stenting<br />Prospective observational study <br />75 pts<br /><ul><li>58 pts with severe disease (the anterior and posterior walls touch) </li></ul>Therapeutic rigid bronchoscopy with stent placement<br />Measurements at baseline compared to 10 - 14 days after stent placement, showed improvement<br />Symptoms<br />Quality of life<br />Functional status scores improved <br />Airway stabilization with silicone stents for treating adult tracheobronchomalacia: a prospective observational study.<br />Chest. 2007;132(2):609-16.<br />
  36. 36. Tracheal and Bronchial silicone stents<br />For tracheal and bronchial obstructions and stenosis<br />Non-adherent smooth surface <br />Anti-migration stud system <br />Available in clear or radiopaque material<br />Tracheobronchial Y Stent<br />Less likely to migrate <br />Non-adherent smooth surface <br />Anti-migration stud system <br />Available in clear or radiopaque material<br />
  37. 37. Complications of Silicone Stents<br />Silicone stents often migrate (manifests as a new cough)<br />Requires repositioning, removal, or replacement of the stent <br />Silicone Y-shaped stents are less likely to migrate than tubular silicon stents<br />Infection, cough, mucus-plugging, and granulation tissue<br />Complications of silicone stent insertion in patients with expiratory central airway collapse.<br />Ann Thorac Surg. 2007;84(6):1870-7.<br />
  38. 38. Retrospective chart review<br />15 pts who failed medical therapy and were not surgical candidates, treated by silicone stent insertion<br />Short term complications (within 48 hrs)<br />3/15 stent-related complication<br />12 pts underwent 188 days follow-up<br />10/12 stent related complications<br />Granulation, migration, and mucus plugging<br />Short and Long Term Complications of Silicone Stents<br />Complications of silicone stent insertion in patients with expiratory central airway collapse.<br />Ann Thorac Surg. 2007;84(6):1870-7.<br />
  39. 39. Metal Stents (Expandable Wire Stents) <br />Not recommended in benign airway obstruction (TM)<br />More useful in malignant airway obstruction<br />Easy placement with flexible bronchoscopy<br />May preserve the mucociliary function (some stent types)<br />Cannot be easily removed<br />a/w with many complications<br />Granulation tissue<br />Breakage<br />Airway obstruction<br />Airway perforation<br />Use of expandable wire stents for malignant airway obstruction.<br />Ann Thorac Surg. 1994;57(6):1573-7; discussion 1577-8.<br />
  40. 40. Fractured metallic stent<br />Torn silicone stent<br />
  41. 41. SURGICAL REPAIR Tracheobronchoplasty <br />The definitive operative technique <br />All surgically candidate pts with symptomatic improvement on stent trial should undergo tracheobronchoplasty<br />Splinting of the posterior wall of the trachea and main stem bronchus with polypropylene mesh<br />Tracheobronchoplasty for severe tracheobronchomalacia: a prospective outcome analysis.<br />Chest. 2008;134(4):801-7.<br />
  42. 42. Dynamic Bronchoscopy<br />Forced Expiratory Maneuver<br />Dynamic CT<br />Forced Expiratory Maneuver<br />3 months<br />Post-op<br />Tracheobronchoplasty for severe tracheobronchomalacia: a prospective outcome analysis.<br />Chest. 2008;134(4):801-7.<br />
  43. 43. Prospective cohort study <br />35 pts with severe symptomatic tracheomalacia underwent tracheobronchoplasty using a polypropylene mesh <br />3 months follow-up: improvement<br />QOL<br />Dyspnea<br />Mean exercise capacity<br />Functional status<br />SURGICAL REPAIR Tracheobronchoplasty <br />Tracheobronchoplasty for severe tracheobronchomalacia: a prospective outcome analysis.<br />Chest. 2008;134(4):801-7.<br />
  44. 44. SURGICAL REPAIROther Possible Surgeries<br />Conventional resection and reconstruction<br />Localized, segmental cervical tracheomalacia<br />Tracheal stenosis is a potential complication<br />Tracheal replacement <br />Tracheal replacement with cryopreservedallogenicaorta. Chest. 2010;137(1):60-7.<br />Tracheal replacement with aortic allografts. N Engl J Med. 2006;355(18):1938-40.<br />Tracheal replacement: a critical review. Ann Thorac Surg. 2002;73(6):1995-2004.<br />
  45. 45. Tracheostomy<br />Tracheostomy tube should bypass the abnormal tracheal segment <br />May require longer tracheostomy tubes<br />In diffuse TM , tracheostomy may be beneficial as a route to deliver positive airway pressure<br />Tracheostomy itself can worsen TM by destroying the tracheal cartilage and weakening the tracheal wall<br />Tracheostomy is a treatment of last resort.<br />
  46. 46. Tracheostomy and Tracheal T-Tube<br />Functions like a straight stent, spanning the cervical trachea<br />Sometimes used for long-term stenting<br />Localized, segmental cervical tracheomalacia<br />Use of a T-tube stent to treat a patient with tracheal stenosis. JAPPA.<br />
  47. 47. Positive Pressure Ventilation<br />Indicated in diffuse dynamic airway obstruction<br />Indicated in pts failed stenting trial<br />Symptoms unchanged or worse with stenting<br />Pt initially receives continuous CPAP<br />Gradual transition to intermittent CPAP<br />Improvement<br />Sputum production<br />Atelectasis<br />Exercise tolerance<br />Symptoms<br />Reduced need for medical care<br />BIPAP may be used in dynamic central airway obstruction with hypercapnic respiratory failure<br />Treatment of diffuse tracheomalacia secondary to relapsing polychondritis with continuous positive airway pressure. Chest. 1997;112(6):1701-4.<br />Nasal continuous positive airway pressure in the treatment of tracheobronchomalacia. Am Rev Respir Dis. 1993;147(2):457-61.<br />
  48. 48. Treatment Algorithm For Adult Tracheomalacia<br />Tracheomalacia and tracheobronchomalacia in children and adults: An in-depth review. <br />Chest 2005; 127:984. <br />

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