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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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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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