Tracheobronchomalacia

Dr. Thapa presented an interesting case for intern report of an older female with a complicated history of pulmonary and cardiac sarcoidosis, chronic systolic HF, and OSA on CPAP who presented with subacute progressive dyspnea on exertion and cough, initially admitted with concern for acute decompensated heart failure. She continued to have DOE and cough despite adequate diuresis and a RHC showing euvolemia. Eventually, she was diagnosed with tracheobronchomalacia on dynamic CT chest imaging.

 Image from: http://curetbm.org/about-tbm.html

Image from: http://curetbm.org/about-tbm.html

Learning Points:

Tracheobronchomalacia can be congenital or acquired. Factors associated with its development include endotracheal intubation (worse with recurrent intubation, prolonged intubation, concurrent steroid therapy), cartilage injury, chronic compression, relapsing polychondritis, recurrent infection (chronic bronchitis, CF), severe emphysema/smoking, mustard gas, and GERD.

Diagnosis can be made with dynamic CT chest imaging, but gold standard remains direct visualization of airway collapse on bronchoscopy. PFTs are not diagnostic and have variable patterns (obstructive, restrictive, mixed, normal).

Treatment includes optimizing the underlying issue, performing functional assessments, and inserting a trial of silicone stents. If helpful symptomatically and the patient is a surgical candidate, definitive surgical repair can be considered.