What Is Tracheobronchomalacia

Introduction

The illness known as tracheobronchomalacia (TBM) is brought on by a weak airway that collapses during breathing. It can manifest as a cough, dyspnea, and/or recurring infections in infancy or maturity.¹

Weakness of the airway walls, namely the trachea and bronchi, results in TBM. The weak airway collapses partially or totally as the patient exhales. Primary (congenital) and secondary (acquired) TBM are the two types. A faulty airway is usually the cause of primary TBM, which manifests at birth or during infancy. The acquired type of TBM known as secondary TBM typically affects people with compromised airways. People with TBM frequently experience wheezing, dyspnea, and respiratory infections.³

Symptoms of Tracheobronchomalacia

TBM symptoms in young children and babies include:

1. loud or rattling respiration.
2. exhaling with a high-pitched sound.
3. breathing issues that worsen when a baby is coughing, or crying, or the mother is nursing or using a bottle to feed them.²

A large number of TBM patients have no symptoms. Among the most typical symptoms are:

1. breathlessness, particularly when exercising or eating
2. A persistent "barking" cough
3. respiratory diseases that recur
4. Stridor: a high-pitched sound produced similar to exhaling
5. blush surrounding the nose and lips
6. accumulated mucus
7. breathing difficulties

The symptoms of secondary TBM in adults will worsen gradually over time.³

Causes of Tracheobronchomalacia

Primary TBM (existing from birth) may result from:

1. an underlying hereditary disorder, such as Ehlers-Danlos syndrome, Hunter syndrome, or Hurler syndrome
2. prematureness
3. Birth malformations include faulty blood vessel formation, airway branching, esophageal atresia, and tracheoesophageal fistula.²

Although the exact causes of acquired TBM that manifest in adults are frequently unknown, they may be linked to:

1. respiratory disorders, such as acid reflux illness, COPD, asthma, and persistent infections
2. Trauma (such as trachea or thyroid surgery, or endotracheal intubation)
3. Inflammatory disorders (such as recurrent polychondritis)
4. Exposure to toxins, such as mustard gas
5. Compression caused by adjacent anatomy (e.g., goitres, tumours)
6. Tracheobronchomalacia can be brought on by several disorders, which break down the cartilage that keeps the airway open.³

Diagnosis

A flexible bronchoscopy and dynamic CT scan can assess the severity of the ailment and validate the diagnosis. During the flexible bronchoscopy, the patient is instructed to cough or take deep breaths while numbed in. When a patient is exhaling, TBM is classified as mild if the trachea narrows to 50% of its original size, moderate if it narrows to 25%, and severe if the trachea walls touch.²

To find out if someone has TBM, tests could include:

1. bronchoscopy: To observe how the trachea works while a patient breathes in and out, healthcare professionals place a thin, flexible tube down to the trachea through the mouth or nose.
2. CT scan, or computed tomography. The way that the patient breathes in and out will be assessed by the providers.
3. Swallow study. The patient will be required to consume a mixture of food and drink, called barium, during this test. As the patient swallows, X-rays are obtained to trace the barium. This test allows medical professionals to examine the oesophagus and throat.
4. Laryngoscopy. A laryngoscope is used by medical professionals to examine the throat. Flexible tubes with lights and tiny cameras at the end are called laryngoscopes.³

Treatment for tracheobronchomalacia

If there is an underlying problem, the treatment team will attempt to treat it before pursuing surgery. If at all feasible, chronic diseases and traumas ought to be treated first. other options are considered if the cause of the TBM is genetic or cannot be treated with medication.³

Patients may be given continuous positive airway pressure (CPAP), which is a device that forces air into the lungs to maintain their inflation and is frequently used to treat obstructive sleep apnea. The airway may be held open by inserting a silicone stent. In more serious situations, the compromised airway must be surgically corrected.³

Treatment options for TBM that worsens over time may include the following, depending on severity:

1. Tracheobronchoplasty is a surgical technique in which a mesh is sewn to the windpipe's exterior. By keeping the airway open, the mesh helps keep it from collapsing. The procedure lasts for about eight hours, and long-term monitoring is necessary to make sure the tissue is not being eroded or the body rejecting the mesh—a rare occurrence.

2. Continuous positive airway pressure, or CPAP, is a machine that forces air into the lungs to maintain their inflation and is frequently used to treat obstructive sleep apnea. Patients who cannot have surgery or who are awaiting surgery are the ones who use it most frequently.

3. For children with vascular abnormalities, aortopexy is a surgical technique that involves removing the big blood artery that is compressing the airway and attaching it to the chest wall. Unlike a tracheobronchoplasty, it does not reinforce the poor cartilage; instead, it helps expand the airway to facilitate easier breathing.
4. silicone and/or extended stent placement. During this technique, the airway is held open by inserting a plastic tube into it.

5. When TBD is more localized, a surgical technique called resection and reconstruction may be employed.

6. As a last option, a tracheostomy treatment is performed, which involves making an incision in the neck to insert a tube into the airway, preferably beneath the area that is compressing as a result of TBM.³

Disorders that show similar symptoms

1. Tracheomalacia: When the trachea's cartilage is compromised, the trachea collapses during exhalation.

2. Bronchomalacia: when the bronchus's cartilage is compromised, it collapses during exhalation.

3. Excessive dynamic airway collapse (EDAC) is a condition in which the trachea collapses during exhalation due to excessive posterior wall mobility, even while the airway cartilage is normal.

Congenital vascular disorders: these comprise any abnormal blood artery, such as vascular rings, innominate arteries, and double aortic arches, that compresses and weakens the windpipe.

4. A rare birth condition known as a tracheoesophageal fistula occurs when the oesophagus forms improperly and joins the windpipe instead of the stomach. Babies will need surgery because they will have difficulty breathing and swallowing.³

Summary

A compromised airway that may collapse during breathing is the hallmark of tracheobronchomalacia (TBM), a medical disorder that causes symptoms like coughing, dyspnea (difficulty breathing), and recurring respiratory infections. TBM can be present in both adults and newborns, and it is divided into two types: primary (acquired) and secondary (congenital).

Primary TBM is commonly associated with underlying genetic abnormalities or birth deformities affecting the trachea and bronchi and is usually present from birth or early infancy. Adults who develop secondary TBM typically have a history of acid reflux, asthma, chronic obstructive pulmonary disease (COPD), or traumatic events such as surgery.

TBM symptoms include high-pitched exhalations, noisy or rattling breathing, and worsened breathing during activities like eating or exercising. Tests like bronchoscopy, CT scans, swallow studies, and laryngoscopies are used in the diagnosis process.

The underlying cause and the degree of TBM determine the course of treatment. Depending on the exact situation, management may include treating the underlying issue, maintaining breathing with continuous positive airway pressure (CPAP), keeping the airway open with silicone stents, or undergoing surgery such as a tracheobronchoplasty, aortopexy, or tracheostomy.

It is noteworthy that several illnesses can be mistaken for TBM, including tracheomalacia, bronchomalacia, congenital vascular abnormalities, excessive dynamic airway collapse (EDAC), and tracheoesophageal fistula. To identify the precise ailment and the best course of treatment, a proper diagnosis and medical evaluation are essential.