eMedicine Specialties > Pediatrics: General Medicine > Pulmonology

Tracheomalacia: Differential Diagnoses & Workup

Author: Michael R Bye, MD, Professor of Clinical Pediatrics, Division of Pulmonary Medicine, Columbia University College of Physicians and Surgeons; Attending Physician, Pediatric Pulmonary Medicine, Morgan Stanley Children's Hospital of New York Presbyterian, Columbia University Medical Center
Contributor Information and Disclosures

Updated: Aug 27, 2009

Differential Diagnoses

Asthma
Gastroesophageal Reflux
Bronchiolitis
Pulmonary Artery Sling
Bronchogenic Cyst
Vascular Ring, Double Aortic Arch
Bronchopulmonary Dysplasia
Vascular Ring, Right Aortic Arch
Cystic Fibrosis

Other Problems to Be Considered

Anomalous innominate artery
Complete tracheal rings
Tracheal stenosis
Williams-Campbell syndrome

Workup

Laboratory Studies

  • Oxygen saturation should be assessed in tracheomalacia.

Imaging Studies

  • Fluoroscopy and radiography
    • The diagnosis can often be confirmed by performing fluoroscopy of the airway.
    • During the study, the pediatric radiologist observes the airway collapsing and opening up. This finding may appear on anteroposterior images, on which the tracheal air shadow seems to disappear and reappear with respirations in the affected area of the trachea.
    • The lesion may be observed most easily on lateral images, on which the anterior and posterior walls of the trachea may be observed apposing dynamically.
    • Loss of the tracheal air shadow with no respiratory changes suggests static collapse of the airway.
  • CT scanning
    • Chest CT scanning may reveal the abnormal shape of the trachea as the apposition of the walls.
    • "Expiratory frown" shapes are observed in CT scans when the area is scanned during an exhalation or cough.3
    • Chest CT scanning may not reveal the dynamic nature of the lesion and may not depict the lesion at all.
    • A CT scan, especially one obtained with contrast material, may reveal vascular lesions that mimic tracheomalacia and that may lead to tracheomalacia.
  • Esophagraphy
    • Esophagraphy can be performed to evaluate for a vascular anomaly, for a bronchogenic cyst, or for esophageal duplication.
    • Esophagraphy does not assist the physician in making a definitive diagnosis.

Other Tests

  • The definitive method of diagnosis is bronchoscopy.
    • In one series, when a pediatric pulmonologist suspected tracheomalacia, the correct diagnosis was tracheomalacia in 74% of the cases.1 However, tracheomalacia was not suspected in 52% of patients who were eventually diagnosed with it.
    • During bronchoscopy, the anterior wall can be observed to collapse against the posterior wall. At the same time, other lesions can be diagnosed or excluded under direct visualization.
    • The authors prefer flexible bronchoscopy to confirm the diagnosis. With flexible bronchoscopy, the baby is breathing spontaneously with light anesthesia. This method preserves respiratory dynamics better than rigid bronchoscopy. In addition, the rigid bronchoscope may serve as a stent to the airway, masking the diagnosis.
  • Confirming the diagnosis is important for differential diagnosis. Otherwise, one or more tests may be unnecessarily considered.
    • A sweat test may be performed to reduce the likelihood of cystic fibrosis.
    • Esophagraphy may be performed to eliminate the likelihood of most of the vascular anomalies. These diagnoses are usually eliminated by bronchoscopy.
    • CT scanning to reduce the likelihood of airway foreign body and other lesions that may be compromising the airway. If bronchoscopy is performed, it is an efficient and direct method of looking for foreign bodies.
  • If tracheomalacia is diagnosed, a sweat test is not necessary unless other manifestations of cystic fibrosis are present. The adage still holds that a sweat test has no contraindication.
  • If gastroesophageal reflux is a concern, evaluate this condition by using a pH probe or esophageal biopsy. If bronchoscopy is performed, bronchoalveolar lavage can be done to assess for lipid-laden macrophages.

More on Tracheomalacia

Overview: Tracheomalacia
Differential Diagnoses & Workup: Tracheomalacia
Treatment & Medication: Tracheomalacia
Follow-up: Tracheomalacia
Multimedia: Tracheomalacia
References
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References

  1. Boogaard R, Huijsmans SH, Pijnenburg MW, et al. Tracheomalacia and bronchomalacia in children: incidence and patient characteristics. Chest. Nov 2005;128(5):3391-7. [Medline].

  2. Jamal N, Bent JP, Vicencio AG. A neurologic etiology for tracheomalacia?. Int J Pediatr Otorhinolaryngol. Jun 2009;73(6):885-7. [Medline].

  3. Boiselle PM, Ernst A. Tracheal morphology in patients with tracheomalacia: prevalence of inspiratory lunate and expiratory "frown" shapes. J Thorac Imaging. Aug 2006;21(3):190-6. [Medline].

  4. Vinograd I, Keidar S, Weinberg M, Silbiger A. Treatment of airway obstruction by metallic stents in infants and children. J Thorac Cardiovasc Surg. Jul 2005;130(1):146-50. [Medline].

  5. Valerie EP, Durrant AC, Forte V, et al. A decade of using intraluminal tracheal/bronchial stents in the management of tracheomalacia and/or bronchomalacia: is it better than aortopexy?. J Pediatr Surg. Jun 2005;40(6):904-7; discussion 907. [Medline].

  6. Austin J, Ali T. Tracheomalacia and bronchomalacia in children: pathophysiology, assessment, treatment and anaesthesia management. Paediatr Anaesth. Jan 2003;13(1):3-11. [Medline].

  7. Casiano RR, Numa WA, Nurko YJ. Efficacy of transoral intraluminal Wallstents for tracheal stenosis or tracheomalacia. Laryngoscope. Oct 2000;110(10 Pt 1):1607-12. [Medline].

  8. Dave S, Currie BG. The role of aortopexy in severe tracheomalacia. J Pediatr Surg. Mar 2006;41(3):533-7. [Medline].

  9. Furman RH, Backer CL, Dunham ME, et al. The use of balloon-expandable metallic stents in the treatment of pediatric tracheomalacia and bronchomalacia. Arch Otolaryngol Head Neck Surg. Feb 1999;125(2):203-7. [Medline].

  10. Inoue K, Yanagihara J, Ono S, et al. Utility of helical CT for diagnosis and operative planning in tracheomalacia after repair of esophageal atresia. Eur J Pediatr Surg. Dec 1998;8(6):355-7. [Medline].

  11. Masters IB, Chang AB. Interventions for primary (intrinsic) tracheomalacia in children. Cochrane Database Syst Rev. 2005;CD005304. [Medline].

  12. Panitch HB, Keklikian EN, Motley RA, et al. Effect of altering smooth muscle tone on maximal expiratory flows in patients with tracheomalacia. Pediatr Pulmonol. 1990;9(3):170-6. [Medline].

  13. Vinograd I, Filler RM, Bahoric A. Long-term functional results of prosthetic airway splinting in tracheomalacia and bronchomalacia. J Pediatr Surg. Jan 1987;22(1):38-41. [Medline].

  14. Yalcin E, Dogru D, Ozcelik U, et al. Tracheomalacia and bronchomalacia in 34 children: clinical and radiologic profiles and associations with other diseases. Clin Pediatr (Phila). Nov-Dec 2005;44(9):777-81. [Medline].

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Further Reading

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Keywords

tracheomalacia, tracheal wall collapse, airway obstruction, airway compression, compression of the airway, asthma, chronic asthma, bronchiolitis, vascular ring and sling, vascular sling and ring, tracheoesophageal fistula, gastroesophageal reflux, GER, gastroesophageal reflux disease, GERD, wheeze, wheezing, happy wheezer, treatment, diagnosis

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Contributor Information and Disclosures

Author

Michael R Bye, MD, Professor of Clinical Pediatrics, Division of Pulmonary Medicine, Columbia University College of Physicians and Surgeons; Attending Physician, Pediatric Pulmonary Medicine, Morgan Stanley Children's Hospital of New York Presbyterian, Columbia University Medical Center
Michael R Bye, MD is a member of the following medical societies: American Academy of Pediatrics, American College of Chest Physicians, and American Thoracic Society
Disclosure: Merck Honoraria Speaking and teaching

Medical Editor

Susanna A McColley, MD, Director of Cystic Fibrosis Center; Head, Division of Pulmonary Medicine; Associate Professor, Department of Pediatrics, Children's Memorial Medical Center of Chicago, Northwestern University
Susanna A McColley, MD is a member of the following medical societies: American Academy of Pediatrics, American College of Chest Physicians, American Sleep Disorders Association, and American Thoracic Society
Disclosure: Genentech Honoraria Speaking and teaching; Genentech Honoraria Consulting; Novartis Honoraria Consulting; Altus  Consulting fee Consulting; Axcan Scandi Consulting fee Consulting; Boston Scientific Consulting fee Consulting; Gilead  Speaking and teaching

Pharmacy Editor

Mary L Windle, PharmD, Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy, Pharmacy Editor, eMedicine
Disclosure: Pfizer Inc Stock Investment from financial planner; Avanir Pharma Stock Investment from financial planner ; WebMD Salary and stock Employment and investment from financial planner

Managing Editor

Heidi Connolly, MD, Associate Professor of Pediatrics and Psychiatry, University of Rochester; Director, Pediatric Sleep Medicine Services, Strong Sleep Disorders Center
Heidi Connolly, MD is a member of the following medical societies: American Academy of Pediatrics, American Thoracic Society, and Society of Critical Care Medicine
Disclosure: Nothing to disclose.

CME Editor

Mary E Cataletto, MD, Associate Director, Division of Pediatric Pulmonology, Winthrop University Hospital; Professor of Clinical Pediatrics, State University of New York at Stony Brook; Director of Children's Sleep Services, Winthrop University Hospital
Mary E Cataletto, MD is a member of the following medical societies: American Academy of Pediatrics and American College of Chest Physicians
Disclosure: Shering Plough Pharmaceuticals Honoraria Consulting

Chief Editor

Michael R Bye, MD, Professor of Clinical Pediatrics, Division of Pulmonary Medicine, Columbia University College of Physicians and Surgeons; Attending Physician, Pediatric Pulmonary Medicine, Morgan Stanley Children's Hospital of New York Presbyterian, Columbia University Medical Center
Michael R Bye, MD is a member of the following medical societies: American Academy of Pediatrics, American College of Chest Physicians, and American Thoracic Society
Disclosure: Merck Honoraria Speaking and teaching

 
 
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