Tracheomalacia Workup

  • Author: Daniel S Schwartz, MD, FACS; Chief Editor: Mary C Mancini, MD, PhD   more...
 
Updated: Jan 19, 2012
 

Imaging Studies

  • Chest radiograph may demonstrate hyperinflation, excessive narrowing of the tracheal lumen during expiration, or vascular anomalies such as double aortic arch; further evaluation usually is required. See the images below. Lateral chest radiograph shows excessive tracheal Lateral chest radiograph shows excessive tracheal narrowing. This shows the trachea during inspiration and expiThis shows the trachea during inspiration and expiration. Tracheal collapse of more than 50% during expiration is diagnostic of tracheomalacia. A 58-year-old woman with a history of polychondritA 58-year-old woman with a history of polychondritis presented with inspiratory stridor and respiratory difficulties. The chest radiograph shows narrowing of the distal trachea on bronchoscopy. More than a 50% decrease in tracheal lumen occurred during expiration (see CT images).
  • Cinefluoroscopy performed with contrast in the esophagus utilizing quiet respiration and coughing has proved to be an optimal means of establishing a diagnosis. During coughing, more than half to complete collapse of tracheal lumen confirms the diagnosis. In addition to showing collapse of the tracheal wall, cinefluoroscopy may identify esophageal defects, and it may reveal deformation of tracheal contour due to vascular anomaly.
  • The dynamic airway collapse is better appreciated with ultrafast CT scans. Dynamic expiratory CT elicits a larger degree of airway collapse than standard end-expiratory CT in patients with tracheobronchomalacia. Fourteen patients (11 men, 3 women; age range, 19-79 y) were included in a study to assess airway collapse for confirmation of a diagnosis of tracheobronchomalacia. Dynamic expiratory CT revealed a significantly greater degree of airway collapse than end-expiratory CT.[10] See the images below. The CT scan of a 58-year-old woman with a history The CT scan of a 58-year-old woman with a history of polychondritis who presented with inspiratory stridor and respiratory difficulties shows tracheal narrowing of the distal trachea. CT image showing tracheal narrowing in a 58-year-oCT image showing tracheal narrowing in a 58-year-old woman with a history of polychondritis who presented with inspiratory stridor and respiratory difficulties. A 3-dimensional reconstruction of CT scan images cA 3-dimensional reconstruction of CT scan images confirms the presence of tracheomalacia in a 58-year-old woman with a history of polychondritis who presented with inspiratory stridor and respiratory difficulties.
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Other Tests

  • In pulmonary function testing, flow volume curve, although usually performed in adults rather than children, may demonstrate a normal inspiratory curve but a truncated expiratory limb.
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Diagnostic Procedures

  • The definitive diagnosis of major airway depends on obtaining an accurate history combined with proper endoscopic evaluation. The airway is directly visualized during spontaneous respiration using ventilating laryngoscope and telescoping bronchoscopy. Flexible bronchoscopy also may be utilized. The findings consist of the following classic triad:
    • Loss of normal semicircular shape of tracheal lumen
    • Forward ballooning of the posterior membranous wall
    • Anteroposterior narrowing of the tracheal lumen
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Contributor Information and Disclosures
Author

Daniel S Schwartz, MD, FACS  Assistant Clinical Professor of Cardiothoracic Surgery, Mount Sinai School of Medicine; Chief of Thoracic Surgery, Huntington Hospital

Daniel S Schwartz, MD, FACS is a member of the following medical societies: American College of Chest Physicians, American College of Surgeons, Society of Thoracic Surgeons, and Western Thoracic Surgical Association

Disclosure: Nothing to disclose.

Coauthor(s)

Sat Sharma, MD, FRCPC  Professor and Head, Division of Pulmonary Medicine, Department of Internal Medicine, University of Manitoba; Site Director, Respiratory Medicine, St Boniface General Hospital

Sat Sharma, MD, FRCPC is a member of the following medical societies: American Academy of Sleep Medicine, American College of Chest Physicians, American College of Physicians-American Society of Internal Medicine, American Thoracic Society, Canadian Medical Association, Royal College of Physicians and Surgeons of Canada, Royal Society of Medicine, Society of Critical Care Medicine, and World Medical Association

Disclosure: Nothing to disclose.

Specialty Editor Board

Richard Thurer, MD  B and Donald Carlin Professor of Thoracic Surgical Oncology, University of Miami, Leonard M Miller School of Medicine

Richard Thurer, MD is a member of the following medical societies: American Association for Thoracic Surgery, American College of Chest Physicians, American College of Surgeons, American Medical Association, American Thoracic Society, Florida Medical Association, Society of Surgical Oncology, and Society of Thoracic Surgeons

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD  Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

Shreekanth V Karwande, MBBS  Chair, Professor, Department of Surgery, Division of Cardiothoracic Surgery, University of Utah School of Medicine and Medical Center

Shreekanth V Karwande, MBBS is a member of the following medical societies: American Association for Thoracic Surgery, American College of Chest Physicians, American College of Surgeons, American Heart Association, Society of Critical Care Medicine, Society of Thoracic Surgeons, and Western Thoracic Surgical Association

Disclosure: Nothing to disclose.

Timothy D Rice, MD  Associate Professor, Departments of Internal Medicine and Pediatrics and Adolescent Medicine, St Louis University School of Medicine

Timothy D Rice, MD is a member of the following medical societies: American Academy of Pediatrics and American College of Physicians

Disclosure: Nothing to disclose.

Chief Editor

Mary C Mancini, MD, PhD  Professor and Chief of Cardiothoracic Surgery, Department of Surgery, Louisiana State University School of Medicine in Shreveport

Mary C Mancini, MD, PhD is a member of the following medical societies: American Association for Thoracic Surgery, American College of Surgeons, American Surgical Association, Phi Beta Kappa, Society of Thoracic Surgeons, and Southern Surgical Association

Disclosure: Nothing to disclose.

References

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Lateral chest radiograph shows excessive tracheal narrowing.
This shows the trachea during inspiration and expiration. Tracheal collapse of more than 50% during expiration is diagnostic of tracheomalacia.
The mechanism of tracheal narrowing is shown here in healthy cases and in cases of tracheomalacia. Adapted from Feist JH, et al. Chest 68:3, Sept, 1975.
Healthy trachea is visualized endoscopically.
A 58-year-old woman with a history of polychondritis presented with inspiratory stridor and respiratory difficulties. The chest radiograph shows narrowing of the distal trachea on bronchoscopy. More than a 50% decrease in tracheal lumen occurred during expiration (see CT images).
The CT scan of a 58-year-old woman with a history of polychondritis who presented with inspiratory stridor and respiratory difficulties shows tracheal narrowing of the distal trachea.
CT image showing tracheal narrowing in a 58-year-old woman with a history of polychondritis who presented with inspiratory stridor and respiratory difficulties.
A 3-dimensional reconstruction of CT scan images confirms the presence of tracheomalacia in a 58-year-old woman with a history of polychondritis who presented with inspiratory stridor and respiratory difficulties.
Patterns of upper airway obstruction are presented here. Patient A has fixed upper airway obstruction. Patient B has variable extrathoracic obstruction, eg, vocal cord dysfunction. Patient C has variable intrathoracic obstruction, eg tracheomalacia.
A flow volume loop shows a pattern of variable extrathoracic obstruction. Truncation of the expiratory limb is present. As the pleural pressure exceeds the airway pressure, airway collapse occurs due to flow limitation during expiration and not during inspiration.
A flow volume loop shows the classic pattern of fixed upper airway obstruction. Truncation of both inspiratory and expiratory limbs is present.
 
 
 
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