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17. Surgical Treatment of Diffuse Tracheobronchomalacia
Simon K Ashiku, Jr., Robert L. Thurer, Armin Ernst, David Feller-kopman, Stephen Loring, Carl Odonnell, Phillip M Boiselle, Malcolm M Decamp; Boston, MA

Objective:
Tracheobronchial malacia (TBM) results in flattening of the normally C-shaped tracheal rings and redundancy of the posterior membranous wall. TBM is more frequently recognized, though little is known regarding its optimal management. The objective of this study was to describe its presentation, efficacy of diagnostic modalities, and response to surgical therapy.
Methods:
Patients with suspected TBM were evaluated by a multidisciplinary airway team and underwent spirometry, dynamic airway CT scanning, and awake bronchoscopy under dynamic breathing conditions with intraesophageal manometry both before and within 3 months after right thoracotomy with membranous tracheobronchoplasty.
Results:
Between April 2002 and September 2004, 17 consecutive patients with diffuse TBM underwent membranous tracheobronchoplasty with polypropylene mesh. Mean age was 58 (range 39-80), 10 (59%) were men, and 13 (76%) had > 30 pack-years of smoking. Patients had been previously diagnosed with: COPD (8), asthma (5), obstructive sleep apnea (4), and localized bronchiectasis (3). Common symptoms were inability to clear secretions with recurrent infections 17 (100%), progressive dyspnea 16 (94%), and intractable cough 3 (18%). CT scan documented collapse in 16 (94%) patients, while bronchoscopy detected collapse in all patients. Spirometry was not useful for diagnosis. There were no postoperative deaths, infections or reoperations. Sixteen (94%) patients had complete or near-complete resolution of symptoms within 3 months. One patient had sub-optimal restoration of normal tracheal configuration and only partial symptomatic relief.
Conclusions: Diffuse TBM though infrequently diagnosed, is likely a more common explanation for exertional dyspnea and productive cough in the setting of unremarkable spirometry. Unless properly diagnosed and treated, symptoms are progressive and debilitating. Dynamic airway CT is an excellent screening test, but awake bronchoscopy with forced expiratory maneuvers is diagnostic. In experienced hands, tracheobronchoplasty with polypropylene mesh restores normal airway anatomy and improves clearance. When properly selected by a multidisciplinary airway team, patients with diffuse TBM can expect relief of their debilitating symptoms in over 90% of cases.

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