Tracheomalacia
Tracheomalacia
Tracheomalacia is a condition characterized by excessive collapsibility of the tracheal walls due to weakness or softening of the tracheal cartilage, leading to dynamic airway obstruction, particularly during expiration.
🔬 Definition
Loss of structural rigidity of the tracheal cartilage rings resulting in >50% reduction in tracheal lumen during expiration.
🧠 Pathophysiology
Normally, C-shaped tracheal cartilages maintain airway patency.
In tracheomalacia:
• Cartilage becomes weak or floppy
• Posterior membranous wall bulges inward
• Trachea collapses during expiration or coughing
➡ Leads to airway obstruction and airflow limitation.
📚 Types
1️⃣ Congenital Tracheomalacia
Present at birth.
Causes:
- Immature tracheal cartilage
- Associated anomalies:
- Tracheoesophageal Fistula
- Esophageal Atresia
- Vascular Ring
2️⃣ Acquired Tracheomalacia
Causes:
• Prolonged endotracheal intubation
• Chronic airway inflammation
• External compression by tumors
• Chronic infection
Associated diseases:
- Chronic Obstructive Pulmonary Disease
- Relapsing Polychondritis
⚠️ Clinical Features
Typical symptoms include:
• Barking cough
• Expiratory wheeze
• Stridor
• Recurrent respiratory infections
• Dyspnea worsening during crying, coughing, or feeding (infants)
🩺 Diagnosis
Gold standard:
Dynamic bronchoscopy
Other tests:
• Dynamic CT scan
• Pulmonary function tests (show variable intrathoracic obstruction)
📊 Characteristic Spirometry
Shows flattening of expiratory limb of flow-volume loop due to dynamic collapse.
💊 Management
Depends on severity.
Mild cases
- Observation
- Airway clearance therapy
Moderate
- CPAP
- Bronchodilators
Severe cases
- Tracheal stenting
- Surgical tracheoplasty
- Aortopexy (especially in pediatric vascular compression)
🎯 High-Yield Exam Pearls
- >50% expiratory collapse of trachea defines tracheomalacia.
- Symptoms worsen during expiration or coughing.
- Dynamic bronchoscopy = gold standard diagnosis.
- Commonly associated with TEF repair in infants.
- Flow-volume loop shows expiratory flattening.
- Severe cases require tracheal stent or tracheoplasty.
🧠 Classic NEET-SS / DM Question
Expiratory collapse of trachea due to weakened cartilage is called:
A. Bronchiectasis
B. Tracheomalacia
C. Tracheal stenosis
D. Bronchomalacia
✅ Answer: B — Tracheomalacia
1. Diagnostic criterion for tracheomalacia:
A. 20% expiratory collapse
B. >50% expiratory collapse
C. Inspiratory collapse
D. 30% narrowing
Explanation: Diagnostic definition is >50% reduction of tracheal lumen during expiration.
2. Gold standard investigation:
A. Dynamic bronchoscopy
B. Static CT
C. Chest X-ray
D. Spirometry
Explanation: Dynamic bronchoscopy directly visualizes airway collapse during forced expiration.
3. Most common congenital association:
A. Congenital diaphragmatic hernia
B. Tracheoesophageal fistula repair
C. Tetralogy of Fallot
D. Meconium aspiration
Explanation: Many children with repaired tracheoesophageal fistula develop tracheomalacia.
4. Flow-volume loop finding:
A. Inspiratory plateau
B. Expiratory flattening
C. Fixed plateau
D. Normal loop
Explanation: Intrathoracic airway collapse causes flattening of expiratory limb.
5. Classic infant symptom:
A. Hemoptysis
B. Dysphagia
C. Barking cough
D. Orthopnea
Explanation: Barking cough and noisy breathing are classic infant presentations.
6. Primary pathology involves:
A. Weak tracheal cartilage
B. Bronchial mucosa
C. Smooth muscle
D. Pulmonary vessels
Explanation: Loss of rigidity of tracheal rings leads to airway collapse.
7. Expiratory collapse occurs due to:
A. Increased intrathoracic pressure
B. Decreased airway resistance
C. Increased surfactant
D. Increased compliance
Explanation: Increased intrathoracic pressure during expiration compresses weak airway walls.
8. Best CT technique:
A. Inspiratory HRCT
B. Dynamic expiratory CT
C. PET CT
D. Contrast CT
Explanation: Dynamic CT comparing inspiratory and expiratory phases shows airway collapse.
9. Common acquired cause:
A. Prolonged intubation
B. Asthma
C. Pneumonia
D. Tuberculosis
Explanation: Prolonged intubation weakens tracheal cartilage.
10. Severe pediatric treatment:
A. Aortopexy
B. Lobectomy
C. Pleurodesis
D. Pneumonectomy
Explanation: Aortopexy pulls the aorta forward relieving tracheal compression.
11. Posterior tracheal wall behavior:
A. Bulges inward during expiration
B. Calcifies
C. Becomes rigid
D. Disappears
Explanation: The posterior membranous wall prolapses inward during expiration producing crescent-shaped airway collapse.
12. Associated disease:
A. Relapsing polychondritis
B. Silicosis
C. Pneumothorax
D. Sarcoidosis
Explanation: Relapsing polychondritis destroys cartilage including tracheal rings leading to secondary tracheomalacia.
13. Primary physiological effect:
A. Dynamic airway obstruction
B. Restrictive defect
C. Diffusion impairment
D. Pulmonary hypertension
Explanation: Tracheomalacia produces dynamic airway obstruction mainly during expiration.
14. Characteristic auscultation:
A. Expiratory wheeze
B. Fine crackles
C. Pleural rub
D. Bronchial breathing
Explanation: Expiratory airway collapse produces wheezing or noisy breathing.
15. External compression cause:
A. Vascular ring
B. Lung cyst
C. Pneumothorax
D. Bronchiectasis
Explanation: Congenital vascular rings can compress the trachea causing secondary tracheomalacia.
16. CPAP mechanism:
A. Pneumatic airway splinting
B. Increase surfactant
C. Reduce lung recoil
D. Increase compliance
Explanation: CPAP maintains positive airway pressure which splints open the airway.
17. Often misdiagnosed as:
A. Asthma
B. Tuberculosis
C. Pneumonia
D. ARDS
Explanation: Adult tracheomalacia commonly mimics asthma due to expiratory wheezing.
18. Collapse occurs during:
A. Expiration
B. Inspiration
C. Sleep
D. Breath hold
Explanation: Expiration increases intrathoracic pressure leading to airway collapse.
19. Imaging demonstration best during:
A. Forced expiration
B. Quiet inspiration
C. Breath hold
D. Sleep
Explanation: Forced expiration accentuates airway collapse on imaging studies.
20. Definitive adult surgery:
A. Tracheobronchoplasty
B. Lobectomy
C. Pleurectomy
D. Decortication
Explanation: Tracheobronchoplasty reinforces the posterior airway wall using mesh.
21. Pediatric improvement age:
A. 2–3 years
B. 6 months
C. 10 years
D. 15 years
Explanation: As cartilage strengthens with age many children improve by 2–3 years.
22. Airway stents indicated in:
A. Severe adult disease
B. Mild infant disease
C. Normal airway
D. Pneumonia
Explanation: Stents are used temporarily in severe symptomatic airway collapse.
23. Bronchoscopic hallmark:
A. Crescent-shaped collapse
B. Nodular mucosa
C. Ulceration
D. Diverticulum
Explanation: Posterior membrane prolapse produces crescent-shaped airway lumen.
24. Major complication:
A. Recurrent infections
B. Hemoptysis
C. Pneumothorax
D. Lung cancer
Explanation: Poor mucus clearance leads to repeated respiratory infections.
25. Core pathology:
A. Loss of cartilaginous rigidity
B. Ciliary dysfunction
C. Surfactant deficiency
D. Bronchial edema
Explanation: Weak cartilage rings allow airway collapse during expiration.
26. Condition mimicking:
A. EDAC
B. COPD
C. Fibrosis
D. Pneumonia
Explanation: Excessive Dynamic Airway Collapse resembles tracheomalacia but involves posterior membrane laxity.
27. Severe collapse threshold:
A. >75%
B. 30%
C. 40%
D. 50%
Explanation: Collapse greater than 75% of airway lumen indicates severe disease.
28. Best bedside clue:
A. Expiratory noisy breathing
B. Clubbing
C. Cyanosis
D. Fever
Explanation: Expiratory noisy breathing or wheeze is a common clinical clue.
29. Collapse best seen during:
A. Forced expiration
B. Inspiration
C. Sleep
D. Breath holding
Explanation: Forced expiration maximizes airway narrowing making collapse visible.
30. Definitive management diffuse disease:
A. Tracheobronchoplasty
B. Antibiotics
C. Steroids
D. Bronchodilators
Explanation: Diffuse severe tracheomalacia in adults is best treated with tracheobronchoplasty.
