Treatment for Tracheobronchomalacia After Maximum Medical Therapy Has Not Achieved Adequate Control
This protocol addresses the clinical next step for patients with tracheobronchomalacia (TBM) in whom a complete course of maximum medical therapy has failed to reach the required control targets.
Maximum medical therapy aimed at optimising mucociliary clearance included: Ipratropium bromide (Atrovent®), nebulized saline, pulmonary hygiene and chest physiotherapy, inhaled corticosteroids, early antibiotics for active respiratory infections, and control of gastroesophageal reflux (GER).
Goals not achieved: controlled airway secretions and respiratory infections; adequate nutrition with at least two weeks of positive nitrogen balance and appropriate growth.
The goal is meaningful improvement of symptomatic TBM, assessed by airway patency response under controlled suction (the Munoz maneuver). Specific response thresholds and assessment criteria are defined in the full protocol.
When medical optimisation is insufficient, the evidence supports a surgical procedure — posterior tracheobronchopexy — addressing the posterior wall of the trachea and/or main bronchi under direct intraoperative bronchoscopic guidance. Full operative details, patient selection criteria, and the complete decision algorithm are available only in the structured protocol below.
References
DOI: 10.1016/j.sempedsurg.2021.151062
- Posterior tracheobronchopexy is the most common first procedure for posterior intrusion type TBM.
- The anesthesia team then inserts the flexible bronchoscope, and the posterior tracheobronchopexy is performed by passing autologous pledgeted (often pleura) polypropylene sutures (Prolene®) into but not through the posterior membrane of the trachea and/or main bronchi and securing them to the anterior longitudinal spinal ligament.
- Symptomatic TBM typically improves following posterior tracheobronchopexy, even in those who have a minor degree of anterior compression (less than 50%).
- Our goal is greater than 50% airway patency at minus 50mmHg suction applied to the airways.