Tracheobronchomalacia
ICD-10 J39.8 · ICD-11 CA0Y

Tracheobronchomalacia with Transverse or Circumferential Airway Malformation When Maximum Medical Therapy Has Not Achieved Airway Control

This protocol applies to patients with tracheobronchomalacia who present with a specific anatomic variant — transverse tracheal or bronchial malformation, scabbard or lateral airway deformity, or circumferential collapse — and in whom a full course of maximum medical management has not achieved the required clinical milestones.

Clinical Scenario
The airway demonstrates transverse tracheal and/or bronchial malformation, scabbard or lateral deformity, or circumferential collapse deformity. These anatomic variants present structural challenges that differ from standard tracheobronchomalacia and often require approaches beyond conventional tracheopexy alone.
Prior Treatment Line — Escalation Trigger
The preceding treatment line comprised maximum medical therapy targeting mucociliary clearance: Ipratropium bromide (Atrovent®), nebulized normal or hypertonic saline, pulmonary hygiene and chest physiotherapy, low-dose inhaled corticosteroids, early antibiotics for active infections, and gastroesophageal reflux control. This protocol is indicated when that regimen has not achieved controlled airway secretions and respiratory infections, or has not established at least two weeks of adequate growth and positive nitrogen balance.
Surgical Approach — Partial Overview
Management centers on direct tracheopexy combined with a customized external airway splinting technique designed to provide the specific lateral or circumferential support that standard tracheopexy approaches cannot deliver in these anatomic variants. The complete intraoperative protocol — including construct selection, material details, and technique — is available in the full regimen.
Target: greater than 50% airway patency at −50 mmHg suction (Munoz maneuver).
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References

  • We found that anterior and posterior tracheobronchopexy have limited utility in cases of transverse tracheal and/or bronchial malformations and that application of an external splint provides better airway support in these conditions, often in combination with the other procedures.
  • We pursue direct tracheopexy options for all of our patients as the first-line surgical intervention but find these certain anatomic variants (scabbard or lateral deformities, circumferential collapse) to require additional support from the external splints.
  • Our team at the EAT Center has been utilizing readily available moldable bioresorbable plates (Rapid-Sorb, Synthes CMF) to make customized external splints intra-operatively in patients found to have transverse compression or malformations (scabbard deformities) and circumferential collapse deformities, which require lateral or circumferential support.
  • Our goal is greater than 50% airway patency at minus 50mmHg suction applied to the airways.
  • DOI: 10.1016/j.sempedsurg.2021.151062
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