tracheomalacia-131030001629-phpapp01.ppt

8/9/2019 tracheomalacia-131030001629-phpapp01.ppt

1/52


2/52

GL 95yo M

C/O rogressi!e s"ortness of #reat" $ %mont"

ssociate' wit" 'ry coug"

C/O ("ee)ing on lying 'own * #etter wit"sitting u+

,o fe!er/c"ills/nig"t sweats/weig"t loss

,o P,D/ort"onea -reate' for CP wit" le!a.uin


3/52

Past Me'ical istory

MAI (progressive pulmonary infilterates on CT scan + per culturereports from BAL in 2007! starte" on A#it$ro + %ifampin +&t$am'utol 'ut patient too it ) * mont$ an" stoppe" ,o follo- ups

Trac$eomalacia per 'ronc$oscopy in 0./200. 1 focal on t$e rig$tsi"e

Tac$ycar"ia1'ra"ycar"ia syn"rome status post pacemaerplacement

Atrial fi'rillation status post A a'lation 3iastolic "ysfunction 4ypertension 4ypot$yroi"ism 5&%3 4istory of previous 5I 'lee"ing 6steoart$ritis Benign positional vertigo


4/52

llergies 0 ,KD

Family "istory1,on contri#utory

2ocial "istory1

*,on smo3er*Occasional 4tO * .uit % years #ac3

*6etire' steel wor3er+

*Li!es at ,


5/52

Me'ications

Combivent 2 puffs times/"ay

DuonebDuonebTI8

Prednisone90 mg "aily

Azithromycin 500 mg daily. Rocephin 1 gram daily.

Cor"arone 200 mg "aily

Calcium -it$ itamin 3 900 mg * ta' ti"

Loveno) 0 mg su': at 'e"time

;epci" 20 mg 'i"

8ynt$roi" *


6/52

4$amination B; **9/92 4% 70 ;ulse o) is ==> on 2L/min via ,C

5&,&%AL? A6 ) @ pleasant an" in no "istress

4&&,T? ,o 6ral/,asal lesions or e)u"ates note"

,&C? ,o 3 lymp$a"enopat$y or t$yromegaly

%&8;I%AT6%? Chest expansion is equal and bilateral with good effort. Faint bilateralwheezing throughout.

4&A%T? %%% normal 8* an" 82 ,o 5M%

AB36M&,? 8lig$tly protu'erant soft ,T/,3 B8 + ,o organomegaly

&DT%&MITI&8? Earm ,o cyanosis clu''ing or e"ema

,&F%6L65IC? 5ait normal Cranial nerves 21*2 are grossly intact

8I,? Earm "ry an" intact


7/52

La#s

%7+7

88+5 %9

7+:

%87 : %5

;+9 8: %+%8


8/52

6a'iology

C=6 %/>/%1 no focal infiltrates

C- c"est %/%8/%1

Diffuse em"ysematous c"anges Patc"y oacities in 6LL an' LLL concerning for

neumonia

Multile linear no'ular oacities at aices


9/52

PF-s

%/8:/5

*F4A%/FAC * normal

*F4A%* normal*,o significant c"anges wit" #ronc"o'ilator

*Flow !olume loo * unremar3a#le

*-LC * ele!ate' Bs"ows "yerinflation*DLco 0 normal


10/52


11/52

-rac"eomalacia

Malacia G Hsoftness

,ormal intrat$oracic trac$ea"ilates some-$at -it$inspiration an" narro-s -it$e)piration

,arro-ing is most prominent-$en intrat$oracic pressure issu'stantially greater t$anintraluminal pressure as it is"uring force" e)pirationcoug$ or t$e alsalva

maneuver &)trat$oracic or cervical TM

upper air-ay collapses "uringinspiration


12/52

-yes

Tracheomalacia - trachea

Bronchomalacia - one or both of

the main-stem bronchiTracheobronchomalacia - both


13/52

4$cessi!e 'ynamic

airway collase

re -rac"eomalacia & Dynamic

airway collase t"e same%+ -rac"eo#ronc"ial collase@

8+ 4$iratory trac"eo#ronc"ial collase@

;+ 4$iratory trac"eo#ronc"ial stenosis@

7+ -ac"eo#ronc"ial 'ys3inesia

En!agination of t"e osterior mem#rane

softening of t"e suorting cartilage an' "yotonia of myoelasticelements

-rac"eo#ronc"ial lumen 'uring

coug"ing is %:*;9 narrower t"an t"e

ma$imal insiratory lumen o#ser!e' 'uring

restful resiration


14/52

irway lumen 'uring insiration B+ During e$iration t"ere is inwar' #ulging of t"e osterior mem#rane+-"is rocess is "ysiological an' is calle' 'ynamic airway collase BDC B


15/52

4istory *.=7 ! C#y$lar# ? -as t$e first to "escri'e t$e postmortem fin"ing of an

unusually large trac$ea an" 'ronc$i

*== 1 Lemoine ? -as t$e first to use 'ronc$oscopy to "ocument acJuire"trac$eal enlargement in t$e a"ult

*=


16/52

www.chronolab.com/embryo/respiratory.htm

4th week : endodermallining of the respiratory

diverticulum gives rise tothe epithelial lining of thelarynx, trachea, bronchiand alveoli

The cartilaginous andmuscular components ofthe trachea and lungs arederived from the

surrounding splanchnicmesoderm

&m'ryology

1. 8tomo"eum

2 ;$aryngeal gut

@ T$yroglossal "uct

Trac$eo'ronc$ial "iverticulum
http://www.chronolab.com/embryo/respiratory.htmhttp://www.chronolab.com/embryo/respiratory.htmhttp://www.chronolab.com/embryo/respiratory.htm


17/52

!lassi"cation

!ongenital disease #also called primary$: conse%uence of theinade%uate maturity of tracheobronchial cartilage

& 'olychondritis

& !hondromalacia

& (ucopolysaccharidoses: )unter syndrome and )urlersyndrome

& Idiopathic giant trachea or Mounier- Kuhnsyndrome

& most common associated disease is tracheoesophageal"stula

trachea receiving too much tissue during embryologicseparation

*c%uired disease #also called secondary$


18/52

AcJuire" Trac$eomalacia

'osttraumatic& 'ost-intubation

& 'ost-tracheostomy

& +xternal chest trauma

& 'ost-lung transplantation

+mphysema !hronic infectionbronchitis

!hronic inammation& .elapsing polychondritis

!hronic external compression of the trachea& (alignancy

& Benign tumors

& !ysts

& *bscesses

& *ortic aneurysm

/ascular rings, previously undiagnosed in childhood


19/52

(ounier- 0uhn syndrome

Third or fourth decade of life *trophy of longitudinal elastic "bers and thinning of

the muscularis mucosa

1iagnostic criteria: if& .ight mainstem 2 34cm

& eft mainstem 2 35cm

& Trachea exceed 2 56 cm

7ecretions are poorly mobili8ed, leading to the chronicaccumulation of secretions

& .ecurrent infections,

& Bronchiectasis

& .arely pulmonary "brosis


20/52

Trac$eostomy

1egeneration of normal cartilaginous support

& 'rolonged intubation

& Tracheotomy

& 7evere tracheobronchitis

'ost-intubation 9malacia is most commonly 5 cm inlength and is segmental in nature

'redisposing factors

& .ecurrent intubation,

& 1uration of intubation

& ;se of high-dose steroids

& !hronic inammation

&


21/52

Trac$eostomy/Intu'ation

SITES& 7toma

& cu= site

& impingement point Mechanism

& 'ressure necrosis,

&


22/52

.elapsing 'olychondritis

Hrecurrent episo"es ofinflammation of t$e cartilageof various tissues of t$e'o"y

Involves trac$eal rings in of cases 'ut t$erespiratory symptoms arefoun" on presentation inonly *> of cases

Eorse prognosis an" poorerresponse to corticosteroi"s

(orl' 6a'iol+ 8% uly 8:H 8B1 8;087

C"aracteristic t"ic3ening of t"e anterior cartilaginous wall of

t"e trac"ea + -"e osterior mem#ranous wall is unin!ol!e'


23/52

4istology

;ars mem'ranacea is "ilate"an" flacci"

Anterio1posterior narro-ing oft$e 'ronc$ial lumen

Atrop$y of t$e longitu"inalelastic fi'ers of t$e parsmem'ranacea

T$e normal trac$eal cartilage1to1soft tissue ratio is appro)imately< ? * In patients -it$ TBMt$is ratio is often as lo- as 2 ? *


24/52

;revalence

*= TBM 1 92> isolate" BM in*

*==2 1 Ie"a 8 4ana-a T onis$i T et al

! %ate of air-ay collapse -as in -it$ from pulmonary "isease -$o un"er-ent

'ronc$oscopy


25/52

8ymptoms

Dyspnea* Cough Sputum production

)emoptysis

(ore symptoms during forced exhalation


26/52

"tt1//www+youtu#e+com/watc"!J80>%P$04&featureJrelate'"tt1//www+youtu#e+com/watc"!J80>%P$04&featureJrelate'
http://www.youtube.com/watch?v=j2-61pPx-ZE&feature=relatedhttp://www.youtube.com/watch?v=j2-61pPx-ZE&feature=relatedhttp://www.youtube.com/watch?v=j2-61pPx-ZE&feature=relatedhttp://www.youtube.com/watch?v=j2-61pPx-ZE&feature=relatedhttp://www.youtube.com/watch?v=j2-61pPx-ZE&feature=relatedhttp://www.youtube.com/watch?v=j2-61pPx-ZE&feature=relatedhttp://www.youtube.com/watch?v=j2-61pPx-ZE&feature=relatedhttp://www.youtube.com/watch?v=j2-61pPx-ZE&feature=related


27/52

3iagnosis

experience respiratory distress,whee8ing, and apparent stridor? onextubation

$ne%plained e%tu"ation &ailureshould prompt e'aluation &or TM(


28/52

6a'iology

'lain "lms: not good

& compression from other structuresmay be occasionally seen


29/52

%a"iology

@A6s: Tracheograms andBronchograms:

& radiopa%ue material into the trachea,to outline the bronchial tree and toevaluate the si8e of the structures

!inetracheograms were used in the

hopes of seeing >tracheal utter,? Cluoroscopy


30/52

>Dold 7tandard?

1irect visuali8ation by bronchoscopy todocument a narrowing of at least E6F in thesagittal diameter in expirationG& (ild : obstruction during expiration is to one half of

the lumen& (oderate : reaches three %uarters of the lumen

& 7evere : the posterior wall touches the anterior wall

7training!oughing/alsalva :& to elicit airway wall collapse,

& the expiratory e=ort to achieve collapse has neverbeen standardi8ed

I ,uutinen + c.uire' trac"eo#ronc"omalacia1 a clinical stu'y wit" #ronc"ological correlations+ nn Clin 6es %9H91;5*;55


31/52


32/52

Dynamic C- scan

1ynamic !T scan images, although not thereference standard, are useful in diagnosing

T(

+nd-expiratory imaging rather than dynamicexpiratory imaging may re%uire a lowerthreshold criterion for diagnosing TB(

Frown face

"tt1//imaging+consult+com/image2earc".uery Jlumen&t"esJfalse&resultOffsetJ%%
http://imaging.consult.com/imageSearch?query=lumen&thes=false&resultOffset=11http://imaging.consult.com/imageSearch?query=lumen&thes=false&resultOffset=11http://imaging.consult.com/imageSearch?query=lumen&thes=false&resultOffset=11http://imaging.consult.com/imageSearch?query=lumen&thes=false&resultOffset=11http://imaging.consult.com/imageSearch?query=lumen&thes=false&resultOffset=11http://imaging.consult.com/imageSearch?query=lumen&thes=false&resultOffset=11http://imaging.consult.com/imageSearch?query=lumen&thes=false&resultOffset=11http://imaging.consult.com/imageSearch?query=lumen&thes=false&resultOffset=11http://imaging.consult.com/imageSearch?query=lumen&thes=false&resultOffset=11http://imaging.consult.com/imageSearch?query=lumen&thes=false&resultOffset=11


33/52

(ulti-detector !T

;ermit imaging of t$e entire central air-ays in only afe- secon"s

5ileson et al (200*? reporte" agreement 'et-een"ynamic e)piratory CT scan fin"ings an"collapsi'ility seen "uring 'ronc$oscopy

$ang et al (200 control su'Nects 90> an" -as more severe in t$e

patients -it$ TM


34/52

Excessive narrowing of bronchi black arrows!

"reas of geographicall# marginated radiolucenc# white arrows! within lungs$ % air trapping

"ang @ asegawa E@ ata#u @ et al+ Fre.uency an' se!erity of air traing at 'ynamic e$iratory C- in atients wit"

trac"eo#ronc"omalacia+ 6 m 6oentgenol 87H %:81:%*:5


35/52

2aggital reconstruction


36/52

1ynamic (.collapsi"ility inde%?

& !< J #(axcsa& (incsa$(axcsa

& lack of ioni8ing radiation


37/52

(ultiplanar !T

Three-dimensional !T scan reconstructions,

/irtual bronchoscopy

K)L multiplanarM& images are less than ideal for evaluating airways

that course obli%uely #eg., the mainstem bronchi$


38/52

Airtual #ronc"oscoic image o#taine' at le!el of #ronc"us

interme'ius 'uring full insiration s"ows mil'ly narrowe'

#ut atent rig"t mi''le BM an' lower BL lo#e #ronc"i+

Airtual #ronc"oscoic image o#taine' 'uring 'ynamic

e$iration s"ows mar3e' narrowing of rig"t mi''le lo#e

#ronc"us Bstraig"t arrow wit" comlete collase of lower

lo#e orifice Bcur!e' arrow +

2"a'e'0surface

'islay image ofcentral airways in

ostero0lateral

roection s"ows

'iffuse narrowing

of trac"ea an'

#ronc"i Barrows +


39/52

'ulmonary functionstudies

Fseful 'ut not "iagnostic

8pirometry is not in proportion to t$e severity of

malacia

Decrease' F4A% an'

a low PF6 wit" a

rai' 'ecrease in

flow

,ear comlete a#sence

of t"e usual sloing"ase of t"e mi'0

ortion of t"e cur!e

IMay #e seen in mo'erate0to0se!ere em"ysema


40/52

Clow oscillations

7e%uence of alternating decelerations and accelerationsof ow, are often seen on the expiratory curve

*lso seen in

& redundant pharyngeal tissue, as in obstructive sleepapnea syndrome,

& structural or functional disorders of the larynx,

& neuromuscular diseases

/incken K, !osio (D Clow oscillations on the ow-volume loop: a nonspeci"cindicator of upper airway dysfunction Bull +ur 'hysiopathol .espir @AHEN3@:EEA&EO


41/52

Treatment

7upportive &

& unless the situation is emergent or progressivelyworsening

T( fre%uently occurs in patients who also have !P'1:

& the obstructive disorder optimally should be treated "rst

Bronchospasm must be controlled

& large pressure swings in the thorax

& worsening the degree of collapse of the malacic trachealsegments


42/52


43/52


44/52


45/52

2tents + + +

2ilicone stents

* easily inserte'@ reositione'@ an'

remo!e'

Pro#lems

* rigi' #ronc"oscoy an' general

anest"esia

* stent migration Bnew coug"* 'irect !isuali)ation an'

reositioning


46/52

Dynamic features of - years as 9@ >@ 5%@ 7@;: an' 8;@ resecti!ely+ B'ie' of comor#i' causes


47/52

2urgical Otions

Tracheostomy

& either bypass the malacic segment

& might splint the airway open


48/52

2urgery


49/52

Measure of success QQ

%+ Emro!ement of resiratory symtoms@

8+ Clearing of infectious rocesses@

;+ Lac3 of stent comlications

7+


50/52

-wenty0two atients un'erwent ;7 trac"eal an'/or #ronc"ial stent lacement

roce'ures for #enign airway stenoses an' "a' t"e results of ulmonary

function tests a!aila#le+ 2tent lacement in'ications inclu'e' #ronc"omalacia

after lung translantation Bn%%@ ostintu#ation stenoses Bn>@ relasing

olyc"on'ritis Bn8@ an' % eac" of trac"eomalacia@ trac"eal comression@ an'

"istolasmosis+

Gotway M


51/52

Kelly + Car'en@ P"ili M+


52/52

Thanks

Documents

tracheomalacia-131030001629-phpapp01.ppt