One of the first symptoms to be noted in children is the typical expiratory stridor noted within 4 to 8 weeks after birth. This noise may increase during conditions which have more demand for air flow like crying and respiratory illnesses. Wheeze may reduce when the child is quiet. While feeding, some children may show difficulty, cough, regurgitation and cyanosis and hence should not be ignored.

In some cases the symptoms of tracheomalacia resemble that of allergic asthma and make diagnosis difficult. Close observation of the patient may show retractions in the supraclavicular and intercostal spaces. Those with a chronic form of tracheomalacia may develop abnormalities in the thoracic region which may be pronounced. This is more common among young children. In severe cases of tracheomalacia, the child may present with difficulty in breathing, dyspnea, cyanosis and respiratory failure. Isolated tracheomalacia is often characterized by the presence of bark-like cough. When the tracheal abnormality is in the extrathoracic region, inspiratory stridor may be noticed.

• Fatigue

  We ask about general symptoms (anxious mood, depressed mood, fatigue, pain, and stress) regardless of condition. Last updated: March 28, 2019 [patientslikeme.com]

  […] to physical health Tracheomalazie General population 86.43 HIV 63.96 Hip replacement 12.63 Lung cancer 32.69 Role limitations due to emotional problems Tracheomalazie General population 91.77 HIV 60.83 Hip replacement 69.53 Lung cancer 66.87 Energy fatigue [diseasemaps.org]

• Foreign Body Aspiration

  Differential diagnosis includes foreign body aspiration, difficult controlled asthma and other diseases. This disease may be congenital or it may be acquired. Acquired tracheomalacia can be treated. [ncbi.nlm.nih.gov]

• Hypoxemia

  To the Editor: We describe two cases associated with incidences of life-threatening hypoxemia due to tracheomalacia that were repressed by rocuronium. Case 1: A 6-month-old female was admitted to hospital due to cyanosis. [link.springer.com]

• Aspiration

  Differential diagnosis includes foreign body aspiration, difficult controlled asthma and other diseases. This disease may be congenital or it may be acquired. Acquired tracheomalacia can be treated. [ncbi.nlm.nih.gov]

  Twe had a cycle to break -- his lungs and airway were damaged from the aspiration which made him use his stomach muscles to breathe, which put pressure on his stomach which made him reflux/aspirate. [mothering.com]

  Children with gastroesophageal reflux, or aspiration from above, have an increased incidence of tracheomalacia. The problem in this last situation is trying to decide which condition is the cause and which is the effect. [emedicine.com]

  Reccurent bronchitis and pneumonia Because of these various complications, including tracheomalacia, swallowing dysfunction and/or esophageal strictures and aspiration, and GERD and aspiration, people with EA are more prone to chronic coughs and respiratory [we-are-eat.org]

  Also, aspiration pneumonia can occur from inhaling food. [hopkinsmedicine.org]

• Dry Cough

  He presented at 12 years of age with a 5-month history of shortness of breath on exertion, dry cough, and audible wheeze. [ncbi.nlm.nih.gov]

  GL 95yo M • C/O progressive shortness of breath x 1 month • Associated with dry cough • C/O Wheezing on lying down – better with sitting up. • No fever/chills/night sweats/weight loss • No PND/orthopnea • Treated for CAP with levaquin 3. [slideshare.net]

• Sneezing

  In tracheomalacia, the tracheal rings are not shaped properly, and are usually flattened, making them very collapsible from positive pressure forces, like coughing or sneezing. [luriechildrens.org]

• Choking

  Tracheomalacia should be considered in a patient with HSS who presents with an unusual cry, stridor, choking, or apnea. [ncbi.nlm.nih.gov]

  Major symptoms of tracheomalacia include: difficulty breathing high-pitched or rattling, noisy breaths severe coughing fits that interrupt daily activities episodes of feeling like you are choking lightheadedness due to coughing recurrent pulmonary infections [entcolumbia.org]

  Apnea (halt in breathing) in infants Choking during feeding Chronic cough Chronic chest congestion and infections Difficulty breathing during activity Frequent bronchitis and pneumonia Noisy breathing Stridor (rattling noise when breathing) Wheezing during [childrens.com]

  […] breathing Rattling or noisy breathing (stridor) Frequent infections in the airway, such as bronchitis or pneumonia (because your child can’t cough or otherwise clear his lungs) Frequent noisy cough Exercise intolerance More severe signs may include: Choking [childrenshospital.org]

• Fracture

  • Dynamic features of TBM are quite different from stenosis • Constant change in size and shape of the airway predisposes to stent migration and fracture. • Long-term safety and efficacy data are sparse • Ernst et al. 2007 : silicone stent placement [slideshare.net]

  Adult-acquired tracheomalacia is most commonly post-traumatic due to prolonged or recurrent intubation, tracheal fractures, or chronic inflammation such as chronic obstructive pulmonary disease. 10, 11 Extrinsic compression by bronchogenic carcinoma, [academic.oup.com]

  Uncovered self-expanding metal stents are less likely to fracture or cause vascular erosion, but cannot be dilated and are very difficult to remove [114, 116]. [erj.ersjournals.com]

Imaging techniques like computed tomography (CT scan), fluoroscopy and radiography may help in observing the structure of trachea during respiration and thus in diagnosing abnormalities. Computed tomography is a non-invasive technique that has a sensitivity of about 85% in diagnosing of the condition [9]. Dynamic expiratory CT scan reveals a better picture of the situation when compared to end-expiratory imaging [10]. 

Airway fluoroscopy is another imaging technique for optimal diagnosis of tracheomalacia. It helps to identify the amount of tracheal collapse during quiet respiration and coughing. A tracheal collapse of more than 52% during expiration is considered to be indicative of tracheomalacia. This imaging method also helps to identify the defects in esophagus and blood vessels that lead to a change in the structure of the tracheal wall. Radiography also shows collapse of tracheal lumen and also vascular abnormalities including double aortic arch. But in most cases further diagnosis may be required for a confirmation.

Pulmonary function testing is the recommended laboratory method for diagnosis of tracheomalacia. This method is more commonly used in adults than in children. A pulmonary function test may show a truncated curve for expiration in patients with this condition. 

Endoscopy also helps in a more definitive diagnosis of the condition. It reveals the collapse of the tracheal walls during expiration. Laryngoscopy and bronchoscopy also help in observing the airways during the respiration. Direct visualization of the lumen during respiration helps in confirmation of the diagnosis. A confirmed diagnosis would depend on three factors, change in the shape of the lumen of trachea, extension of the posterior wall, and narrowing of the lumen of trachea. A complete medical history of the patient is equally important.

Tracheomalacia in most of the cases is benign and hence conservative management is the safest treatment. As a first step, noninvasive methods are suggested. This includes physical therapy, humidified air, control of infections and careful feeding. In patients who have difficulty in respiration or needs an intervention, continuous positive airway pressure (CPAP) is recommended [8].

Chest physiotherapy is useful in cases where secretions are not cleared. Coexisting or exacerbating conditions if present, should be treated appropriately. If acute respiratory infections are present which increase the symptoms or affect feeding considerably, corticosteroids are suggested. Non-surgical measures are ideal for mild form of tracheomalacia.

Surgical methods are recommended only in those cases where conservative treatments fail and the patient has severe symptoms. In those forms associated with tracheoesophageal fistula and those caused by vascular defects, aortopexy is suggested to widen the tracheal lumen. In diffuse types of tracheomalacia, the use of stents is beneficial. In children, when the condition resolves with time, the cannula can be removed. An underlying cause like tumors or vascular rings should be corrected surgically. When severe symptoms are present in acquired form of tracheomalacia, stenting and tracheostomy may be helpful. If chronic obstructive pulmonary disease is present along with tracheomalacia, it should be treated first for better results. Widening of the posterior wall of the trachea can be corrected by the use of polypropylene and high density polyethylene mesh [11].

One of the most common causes of tracheomalacia is a developmental defect in tracheal cartilage and hence the condition is more prevalent among infants and young children. In most of the cases, it is a self-limiting condition. Primary tracheomalacia generally resolves by around two years of age as trachea develops [8]. The cartilage becomes stronger and the tracheal collapse ceases. Respiratory diseases, inflammatory or infectious, have more intense symptoms and may prolong treatment. Respiratory difficulties are seen only in association with conditions like bronchitis or croup in mild forms of tracheomalacia. But in moderate tracheomalacia, wheezing, stridor, cyanosis and other factors are more common. Children will have wheezing or stridor with normal breathing in case of severe tracheomalacia and this may be life-threatening in some cases.

The disorder is associated with congenital abnormalities like esophageal anomalies, cardiovascular defects and gastroesophageal reflux. About three fourths of the patients with tracheoesophageal fistula is found to have tracheomalacia. Other localized disorders may also cause tracheomalacia including vascular rings, or esophageal artesia [2]. 

Tracheomalacia may be an acquired condition in both children and adults. An asymptomatic period after birth suggests an acquired form. Conditions like presence of endobronchial tube, tracheostomy, chronic tracheobronchitis or inflammation of trachea as in a relapse of polychondritis can result in tracheal abnormality [4]. Prolonged compression of trachea due to benign tumors, aneurysms, cysts or a malignancy may also lead to compressed airways. Tracheomalacia may also develop after procedures like lung transplantation, intubation or tracheotomy.

Tracheomalacia is found to more common among children. The incidence rate of primary tracheomalacia in children is estimated to be about one in 1445 to 2100 children [5]. A study conducted on 299 patients with airway malacia showed that 26.7% have isolated tracheomalacia [6]. Tracheomalacia is associated with a number of other conditions. About 14 to 58% of the patients with this anomaly was found to have cardiac disorders [7]. It was found to be associated with cardiac defects like double aortic arch, septal defects, patent ductus arteriosus and pulmonary artery sling. About 9.7% of the patients with tracheoesophageal fistula had tracheomalacia [6]. More than half of the infants with tracheomalacia was found to have bronchopulmonary dysplasia and gastroesophageal reflux. An overall delay in development, subglottic stenosis and neurological defects are also associated with this abnormality.

Developmental abnormalities in tracheal cartilage results in soft tracheal walls that collapse and obstruct the airway during respiration. It may lead to wheezing and/or stridor. This sound is prominent during inspiration or expiration depending on the location of the lesion. If the abnormality in the extrathoracic part of the trachea, the sound is heard during inspiration. Defects in the intrathoracic part may lead to airway sounds primarily during expiration. Intrathoracic defects and expiratory sounds are more common as most part of the trachea is placed within the thorax.

Extrinsic compression of the trachea may also lead to its collapse and airway obstruction, a condition referred to as secondary tracheomalacia. Benign tumors, vascular rings and artery slings in the pulmonary region all compress the trachea externally. Any disease that affects the structure of trachea may result in a collapse of the trachea during respiration. In many cases the structural abnormality may not be so prominent and may remain undetected. It not only affects airflow but also leads to impaired clearing of secretions in the trachea.

As root cause of the condition is still not clear, definitive preventive measures are not available. But it is possible to prevent the complications associated with tracheomalacia. Continuous monitoring of patients, particularly those who have respiratory infections and illnesses would go a long way in controlling complications. Infants should be fed carefully to prevent aspiration pneumonia. Those who have expiratory noise and breathing difficulty should contact health care provider to reduce problems associated with this disorder.

Tracheomalacia (TM) is a disorder caused by the presence of weak tracheal cartilage and low muscle tone in the posterior wall of trachea leading to the collapse of airway [1]. This structural abnormality in the tracheal wall results in obstruction of airways [2]. Collapse of the airway is more pronounced when the demand of air is increased as in coughing or crying. The abnormality may be localized or involve the entire trachea. It is one of the most common congenital disorder affecting the trachea. This condition is often seen associated with other congenital abnormalities like gastroesophageal reflux, cardiovascular anomalies and esophageal defects. It is seen in both children and adults, but is more common in premature infants [3]. Tracheomalacia is divided into three different types:

• Type I: Congenital tracheomalacia associated with tracheal abnormalities like tracheoesophageal fistula
• Type II: Tracheomalacia caused by external defects causing continued pressure on the trachea including vascular rings, cystic hygromas and tumors
• Type III: Defects caused by chronic infections, intubation or inflammation of the tracheal cartilage

While mild and moderate forms of tracheomalacia remain asymptomatic, severe form of this abnormality can be life-threatening.

Tracheomalacia is a condition in which a structural abnormality in the windpipe causes its collapse during breathing leading to obstruction of airways. Tracheomalacia can be congenital or acquired. Congenital conditions is caused by developmental abnormalities in tracheal structure. Acquired tracheomalacia is caused by diseases that affect the structure of trachea like chronic infections, tumors, inflammation of the tracheal cartilage and prolonged intubation.

Tracheomalacia is seen in infants, young children and adults. One of the most common symptoms is the high-pitched breathing or noisy breathing, especially while breathing out. Recurrent infections in the respiratory tract, shortness of breath, and cough are also seen as symptoms of this condition.

A number of imaging techniques are used to diagnose this condition. Different imaging methods like fluoroscopy, radiography and CT scan help to see the abnormal structure of the trachea. In some of these techniques, both inhalation and exhalation is visualized to see the difference in the structure of trachea while breathing. If the wall of trachea collapses for more than 50% of its normal, it is considered to be indicative of tracheomalacia. Endoscopic methods also help to diagnose the structural defect in trachea.

Severe form of this condition can be life-threatening. But monitoring and appropriate management of the condition helps to resolve the defect. In children, the condition resolves often on its own by the time the child is 24 months old. This is due to the fact that as the child grows, cartilage of trachea also grows and regains its function. Until that time, conservative management including physical therapy and humidified air helps to reduce the symptoms. In some cases when the symptoms are more, surgery may be suggested. Surgery may be used to correct the structure of the trachea either by removing the structures that apply extra pressure on the windpipe or by placing a stent in the trachea to widen the lumen. These stents may be temporary and can be removed after a period of time.

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