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Tracheobronchoplasty for Severe Tracheobronchomalacia FREE TO VIEW

Septimiu D. Murgu, MD, FCCP; Henri G. Colt, MD, FCCP
Author and Funding Information

University of California School of Medicine Irvine, CA

Correspondence to: Septimiu Murgu, MD, FCCP, UCI Medical Center, 101 the City Dr South, Building 53, Room 119, Route 81, Orange, CA 92868; e-mail: smurgu@uci.edu


The authors have reported to the ACCP that no significant conflicts of interest exist with any companies/organizations whose products or services may be discussed in this article.

Reproduction of this article is prohibited without written permission from the American College of Chest Physicians (www.chestjournal.org/site/misc/reprints.xhtml).


© 2009 American College of Chest Physicians


Chest. 2009;135(5):1403-1404. doi:10.1378/chest.08-2660
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To the Editor:

We read with interest the article in a recent issue of CHEST (October 2008) by Majid et al1 on tracheobronchoplasty for the treatment of severe tracheobronchomalacia. Contrary to a previous study,2 the clinical improvements noted in quality of life, dyspnea, and 6-min walk distance were not associated with a significant change in FEV1. The authors offer placebo effect and observer bias as possible explanations for this finding. Another explanation is that the clinical improvements were real but were not identified using FEV1 measurements.

Improved large airway conductance, as expected after tracheobronchoplasty, should be reflected by an increase in FEV1.3 In patients with COPD, the knowledge that therapy with bronchodilators can improve dyspnea, exercise endurance, and health status, with little or no associated change in maximal expiratory flow rates, has prompted a search for other physiologic markers of improved dynamic airway function. These include inspiratory capacity, inspiratory reserve volume, and inspiratory capacity/minute ventilation ratio, all of which are markers of dynamic hyperinflation, which is also a strong predictor of exertional dyspnea. Although these measurements were not performed in the study by Majid et al,1 one might assume that by decreasing the degree of expiratory central airway collapse, exertional airflow limitation and dynamic hyperinflation were also reduced, thus resulting in improved dyspnea and quality of life.

It seems that a majority of patients in the study by Majid et al1 had expiratory central airway collapse from asthma or COPD. Bronchodilator treatment in patients with expiratory central airway collapse often improves hyperinflation, which is reflected by reduced residual volume and increased vital capacity, but results in only a small increase in airflow.4 When patients with expiratory central airway collapse breathe heliox, there is decreased exertional airflow limitation, dynamic hyperinflation, and dyspnea, resulting in improved exercise capacity.5 Heliox is known to modify gas density and improve density-dependent central airway flow. Therefore, treatment by tracheobronchoplasty, by stabilizing and reducing the central airways flow turbulence, might also result in clinical improvement with exertion that might not necessarily be detectable using FEV1 measurements.

Majid A, Guerrero J, Gangadharan S, et al. Tracheobronchoplasty for severe tracheobronchomalacia: a prospective outcome analysis. Chest. 2008;134:801-807. [PubMed] [CrossRef]
 
Wright CD, Grillo HC, Hammoud ZT, et al. Tracheoplasty for expiratory collapse of central airways. Ann Thorac Surg. 2005;80:259-266. [PubMed]
 
O'Donnell DE. Is sustained pharmacologic lung volume reduction now possible in COPD? Chest. 2006;129:501-503. [PubMed]
 
Healy F, Wilson AF, Fairshter RD. Physiologic correlates of airway collapse in chronic airflow obstruction. Chest. 1984;85:476-481. [PubMed]
 
Palange P, Valli G, Onorati P, et al. Effect of heliox on lung dynamic hyperinflation, dyspnea and exercise endurance capacity in COPD patients. J Appl Physiol. 2004;97:1637-1642. [PubMed]
 

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References

Majid A, Guerrero J, Gangadharan S, et al. Tracheobronchoplasty for severe tracheobronchomalacia: a prospective outcome analysis. Chest. 2008;134:801-807. [PubMed] [CrossRef]
 
Wright CD, Grillo HC, Hammoud ZT, et al. Tracheoplasty for expiratory collapse of central airways. Ann Thorac Surg. 2005;80:259-266. [PubMed]
 
O'Donnell DE. Is sustained pharmacologic lung volume reduction now possible in COPD? Chest. 2006;129:501-503. [PubMed]
 
Healy F, Wilson AF, Fairshter RD. Physiologic correlates of airway collapse in chronic airflow obstruction. Chest. 1984;85:476-481. [PubMed]
 
Palange P, Valli G, Onorati P, et al. Effect of heliox on lung dynamic hyperinflation, dyspnea and exercise endurance capacity in COPD patients. J Appl Physiol. 2004;97:1637-1642. [PubMed]
 
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