Obstructive Lung Diseases: Obstructive Lung Disease |

“Exertional Wheeze” Initial Presentation of an Under Recognized Disease - Tracheomalacia FREE TO VIEW

Pavan Gorukanti, MD; Mangalore Amith Shenoy, MBBS; Omar Taha, MD; Karishma Kitchloo, MD; Suchit Khanijao, MBBS; Shyam Shankar, MBBS; Animesh Gour, MBBS; Kabu Chawla, MD
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Maimonides Medical Center, Brooklyn, NY

Copyright 2016, American College of Chest Physicians. All Rights Reserved.

Chest. 2016;149(4_S):A403. doi:10.1016/j.chest.2016.02.418
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SESSION TITLE: Obstructive Lung Disease

SESSION TYPE: Case Report Poster

PRESENTED ON: Sunday, April 17, 2016 at 11:45 AM - 12:45 PM

INTRODUCTION: Tracheomalacia (TM) is defined as airway luminal narrowing of more than 50% on expiration1. It may cause dyspnea, cough, and wheezing, which are often indistinguishable from presentations of many common respiratory diseases. We describe an interesting case of TM initially being treated as “Asthma.”

CASE PRESENTATION: 85 year old Female, nonsmoker, with longstanding GERD, presented with six months of dry cough, dyspnea, and wheezing worse on exertion. Exam revealed a frail elderly lady with normal resting vitals, and vesicular breath sounds at rest; however she developed hypoxia with oxygen saturations to low 90s on minimal exertion and wheezing. Routine labs showed no gross abnormalities. Chest X-ray was unrevealing. She was empirically treated with bronchodilators, steroids, and antibiotics without significant improvement. Subsequently, a CT chest demonstrated near complete collapse of a segment of tracheal lumen. Bedside spirometry was attempted, but she was unable to perform adequately. Bronchoscopy showed extensive expiratory luminal narrowing of 11cm of trachea. The involved segment was too extensive for stent consideration. She did not wish to pursue any invasive treatments or NIPPV trials but agreed to follow with us closely to monitor for progression.

DISCUSSION: The actual prevalence of TM is unknown, however some degree has been identified in up to 22% of patients undergoing bronchoscopy2. Common causes of TM in adults include COPD, prolonged intubation, recurrent infections, irritant exposure, and GERD. Symptoms often first manifest under conditions of stress, during infections, on exertion, or with valsalva maneuvers. Bronchoscopy is the gold standard for diagnosis but newer modalities like dynamic imaging CT have also proven to be sensitive in diagnosing TM. Asymptomatic patients must be monitored for progression. Symptomatic patients amenable to surgical intervention should be considered for a silicon stent trial, and those with favorable response should be considered for definitive surgical correction1. Patients not responding to stent trials, or poor surgical candidates may pursue other options such as NIPPV, or tracheostomy for the most severe cases1.

CONCLUSIONS: TM is a frequently overlooked cause of respiratory distress. It is important to recognize it as a causative etiology, as management options differ from those of the common diseases it mimics. TM is a progressive disease in most patients, and a failure to detect it in a timely manner may not only lead to inappropriate treatment, but can also lead to potentially life threatening complications.

Reference #1: Carden KA, Boiselle PM, Waltz DA, Ernst A. “Tracheomalacia and tracheobronchomalacia in children and adults: an in-depth review.” Chest 2005;127:984.

Reference #2: Hasegawa I, Boiselle PM, Raptopoulos V et al. “Tracheomalacia incidentally detected on CT pulmonary angiography of patients with suspected pulmonary embolism.” AJR Am J Roentgenol. 2003;181(6):1505-9.

DISCLOSURE: The following authors have nothing to disclose: Pavan Gorukanti, Mangalore Amith Shenoy, Omar Taha, Karishma Kitchloo, Suchit Khanijao, Shyam Shankar, Animesh Gour, Kabu Chawla

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