Tracheobronchoplasty for tracheomalacia

Abstract

Tracheobronchomalacia is an uncommon acquired disorder of the central airways. Common symptoms include dyspnea, constant coughing, inability to raise secretions and recurrent respiratory infections. Evaluation includes an inspiratory-expiratory chest computed tomography (dynamic CT), an awake functional bronchoscopy and pulmonary function studies. Patients with significant associated symptoms and severe collapse on CT and bronchoscopy are offered membraneous wall plication. Tracheobronchoplasty is performed through a right thoracotomy. The posterior airway is exposed after the azygous vein is ligated. The posterior wall of the trachea (and usually both main bronchi) is plicated to a sheet of thick acellular dermis (or polypropylene mesh) with a series of 4 mattress sutures of 4-0 sutures from the thoracic inlet to the bottom of the trachea to re-shape the trachea and restore the normal D shape. Patients report generally good results with improvement of their symptoms. Quality of life is usually improved while pulmonary function tests usually are not improved.

Keywords: Tracheoplasty; tracheal surgery; tracheomalacia.

Figure 1

CT scans are helpful to screen for tracheomalacia. (A) Axial CT scan of a patient during inspiration with severe tracheomalacia; (B) axial CT scan of the same patient during expiration. Notice the almost complete collapse of the tracheal lumen.

Figure 2

Schematic drawing of the key elements of a posterior wall membraneous wall tracheoplasty. (A) The membranous wall splinting material is carefully sutured with partial thickness fine 4-0 sutures to the posterior membranous wall to stiffen the membranous wall and reconfigure the shape of the trachea. The strip of the splinting material (I currently use extra thick Alloderm) is carefully measured such that when the sutures are tied the trachea is reconfigured to a more normal shape. Typically 4 rows of sutures are placed across the trachea while 3 are placed across the main bronchi; (B) cross-sectional diagram showing spacing of sutures. The lateral ones restore the D curve of the trachea and the central ones fix the redundant membranous wall to the splinting material. The sutures ideally do not penetrate the tracheal lumen; (C) the completed tracheoplasty with restoration of the normal shape of the trachea.