Isolated Tracheabronchomalacia Misdiagnosed for Years as Bronchial Asthma

Abstract

Tracheomalacia (TM) is an abnormal collapse of the tracheal lumen, which often occurs when the cartilaginous part of the trachea has not developed. It is a rare condition but is seen often in infancy and childhood period. The incidence of primary airway malacia in children was estimated to be at least one in 2,100. It has a wide range of etiologies, and it is often localized but rarely generalized as in our case. It could be severe enough to indicate frequent admission and might expose the patient to multiple unnecessary medications. We are reporting a case with unusual primary tracheobronchomalacia (TBM) that was missed for several years with a huge burden on both families and healthcare providers. A five-year-old Saudi girl had multiple admissions to the intensive care unit with similar presentation each time, and she was misdiagnosed as having asthma exacerbation with an occasional chest infection. Bronchoscopy revealed the underlying condition, and the patient was kept on the minimal intervention of nasal continuous positive airway pressure (CPAP) and aggressive airway hydration therapy, all with the goal of improving the patient's outcome and reducing hospital admissions. We emphasize the importance of alerting physicians about malacia as an important cause of recurrent wheezy chest, which is one of the common asthma mimickers; in such cases, flexible bronchoscopy remains the gold standard diagnostic test, while the treatment remained supportive.

Keywords: brochomalacia; bronchial asthma; tracheabronchomalacia; tracheomalacia; wheeze.

Figure 1. Plain chest x-ray, anteroposterior view, showing opacity in the left lower zone with air bronchogram silhouetting the cardiac border and cardiophrenic border (white arrow) and right-sided peribronchial wall infiltrate (yellow arrow), with compensatory mild hyperinflation

Figure 2. Flexible bronchoscopy at mid trachea showing severe narrowing exceeding 90% with the absence of tracheal cartilage (white arrow)

Figure 3. Virtual bronchoscopy at mid trachea showing severe narrowing exceeding 90% with the absence of tracheal cartilage (yellow arrow)