Traqueobroncoplastia por malacia / Tracheobronchoplasty for malacia

RESUMEN La traqueobroncomalacia es una enfermedad de la vía aérea central caracterizada por una debilidad de la pared, con disminución dinámica de la luz de la tráquea y grandes bronquios principalmente durante la espiración. Genera síntomas crónicos que pueden evolucionar hasta la falla respiratoria grave, frecuentemente diagnosticados de forma errónea como asma o enfermedad pulmonar obstructiva crónica (EPOC). Presentamos el caso de una paciente femenina de 70 años, con antecedente de artritis reumatoide y múltiples internaciones por cuadros respiratorios infecciosos en los 3 años previos.

ABSTRACT Tracheobroncomalacia is a disease of the central airway due to weakness of the wall with dynamic narrowing of the lumen of the trachea and mainstem bronchi during exhalation. It produces chronic symptoms that can progress to severe respiratory failure, often misdiagnosed as asthma or chronic obstructive pulmonary disease (COPD). We report the case of a 70-year-old female patient with a history of rheumatoid arthritis and multiple hospitalizations for recurrent respiratory infections over the past 3 years.

Traqueomalacia: diagnóstico y alternativas terapéuticas / Tracheomalacia: diagnosis and treatment options

La traqueomalacia (TM) consiste en una excesiva colapsabilidad traqueal debida a una anomalía estructural del cartílago y/o de la pared membranosa posterior. Cuando se extiende a uno o ambos bronquios principales se denomina traqueobroncomalacia (TBM). Considerando diferentes clasificaciones, la mayoría de las TM son adquiridas, localizadas e intratorácicas. El diagnóstico clínico es difícil porque los síntomas son inespecíficos y se superponen con los de otras enfermedades respiratorias crónicas. Los síntomas más frecuentes incluyen estridor espiratorio, tos perruna e infecciones respiratorias recurrentes, en los casos más graves se presentan episodios de dificultad respiratoria severa, cianosis e incluso muerte súbita. La fibrobroncoscopía sigue siendo el método diagnóstico estándar de oro, complementándose con la tomografía computarizada que es esencial en la visualización de las estructuras adyacentes a la vía aérea. En los casos leves el tratamiento es conservador, considerando la resolución espontánea de la mayoría de los casos hacia los 2 años de edad. En los pacientes más sintomáticos la estrategia terapéutica se debe evaluar caso a caso, siendo la presión positiva contínua en vía aérea (no invasiva o invasiva por traqueostomía) el tratamiento más utilizado. En las TM-TBM más severas, entre posibles tratamientos que incluyen cirugía traqueal y prótesis en la vía aérea, lo más usado es aortoarteriopexia y traqueopexia, a la espera de resultados promisorios de mallas endoluminales biodegradables y prótesis reabsorbibles personalizadas impresas en 3D.

Tracheomalacia (TM) is defined as an increased collapsibility of the trachea due to structural anomalies of the cartilaginous rings and/or the posterior membrane. When the main bronchi is also affected this condition is termed as tracheobronchomalacia (TBM). According classifications TM is mostly acquired, localized and intrathoracic. Diagnosing TM is challenging because symptoms are nonspecific and overlap with those of other chronic respiratory disorders. The most common symptoms include expiratory stridor, barking cough and recurrent respiratory tract infections, in severe cases, severe respiratory distress episodes and acute life threatening events can occur. While flexible bronchoscopy is still considered as the gold standard diagnostic method, computed tomography is essential in assessing the surrounding structures. Conservative therapy is preferred in milder cases since the outcome is usually favorable within the first 2 years of life. Treatment of more symptomatic children should be discussed on an individual basis, continuous positive airway pressure (non invasive o invasive via tracheostomy) being the most widely used therapy. For more severe TM-TBM, amongst possible treatments including tracheal surgery and airway stenting, aortoarteriopexy and tracheopexy are mostly used, nevertheless absorbable stent and 3D printed customed prosthesis are being developed with promising results.

Atelectasia lobar. Manifestación infrecuente de traqueobroncomalacia en adultos / Lobar atelectasis unusual presentation of tracheobronchomalacia in adults

Resumen Las alteraciones dinámicas del sistema respiratorio que condicionan colapso del lumen traqueobronquial durante la espiración favorecen síntomas inespecíficos o no atribuibles a una enfermedad respiratoria en particular. El diagnóstico preciso de la entidad clínica tiene implicaciones terapéuticas y pronosticas. La traqueobroncomalacia se diagnostica cuando existe una disminución en el lumen traqueobronquial mayor al 50% visible mediante exploración con broncoscopía. La etiología más frecuente en adultos es la forma adquirida y es rara la asociación con atelectasia.

Abstract Respiratory dynamic abnormalities that contributes with collapse of the airway luminal during expiration can cause nonspecific symptoms or not related to a respiratory disease. Accurate diagnosis of the clinical entity has therapeutic implications and is important for the prognosis. Tracheobronchomalacia is diagnosed when there is a decrease in the lumen tracheobronchial greater than 50% visible through exploration with Bronchoscopy. The main etiology in adults was the acquired form and association with lung atelectasis was rare.

Stridor and respiratory failure due to tracheobronchomalacia: case report and review of the literature / Estridor e falência respiratória devido a traqueobroncomalácia: relato de caso e revisão da literatura

CONTEXT: Tracheobronchomalacia (TBM) results from structural and functional abnormalities of the respiratory system. It is characterized by excessive collapse: at least 50 percent of the cross-sectional area of the trachea and main bronchi. In this paper, we present a rare case of a patient with TBM who first presented with stridor and respiratory failure due to exacerbation of chronic bronchitis. CASE REPORT: An 81-year-old Caucasian man was admitted presenting coughing, purulent sputum, stridor and respiratory failure. He had a medical history of chronic obstructive pulmonary disease (COPD) and silicosis and was a former smoker. Axial computed tomography on the chest revealed marked collapse of the trachea in its middle third. Bronchoscopy showed characteristics compatible with TBM. He was treated with noninvasive ventilation, without any good response. Subsequently, a Dumon Y stent was placed by means of rigid bronchoscopy. After the procedure, he was discharged with a clinical improvement. CONCLUSION: TBM is fatal and often underdiagnosed. In COPD patients, stridor and respiratory failure may be helpful signs that should alert physicians to consider TBM as an early diagnosis. Thus, these signs may be important for optimizing the treatment and evolution of such patients.

CONTEXTO: Traqueobroncomalácia (TBM) é resultado de alterações funcionais e estruturais do aparelho respiratório. É caracterizada pelo colapso excessivo de pelo menos 50 por cento da área de secção transversal da traqueia e dos brônquios principais. Neste trabalho, descrevemos um raro caso de paciente com TBM que primeiro apresentou estridor e insuficiência respiratória devido à exacerbação da bronquite crônica. RELATO DE CASO: Homem de 81 anos de idade, caucasiano, foi admitido apresentando tosse, expectoração purulenta, estridor e falência respiratória. Ele apresentava história médica prévia de doença pulmonar obstrutiva crônica (DPOC), silicose e era ex-tabagista. A tomografia axial computadorizada de tórax revelou marcado colapso da traqueia em seu terço médio. A broncoscopia mostrou aspectos compatíveis com TBM. Foi submetido a ventilação não invasiva, sem boa resposta. Na sequência, foi colocado stent Dumon em Y por broncoscopia rígida. Após o procedimento, o paciente teve alta com melhora clínica. CONCLUSÃO: TBM é uma entidade fatal e muitas vezes subdiagnosticada. Em pacientes com DPOC, o estridor e a insuficiência respiratória podem ser sinais úteis que devem alertar os médicos a considerar TBM como diagnóstico precoce. Assim, pode ser importante para otimizar o tratamento e a evolução dos pacientes.

Traqueobroncomalacia en niños / Tracheobronchomalacia in children

Tracheobronchomalacia refers to the presence of trachea and bronchi with soft, collapsible walls. Its incidence has been reported from 1:1500 to 1:2500. It can be congenital or acquired. This disease ranges from mild to life threatening. A high clinical suspicion is required for diagnosis, which needs to be confirmed endoscopically. Depending on severity, treatment can include from physical therapy and antibiotics to mechanical ventilation, surgery and tracheostomy, and is based on expert opinion and case series. Prognosis is usually good, with tendency to spontaneous resolution near the 2d year of life.

Traquebroncomalacia se refiere a la presencia de tráquea y/o bronquios cuya pared es blanda y tiene tendencia al colapso. Se ha reportado una incidencia entre 1:1.500 a 1:2.500. Puede ser congénita o adquirida. La severidad de los síntomas varía desde leve a incluso riesgo vital y muerte. El diagnóstico requiere una alta sospecha clínica y confirmación endoscópica. El tratamiento está basado en opiniones de expertos y series clínicas y varía según la severidad de los síntomas desde kinesioterapia y antibióticos en los casos más leves hasta ventilación mecánica, traqueostomía y cirugía en los más severos. El pronóstico en general es bueno con tendencia a la resolución espontánea aproximadamente a los 2 años de vida.