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      Diagnosis and management of an elderly patient with severe tracheomalacia: A case report and review of the literature

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          Abstract

          Severe adult tracheomalacia is a dangerous disease that is difficult to manage, particularly at the time of airway infection, and has a high mortality rate. The present study reports the diagnosis and treatment of an elderly patient with severe adult tracheomalacia. In March 2012, the 59-year-old patient presented with progressive dyspnea to the Department of Respiratory Medicine, Taizhou People’s Hospital (Jiangsu, China). Following admission, chest radiography revealed symptoms consistent with chronic obstructive pulmonary disease (COPD) and chest computed tomography (CT) demonstrated an evident stenosis of the tracheal lumen at the end of expiration. Bronchoscopy revealed a 91% reduction in the cross-sectional area of the tracheal lumen at the end of expiration. Following the final diagnosis, the patient was successfully treated with nasal continuous positive airway pressure (CPAP) combined with implantation of a temporary Chinese Li’s metallic stent. These treatment methods appeared to be temporarily effective in alleviating the symptoms of the disease.

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          Most cited references 15

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          Airway stabilization with silicone stents for treating adult tracheobronchomalacia: a prospective observational study.

          It is postulated that in patients with severe tracheobronchomalacia (TBM), airway stabilization with stents may relieve symptoms. To evaluate the effect of silicone stents (tracheal, mainstem bronchus, or both) on symptoms, quality of life, lung function, and exercise capacity in these patients. A prospective observational study in which baseline measurements were compared to those obtained 10 to 14 days after stent placement. Of 75 referred patients, 58 had severe disease and underwent therapeutic rigid bronchoscopy with stent placement. Mean age was 69 years (range, 39 to 91 years), 34 were men, 33 had COPD, and 13 had asthma. Almost all patients (n = 57) had dyspnea as a sole symptom or in combination with cough and recurrent infections; four patients required mechanical ventilation for respiratory failure. In 45 of 58 patients, there was reported symptomatic improvement; quality of life scores improved in 19 of 27 patients (p = 0.002); dyspnea scores improved in 22 of 24 patients (p = 0.001); functional status scores improved in 18 of 26 patients (p = 0.002); and mean exercise capacity improved from baseline, although not significantly. The 49 complications included mainly 21 partial stent obstructions, 14 infections, and 10 stent migrations. Most patients with concomitant COPD also improved on most measures. In the short term, airway stabilization with silicone stents in patients with severe TBM can improve respiratory symptoms, quality of life, and functional status. Coexisting COPD is not an absolute contraindication to a stenting trial in this population. Stenting is associated with a high number of short-term and long-term but generally reversible complications.
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            Nasal continuous positive airway pressure in the treatment of tracheobronchomalacia.

            The effect of nasal continuous positive airway pressure (CPAP) was assessed in three patients with tracheobronchomalacia (TBM) who failed conventional medical management. Using physiologic measures of airflow and fiberoptic bronchoscopy, we evaluated expiratory airflow and airway collapse during the acute administration of nasal CPAP. FVC increased and dynamic airway collapse [slow vital capacity minus forced vital capacity (SVC--FVC)] decreased with increasing levels of CPAP. Notching associated with airway collapse was observed in the baseline spirograms of all three patients, and it disappeared with the addition of nasal CPAP. Fiberoptic bronchoscopy confirmed the severity of TBM in each patient and documented an acute improvement in expiratory airway collapse with the addition of nasal CPAP. Intermittent nasal CPAP was then added to the patients' treatment regimens, improving the course of their disease. Specific treatment outcomes varied from patient to patient, but they included improved sputum production, atelectasis, exercise tolerance, and patient symptoms plus reduced need for medical care. These findings suggest that the addition of intermittent nasal CPAP to routine medical therapy may be of benefit to patients with severe TBM unresponsive to conventional medical management.
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              Outcomes of tracheobronchial stent placement for benign disease.

              To retrospectively determine long-term outcomes in patients who have undergone tracheobronchial stent placement for benign diseases. Institutional Review Board approval was obtained for this retrospective HIPAA-compliant study, with waiver of informed consent. Forty patients (22 female, 18 male; mean age, 52.0 years) who were treated with metallic airway stents for benign stenosis were identified from an interventional radiology database. Causes of airway stenosis included transplant stricture (n = 13), tracheal tube injury (n = 10), inflammation (n = 6), tracheobronchomalacia (n = 4), infection (n = 3), and extrinsic compression (n = 4). Follow-up, which ranged from 6 to 2473 days, was performed by means of chart review for deceased patients and by means of clinical visit or telephone interview for surviving patients. Survival, primary patency, and assisted patency were estimated by using the Kaplan-Meier product limits method. Initial technical success was achieved in all cases. Symptomatic improvement was present in 39 of 40 cases. At review, 15 patients were alive and had clinical improvement, 18 had died of comorbid causes, one had died of uncertain causes, three had undergone subsequent airway surgery, two had undergone airway stent retrieval, and one was lost to follow-up. Survival at 1, 2, 3, 4, 5, and 6 years was 79%, 76%, 51%, 47%, 38%, and 23%, respectively. Loss of primary patency was most rapid during the 1st year. With repeat intervention, assisted patency was 90% at 6.8 years. Attrition of tracheobronchial stent patency is most rapid during the 1st year, and a high rate of long-term patency can be achieved with secondary interventions. Metallic airway stents are well-tolerated and useful adjuncts for management of select benign tracheobronchial stenoses. RSNA, 2006
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                Author and article information

                Journal
                Exp Ther Med
                Exp Ther Med
                ETM
                Experimental and Therapeutic Medicine
                D.A. Spandidos
                1792-0981
                1792-1015
                September 2013
                02 July 2013
                02 July 2013
                : 6
                : 3
                : 765-768
                Affiliations
                Department of Respiratory Medicine, Taizhou People’s Hospital, Taizhou, Jiangsu 225300, P.R. China
                Author notes
                Correspondence to: Dr Ai-Gui Jiang, Department of Respiratory Medicine, Taizhou People’s Hospital, 210 Yingchun Road, Taizhou, Jiangsu 225300, P.R. China, E-mail: jiangaigui@ 123456126.com
                Article
                etm-06-03-0765
                10.3892/etm.2013.1195
                3786812
                24137262
                Copyright © 2013, Spandidos Publications

                This is an open-access article licensed under a Creative Commons Attribution-NonCommercial 3.0 Unported License. The article may be redistributed, reproduced, and reused for non-commercial purposes, provided the original source is properly cited.

                Categories
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                Medicine

                tracheomalacia, continuous positive airway pressure, metallic stent

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